The International Journal of Psychosocial Rehabilitation
Mind the Gap: Improving Transitions for Mentally
Disordered Offenders Leaving Custodial Environments



Alison Pearsall (1,2)
Dr Dawn Edge (1)
 Dr Mike Doyle (1,3)
 Professor Jenny Shaw (1,2)


1-The University of Manchester
Manchester Academic Health Science Centre
Institute of Brain, Behaviour and Mental Health

2- Lancashire Care NHS Foundation Trust

3-Greater Manchester West Mental Health NHS Foundation Trust






Citation:
Pearsall A, Edge D, Doyle M & Shaw J(2014)  Mind the Gap: Iimproving Transitions for Mentally Disordered
Offenders Leaving Custodial Environments
.  International Journal of Psychosocial Rehabilitation. Vol 18(2) 101-112  



Correspondence:
Alison Pearsall
Offender Health Research Network
Institute of Brain, Behaviour and Mental Health
Room 2.309, Jean McFarlane Building
Oxford Road
Manchester, M13 9PL UK
Email: alison.pearsall@postgrad.manchester.ac.uk

Funding Source: This research was supported by a NIHR clinical academic fellowship



Abstract
Topic:
Review of transitional care programmes in various health settings to determine the relevance of transitional case management for individuals with severe enduring mental illness released from custodial environments.
Purpose:
Transitions, such as discharge or transfer from one service to another or between levels of care can be problematic. In some health and social care sectors such as obstetrics, cardiology, and older age services; transitional care programmes have been introduced to improve continuity of care. Examination of the various forms of transitional care, availability of programmes and associated outcomes in a range of health contexts, could provide important lessons for improving services for mental health service users leaving custodial settings.  
Sources Used:
Published health, social care and criminal justice literature
Conclusion and Implications for Practice:
Poor transitional care is evident across health sectors and service domains. The consequences for service users can be far reaching such as interrupted, duplicated or omitted interventions, which may have a detrimental or damaging impact on their health and wellbeing. The resultant effects include increased use of emergency care, readmission to hospital and in extreme cases, death. Recent health policies have substantiated the importance of transitional care programmes. However, these are yet to be fully realised within mental health settings. Transitional case management may optimise offenders’ engagement with mental health services and provide more effective and sustainable strategies for managing their complex health and social care needs in the community. 

Keywords - ‘Transitions’, ‘offenders’, ‘custody’, ‘community’, ‘release’, ‘continuity of care’



Introduction
Recent healthcare policy recommended integrated working between health and social services to ensure the safe transfer of service users within and between services (DH 2009).  The benefits of effective transitional care are improvements to individuals’ health, care and support alongside efficient use of resources (Humphries & Curry, 2011).  However, despite movement between care providers being customary, limited transitional care programmes exist. Consequently, transfer remains the most vulnerable part of the service user care pathway (Royal Pharmaceutical Society, 2010).

This paper introduces the concept of transitional care, before highlighting the availability and the consequences of its absence, particularly for those with complex needs. The relevance for individuals leaving custodial environments who require continued mental health support is discussed. Finally, a case management programme designed to improve transitional care is described along with its implications for national health policy.

The nature of the problem
Individuals requiring health and social care frequently receive care in diverse locations and from a variety of health professionals within primary, secondary and tertiary services. Each service user has unique personal circumstances, specific symptoms and care objectives. Therefore effective communication between health professionals in each setting is essential to meet care expectations. Each health professional, service or care provider represents a unit of care and a boundary or barrier for the service user to gain access. Without effective information exchange between professionals, the flow and overall quality of care can be interrupted or jeopardised.

Defining transitional care
Kralik et al (2005) highlighted the lack of consensus about definition, nature and components of transitional care. They described widespread disagreement about whether transitional care was linear or cyclical and whether there was an obvious beginning and end point.  Chick and Meleis (1986) seminal work defined care transitions as; ‘passage from one life phase, condition, or status to another’.  Concurring with this, Currie and Watterson said transitions were ‘the purposeful planned movement of patients with chronic physical or medical conditions from one health service to another, or from hospital to residential care’, (Currie & Watterson, 2008, p.8).

Transitional care involves a set of actions or services designed to promote safe, timely and co-ordinated transfer from one level of care to another (in the same location) or to more than one location involving continuity and coordination (Honsleman, 2008, p.13). Coleman contends transitional care is complicated involving several key stages including hospital care, discharge, follow up and support services (Coleman, 2003). Coleman proposed transitional care should cover admission, transfer and discharge procedures (Coleman & Boult, 2003).

