Mind the Gap: Improving Transitions for Mentally
Disordered Offenders Leaving Custodial EnvironmentsAlison 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
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
Offender Health Research Network
Institute of Brain, Behaviour and Mental Health
Room 2.309, Jean McFarlane Building
Manchester, M13 9PL UK
Funding Source: This research was supported by a NIHR clinical academic fellowship
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.
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.
Published health, social care and criminal justice literature
Conclusion and Implications for Practice:
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
Keywords - ‘Transitions’, ‘offenders’, ‘custody’, ‘community’, ‘release’, ‘continuity of care’
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).
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
The nature of the problem
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
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).
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).
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
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).
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
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).
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).
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
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).
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
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
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).
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).
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).
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
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
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).
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.
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).
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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