The issue of preparing inmates for re-entry into the community has been placed decisively on the front burner, and for good reason.

An estimated 11 million offenders are being released from correctional institutions each year and a higher percentage of them have or are at high risk for contracting communicable diseases. When you look at the elements of the equation, the answer seems clear. These offenders need to be able to continue their health care treatment, understand how they infect others and be given the tools to succeed in the community.

"I think the obvious answer is they are a captive audience [in jail or prison] and you need to do what you can do. There has to be a better outcome somewhere [by making these connections]. We're just starting to make a mark in seeing the whole picture - that the community is the jail and the jail is the community," said Priscilla Wood, Special Projects Coordinator for the Florida Department of Health Bureau of HIV/AIDS.

But the process for making these linkages between correctional facility and community happen is complicated.

While several states have made progress in opening the doors between jails and prisons and community services - in large part through demonstration project funding from the Centers from Disease Control and Health Resources and Services Administration (HRSA) - many other jurisdictions have not had the money, the opportunity, or the connections in place to do so.

But as the profile of this issue is raised, many in the field expect that legislators will understand that funding is required to stop both the spread of disease by offenders and the revolving door from community back to jail or prison.

Financial Boost Moves Collaborations Along

Several communities across the country have been able to capitalize on funds received through a national corrections demonstration project for continuity of care programs for inmates with HIV, STDs, tuberculosis or hepatitis who are being released from corrections or detention centers.

In Florida, for example, the Department of Health's Linking Inmates Needing Care (LINC) Program began in 2000 to counsel and test inmates for HIV and help them plan for their release. The program involves both the jail system and the state Department of Corrections where pre-release planners work with inmates prior to release to provide connections to health care appointments and support services to help them after their sentences are over.

From the initial grant from the CDC and HRSA, the program has been able to expand in both the prisons and jails and the state legislature has also begun to pay more attention to the issue.

According to Wood, who helped write the initial grant application, a relationship already existed between the state Department of Health and corrections agencies, which helped cement the partnership after the funding came through. The grant helped that relationship flourish to provide the community linkages that were needed.

"The point is that the demonstration project money got the right people interested. The success we can't measure [specifically], but we can measure that we are doing increased testing and [there is] increased interest in harm reduction and it seems to be moving forward," said Wood.

One of the major forces behind the development of community linkages for this population was the Department of Health itself. According to Wood, the DOH has long felt a responsibility to help reach out to the offender population to keep them, and the community, healthy.

From there, the DOH has made itself available to both the jails and prisons to work with those systems to improve the outcomes for inmates after release.

"We feel in public health it is our duty to make those entrees and supply what we need to supply to get it done and hopefully the jails [and prisons] will think it is worth doing," said Wood. "I think it is our business to understand."

One of the most recent benefits of educating others about services for HIV-positive inmates is the passage of a law requiring mandatory HIV testing for Florida inmates prior to release. This legislation allows the Prison LINC program to better serve those who need health care connections and other support in the community.

Prison LINC provides screening, testing and counseling for HIV, prevention education, release planning and follow-up with offenders for the first six months after release. The services available range from enrollment in the AIDS Drug Assistance Program [ADAP] to assistance with applying for disability, food stamps and Medicaid through the help of case managers.

In the jail setting, the Jacksonville, Fla., Jail has relationships with four separate community agencies to provide a variety of services ranging from HIV, STD, hepatitis and TB screening to maternal and infant primary care for those with HIV. The project has also allowed for a collaborative relationship between the Duval County Department of Health and the county sheriff's office corrections division to impact public health.

According to Wood, the impact Jail LINC has made is unique because of how jails operate and support for the program has followed because of it.

"The health needs are different because people in the jail have come straight from the streets and they haven't had any health care, but when released they get sick again and then come back," she said. "Where we make inroads is by keeping them in some kind of health care and a stable environment. Then that certainly will benefit the jails."

Wood said because of the success of these connections, there is currently a move afoot to fund 10 new jail projects in Florida counties in 2004.

"Now it's on the radar screen," she said.

Transitional Planning Expands

In California, the community-based inmate support agency Centerforce has also expanded its outreach into the community and with offenders that originated with funding from the CDC and HRSA.

Although Centerforce is known for its work with HIV-positive inmates, it has been able to make transitional planning a regular occurrence for many more offenders.

Centerforce Executive Director Barry Zack said the success of community collaborations ties directly to an understanding of the range of problems offenders face upon release.

"In a way, what we are doing is we are dumping people out of jail or prison. The other reality is there are so many regulations and laws that it sets up for individuals to fail," said Zack.

He said that overcoming primary obstacles, such as housing, makes a tremendous difference in offenders being able to turn their lives around.

When an offender convicted of a felony cannot access certain community housing, it means they are often faced with sleeping on the streets.

"We have data that shows 50 percent of men leaving don't have a clue where they are spending the first night and of those who do, 25 percent don't spend the night where they thought they would. Only 25 percent end up with a planned roof over their heads. If that isn't a set-up for failure and recidivism, then we get what we deserve," Zack said.