Despite the availability of professionals at different stages of transitional care, gaps remain that adversely affect the health and safety of service users.  Naylor suggests gaps are due to incomplete information transfer, poor communication and limited access to appropriate aftercare (Naylor, 2003).

Consequences of gaps in transitional care
The consequences of poor transitional care can be extreme. Lafasco reported one in ten seriously ill service users die as a result of inadequate transitional care (Lafasco, 2013). During transitions, service users are at increased risk of medical error, with nearly one quarter experiencing adverse events, most commonly medication related, half of which are preventable (Kripalani, 2007).

Honsleman (2008) found poor transitional care led to serious complications for service users including re-admission and increased emergency treatment. Poor outcomes may be attributable to duplicated, omitted or incomplete care provision (Honsleman, 2008, p.53). Similarly, Fulmer articulated increased physical, psychological and functional problems for service users as a result of inadequate transitional care (Fulmer et al, 2007, p. 207).

Despite these risks, health care policy does not promote practitioners to provide care to individuals throughout the care pathway. A conventional approach is favoured where practitioners remain situated in clinical areas and people attend for pre-arranged appointments. Arguably, this facilitates the development of specialist knowledge but expertise is department rather than pathway based. Consequently information does not follow the person leading to multiple and disparate case note recordings within various clinical settings.

Improved transitional care
Progress in transitional care is evident in health services but more limited within mental health settings (Reynolds et al, 2004). In other clinical areas, enhanced service user outcomes have been reported. For example, in pain management, rehabilitative programmes eased transitions between hospital and community which generated improved outcomes (Brook et al, 2011). Similarly, Naylor et al (2004) revealed positive health outcomes in cardiac care with reduced hospitalisation occurring in those receiving transitional care (Naylor et al, 2004). In cancer care, transitional care programmes increased the support provided to care givers improving relationships and family functioning (Pinquart et al, 2003, p. 112).

Advanced communication and information sharing is the foundation of transitional care programmes.  Effective information sharing in paediatric diabetes services during transitions positively impacted on individuals’ glycaemic control (Orr et al, 1996). Similarly, in orthopaedic care the introduction of a checklist for transitional care planning improved communication between service users and staff (Hadjistavropoulos et al, 2009, p. 183).

Checklists may be beneficial in some specialties but for service users with complex needs like older adults, a ‘transitional manager’ or dedicated discharge planner may be required to prevent re-admission and excessive use of emergency services (Rich et al, 1995). The extent and consequences of poor transitions for older people are some of the most extreme (Naylor & Keating, 2008) including temporary disability, psychological stress, and sometimes death (The National Transitions of Care Coalition, 2008). Crotty (2005) emphasised the importance of effective discharge planning (Crotty et al, 2005, p 1110) and continuity of care in the community (Thraen et al, 2011).

People with mental illness released from custodial environments have similar issues to older people leaving hospital, in terms of the complexity of health and social care needs limiting successful community resettlement. To improve care transitions, a shift in emphasis from provider to service user centred care is required. Often service users, families and informal care-givers are the only link between providers and care settings indicating that transitional care planning must centre on the individual (Gibson et al, 2012).

Transitional care within mental health settings
In spite of continuity of care being defined as essential (Crawford et al, 2004) transitional care is inadequate following discharge from inpatient treatment (Dorwat et al, 1994) elevating service users’ vulnerability to relapse, suicide and violence (Appleby et al, 2006; DH, 2009; Doyle et al, 2012; Goldacre, 1993). Many individuals struggle to cope with reduced levels of support, isolation and resumed self-care (Miguel et al, 2011). Rose found discontinuity of care on discharge led to unmet service user needs in the community (Rose et al, 2007).

Developing awareness of the consequences of poor transitional care has improved discharge management, for example, through assertive outreach or case management (Burns et al, 2007). Assertive outreach was established to promote engagement in people with mental illness (Marshall & Lockwood, 2004) and was found to reduce the likelihood of relapse and rehospitalisation (Marshall & Lockwood, 1998).  Similarly, other studies have demonstrated benefits by case management (Burns et al, 2001; Mueser et al, 1998; Rosen et al, 2007), particularly for people with complex mental health problems and significant health and social needs.

The New Horizons mental health strategy document outlined effective discharge planning to facilitate safe and timely discharge. In the UK, Crisis Resolution Home Treatment (CRHT) services support people following discharge from acute inpatient care by providing rapid follow up in the community. The remit also provides home support, alternatives to hospital and assessment for inpatient treatment (Sainsbury Centre for Mental Health, 2006). Thus, support during transitions to and from hospital is available for individuals eligible for CRHT.

Transitional care for people with mental health problems in the criminal justice system
Offenders with mental health problems are socially disadvantaged with complex needs (Durcan & Corner, 2012; Farrell & Marsden, 2005). Factors related to offending including poor education, unemployment, housing, debts, substance misuse and limited family networks (Social Exclusion Unit, 2002) are also synonymous with mental ill-health (Bonta, et al, 1998; Murali & Oyebode, 2004). Despite recognition of health and social needs, critical information is often not conveyed to community mental health teams prior to prison release (Miguel et al, 2011), limiting effective community care (Caldas, 2011, p. 5).

Mental illness is prevalent throughout the offender care pathway including at arrest, court, remand, during sentence and on release from prison (Ogloff et al, 2007). McKinnon and Grubin (2010) reported high levels of morbidity among arrestees in police custody with systematic failures in detection of mental health problems, substance misuse and social problems. Other studies have similarly reported high prevalence and low detection of mental illness (Gudjonsson et al, 1993; Phillips & Brown, 1998; Steadman et al, 2000). Significant levels of mental illness exists among defendants at court (Joseph & Potter, 1993; Shaw, 1999), but limited identification means limited opportunities for early engagement into services, increasing relapse and likelihood of imprisonment or hospital admission (Durcan, 2008).

Studies report higher rates of mental illness in prisoners compared to the general public (Birmingham et al, 1996; Singleton et al 1998; Fazel & Danesh, 2002) especially among remand prisoners (Birmingham, 1996; Brooke et al, 1996; Gavin et al, 2003; Prins, 1995). Nurse et al (2003) hypothesised that higher rates in remand prisoners could be due to anxiety about facing the future (for example, appearing in court, being found guilty), the effect of imprisonment (such as, first experience of prison), and stresses on the family (including fear of reprisals, financial pressures).

Communication of mental illness between police, court and prison settings is hindered by separate systems and procedures (The Sentencing Project, 2002). National Association of Care and Resettlement of Offenders (NACRO, 2007) and Revolving Doors (2006) raised concern about poor continuity of care for individuals with mental health problems leaving prison. Programmes to link released prisoners with appropriate health and social care are impeded by limited integrated working, widespread geographical locations and absences of inter-agency policy directives (Gaes et al, 2002; Raynor, 2007). Repper (2008) argues for the provision of appropriate transitional care (Repper, 2008, p.110) that is comprehensive and commences prior to release (Petersilla, 2003, p.173). Similarly, Lord Bradley proposed “wherever discharge or release occurs, it is important to ensure that responsibility for care is passed on to the relevant services, and that they are engaged well in advance of discharge (Bradley, 2009, p.114).
The implications of inadequate transition planning are significant including increased risk of suicide, relapse, hospitalisation, re-arrest and imprisonment (Draine & Solomon, 1994; Keil et al, 2008).  Many individuals come from disadvantaged communities and similarly return (Lynch, 2006) with multiple problems including mental health, substance misuse, poor educational attainment and limited employment skills making resettlement more difficult. High numbers of people with mental health problems ‘fall through the gaps’ in the community and become neither the responsibility of mental health or criminal justice services (Harris, 1999) resulting in inconsistent interventions, poor communication and limited clinical outcomes. Consequently, many resort to using health services in a crisis-driven way, with high use of emergency services (McGilloway 2004; Jackson, 2005). Such contact is uneconomic, provides poorer long term outcomes, limited health promotion and inadequate community support (Singleton, 1998).
Osher proposed an integrated framework may reduce duplication, maximise resource availability, information sharing, care co-ordination and opportunities for therapeutic or restorative community work (Osher et al, 2003). They highlight the need for intensive, time-limited interventions that take account of specific vulnerabilities during initial release, provide consistent support which is reduced as the person forges links in the community (Pickup, 2011, p. 2).  However, most support programmes focus on reducing reoffending without incorporation of social support such as housing, finance, employment, education and training and improved links with families. Yet each of these factors can have a significant impact on re-offending (SEU, 2002). Blackburn (2004) highlighted the dichotomy of ‘offence focused’ versus ‘offender focused’ support and suggested amalgamation of both approaches was most effective in treating offenders with mental illness (SEU, 2002). 