Centerforce, which dedicates a portion of its budget to research, has been able to grow its Transitional Case Management Program with HIV-positive offenders into a broader look at the discharge problems that offenders face.

So, in addition to helping all HIV-positive offenders at the prison in San Quentin, California and the California Medical Facility being released into the San Francisco area connect with medical services, it has also focused on many of the other barriers that these and other offenders encounter.

Zack believes that if other agencies don't do the same, then offenders will not receive the assistance they truly need.

"The funding support is so population-specific [so] it is the responsibility of the front-line providers, who want to be successful, to try to integrate it all together. If projects are disease specific, we are going to lose. We have to think beyond one disease or one issue," he said. "Prisons are not designed to have one person dealing with each of the issues; it has to be comprehensive."

In addition, agencies need to be sensitive to the realities of a correctional facility and their primary purpose - security. These institutions are not designed to have many different people working with offenders prior to release. Having agencies that can address a number of transitional release issues is a better plan, he said.

"Our goal is in the release period -- say up to three months - to find the appropriate agency to work with that individual," said Zack.

Zack said communities and those funding institutions supporting transitional planning for offenders should clearly understand what it means to help an offender plan for release - no matter what disease they have.

"So much of it comes down to money. The bottom line is, as taxpayers, it is our money, and whether it is funneled through corrections, public health or housing is secondary," Zack said.

Zack said funding should go towards setting up community and public health linkage infrastructures with correctional institutions and evaluations of those linkages to prove that they work. Without proof that these efforts make a difference in not only health outcomes but also in recidivism, these projects will die on the vine.

Centerforce, with funding assistance from the National Institutes of Health, has been able to take on a five-year project using a comprehensive model of intervention with offenders at release. "It is looking at the family and is more communally focused. We are actively working with the support network of the individual," Zack said.

Although the success of this model remains to be proven, Zack believes that it could be a viable alternative to the case management model currently being used by agencies to help offenders transition to the community.

Those organizations that have had success with the case management model say it is the strength of the individuals behind the effort that make the programs work.

Strength in Linkages

In the Chicago area, several organizations including the department of health, the Cook County Jail, housing partners, substance abuse treatment centers and the AIDS Foundation of Chicago have come together to help offenders with HIV succeed after release.

According to Rev. Doris J. Green, Corrections Coordinator for the AIDS Foundation of Chicago, the program works on two levels: one is to reduce the transmission of HIV from offender to others in the community and the second is lowering recidivism rates in general.

"A lot of research shows that re-incarceration happens because a lot of the needs cannot be met in the community. Take housing, for example. If you don't have a place to lay your head, how can you get a job and be productive," Green said.

Green said a major reason the project has been able to help offenders avoid re-incarceration is the staff working to make community linkages.

"These are people who have a lot of street experience, so they know the streets, they know who is using drugs or who is selling and they know where they are," said Green. "We do a lot of team meetings and share information. They know where to find clients [if they don't show up for an appointment] and they don't take 'no' for an answer."

With four case managers on the inside of the jail and eight on the outside, the communication between the two groups must be clear and quick in order to ensure that clients receive the right kind of services.

The inside case managers begin working with offenders right after their first court date to determine what services they will need after release including HIV-related medical appointments to the re-establishment of social security benefits.

If an offender is released without notice, such as after a hearing before a judge, then the inside case managers will know right away and can notify those case managers in the community.

Another strength of the Chicago project is that the AIDS Foundation stands as the link to more than 50 agencies in the community and that helps cement a plan for continuity of care for released individuals.

Similar links to a menu of services is also an important factor in the success of transitional planning for HIV-positive offenders from jail and prison to Los Angeles County.

At the Tarzana Treatment Center, which has several locations in the L.A. area, the HIV Incarcerated Services program offers case management to offenders leaving the L.A. County Jail and several of California's prisons. The services range from HIV medical treatment to housing.

The program helps stabilize offenders by ensuring they have a transition plan in place for the 60 or 90 days after release that includes having the medications they need upon release as well as access to any other appointments, such as mental health services.

After that time period and once they have stabilized, the center helps the individuals connect with long-term case managers in their community.

"They do take advantage of the services. People are accessing these services to make a change in their lives," said Jenell Lagard, Program Coordinator for Incarcerated Services for the Tarzana Treatment Center.

The positive outcomes being realized by the handful of transitional programs working with offenders upon release - be they HIV-infected or otherwise - are what will translate into support for even more of these services. Those who already see the results say that the success needs to be communicated and, once it is, communities will be healthier and prison populations will decrease.

"It doesn't take great minds to figure out that if you put some interventions in that equation then you make a difference. If you can get the community and the jail to understand that the jail is where we can make interventions - because the inmates are there - then you are going to get a few people to turn some things around [in their lives]," said Wood.

Resources:

Florida Department of Health, Bureau of HIV/AIDS, 850-245-4444
www.doh.state.fl.us

Centerforce - 415-456-9980 or  www.centerforce.org

AIDS Foundation of Chicago - 312-922-2322

Tarzana Treatment Center - www.tarzanatc.org  or 818-996-1051