A range of re-entry programmes exist around drug rehabilitation (Friedmann, 2009;  Knight et al, 1999), education and employment (Adams et al, 1994; Turner and Petersilia, 1996), specialized housing (Lowencamp & Latessa 2004), mentoring schemes (Jucovy, 2006) and building family ties (Shanahan & Villalobo Agundelo, 2011). Theurer highlighted the importance of support programmes combining mental health and substance misuse treatment, crisis support, housing and active case management with frequent contact in home settings (Theurer and Lovell, 2008). One such programme which incorporates all these elements is Critical Time Intervention (CTI).

Critical Time Intervention (CTI) is a variant of Assertive Community Treatment emphasising time-limited, intensive case management at critical points, such as release from prison or hospital. The purpose of CTI is to establish a stable support network in the community, forging effective links with local services including housing and health intentions for people who are additionally vulnerable due to limited informal networks. CTI was developed collaboratively by mental health clinicians and researchers to support homeless people with severe mental illness (SMI) released from hospital. CTI promotes continuity of care during transitions, by effectively linking service users to community services. The aim is to expand supportive networks in the community, including family, friends and services (Draine & Herman, 2007).

There are similarities between the original study population and offenders with mental health problems in respect of levels of disengagement with services (Susser et al, 1997; Durcan & Knowles, 2006). In 2007, CTI was adapted for mentally ill prisoners due to be released (Lennox et al, 2012). The feasibility study aimed to see if CTI effectively connected prisoners with social, clinical, housing and welfare services in the first few weeks after leaving prison. The pilot randomised controlled trial was conducted at three prison sites.  Sixty prisoners were randomised to either CTI or treatment as usual (TAU) and 23 were followed up. At follow up, a higher proportion of the CTI group were involved with services in comparison to the TAU group.  CTI prisoners were significantly more likely to be receiving medication, and be registered with a GP than those receiving TAU. Results suggest continuity of care for prisoners with SMI can be improved through identification of needs prior to release, and by assisting effective engagement with appropriate community agencies.

Effective transitional care is needed to facilitate service users moving in and between services to avoid discontinuity of care and adverse events. Transitional care is needed particularly for individuals with complex health problems requiring co-ordinated input from one or more service providers to ensure consistent delivery of care. CTI has demonstrated improved engagement, reduction in psychotic symptoms (Herman et al, 2000) and high levels of service user and staff satisfaction (Lennox et al, 2012) and may have potential to improve transitional care for client groups with complex needs. CTI is not designed to be a permanent support system, therefore discouraging the formation of service dependency. Significantly, CTI supports the principles of recovery as the intensity of support reduces gradually (to exit) as the person regains independence, generating considerable longer term cost savings (Jones et al, 2003). The development of evidence based interventions such as CTI for offenders should have a significant public health impact, directly influencing service use and possibly reducing re-offending rates (NACRO, 2007; Citizens Advice Bureau, 2007).

Conclusion
Transitional care has become an important focus for health policy with calls for generic, cross-specialty developments, since discontinuity of care represents common challenges in all services and specialities (McDonagh & Viner, 2006). Transitional care is particularly important for people experiencing serious or chronic illness including mental illness; however, useful initiatives such as CTI have not been integrated within routine care systems.

People in the criminal justice system with mental health problems need transitional care before release to ensure receipt of a range of health and social support to optimise resettlement. Offenders with mental health problems may be vulnerable to many issues including recidivism, instability, poor health and well-being outcomes, without intensive intervention (Loveland & Boyle, 2007). Yet many have difficulty accessing and maintaining engagement with mental health and criminal justice agencies (McGilloway et al, 2004).

Critical time intervention (CTI) has generated positive results when applied to pre-release prisoners (Lennox et al, 2012), and homeless populations with SMI (Susser et al, 1997), demonstrating its potential transferability among complex service user groups. This paper has illuminated various aspects of discontinuity of care and emphasised the need for better transitional services for people released from custodial care. Future research should consider the benefits in terms of financial and societal costs, as CTI could be beneficial by engaging people at an earlier stage to reduce risk of relapse and recidivism, while preventing unnecessary waste in health, police and prison resources.


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