University of Southern California Dissertations and Theses

A bridge program from jail to community behavioral health treatment

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A bridge program from jail to community behavioral health treatment

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Content 1
A Bridge Program from Jail to Community Behavioral Health Treatment
Capstone Project
By
Heather Dunn, LCSW, DSW
A Capstone Project Presented to the
FACULTY OF THE USC SUZANNE DWORAK-PECK SCHOOL OF SOCIAL WORK
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
Doctor of Social Work
August 2024

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Table of Contents
Abstract 3
Acknowledgements 4
Positionality Statement 4
Problem of Practice and Literature Review 6
Conceptual/Theoretical Framework 14
Methodology 15
Project Description 19
Implementation Plan 24
Evaluation Plan 26
Challenges/Limitations 27
Conclusion and Implications 28
References 32
Appendix A 37
Appendix B 39
Appendix C 42

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Abstract
Sonoma County is a county in the State of California which has one jail for the county
that houses roughly 750-800 inmates every day. Of those inmates, 45% have been diagnosed
with a behavioral health condition and only 40% of those diagnosed are provided with some
level of discharge planning to help them continue or start treatment and access basic resources in
the community upon discharge. Healthcare accessibility and incarceration have been separately
treated which contributes to this country’s ever growing mass incarceration rates (Ramezani, et
al. 2022). To reduce the incarceration rates, access to necessary mental health and Substance Use
Disorder (SUD) treatment is essential. In Sonoma County there is one discharge planner for the
jail system and that discharge planner focuses on the inmates with moderate to severe level of
behavioral health needs in the jail, therefore inmates with a mild to moderate level of behavioral
health need do not receive discharge services. Sonoma county has multiple community-based
services for individuals coming out of the jail system who have a behavioral health diagnosis;
however, those intensive and comprehensive programs only provide services to the moderate to
severe level of need inmates, leaving the mild to moderate level of need inmates to not have
necessary services in the community. The need to develop a program that collaborates between
the jail services, county and health care partners such as Santa Rosa Kaiser Permanente
(KPSRO) is necessary to help engage this population in much needed treatment and resources
post-release which will impact the recidivism rates positively.

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Acknowledgements
Many thanks to everyone who dedicated time and attention to meeting and discussing the
complex issue of incarceration and behavioral health needs. Your contributions were invaluable
to the development of this capstone project. I extend my gratitude to the Capstone community
team for their critical thinking in addressing the problem and developing concepts, and to the
capstone committee for their consistent support and guidance in refining this project.
A special thank you goes out to the consumers who bravely shared their life experiences,
navigating the challenges of incarceration and behavioral health needs. Your insights have been
instrumental in shaping this project.
Lastly, I want to acknowledge and express my deep appreciation for the person at the heart of
this capstone project, to whom it is dedicated—my best friend and only sister. Her resilience in
overcoming incarceration and debilitating behavioral health issues has inspired me to dedicate
myself to helping others in similar situations within the jail system. Her story serves as a beacon
of hope, illustrating the importance of never giving up on individuals, no matter how
overwhelming their circumstances may seem. Everyone deserves access to support and a path to
overcoming mental illness and drug addiction.
Positionality Statement
I grew up in a family from the lower side of the socioeconomic ladder, with generations on both
sides struggling with mental health challenges and substance addiction. Raised by parents who
themselves battled these issues; I was very familiar to the dysfunction related to behavioral
health struggles. Concern for my family's well-being became a daily part of my life, yet nothing

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could prepare me for the heartbreaking journey my best friend and only sister would face,
dealing with mental health issues and opioid addiction since her high school years.
At the age of 17, my life took a dramatic turn when I welcomed my first child into the world.
This critical moment set me on a path toward becoming a social worker, specializing in assisting
individuals grappling with severe behavioral health needs. While my professional path was
evolving, my sister's life spiraled further into the darkness of severe opioid addiction,
homelessness, and repeated encounters with the justice system.
With each release from jail, my family and I hoped and prayed that the justice system would
offer her the necessary treatment to stabilize her mental health and start her recovery journey.
Unfortunately, time and time again, she was released without any support, inevitably falling back
into the destructive cycle she knew all too well (Grady, et.al, 2023). Over the next decade, her
behavioral health would deteriorate rapidly. She once described opioids as “air”, insisting she
needed them to survive. It felt as though the justice system expected her to refrain from using
drugs without providing the vital support she needed—parallel to forbidding someone from
breathing toxic air without offering an oxygen mask.
Thankfully, my sister was one of the fortunate few with a support system in place. When she
reached the edge of death due to her drug use, she pleaded for help, and my family and I
intervened, ensuring she received the assistance she so desperately needed. This experience
highlighted the critical need for accessible services and resources, particularly for individuals
navigating behavioral health challenges (Comartin et al., 2022; Carr & Hillbrand, 2022; Pettus,
et al., 2023). They deserve the metaphorical oxygen mask to aid in their recovery journey.

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Throughout my personal and professional life, I've witnessed numerous individuals struggling
with behavioral health issues, often feeling trapped due to a lack of awareness about available
services or where to begin seeking help. It's imperative that we provide them with the necessary
support, especially upon their release from incarceration (Tsai & Gu, 2019). By doing so, we can
begin to shift the trajectory of their lives toward healing and recovery. My sister was desperate
for help when she woke up in the hospital, but she had no idea how or where to start getting help.
She cried and begged me to help her and luckily, I was in a position professionally to get her the
necessary help and provide direction for recovery. Without intensive case management and
treatment linkage she would have never been able to get to a place of having almost 2 years
clean.
Problem of Practice and Literature Review
The United States has the highest incarceration rate compared to other countries around
the world. Mass incarceration in our country rose 45 years ago and continues to plague our
country. It has been reported that 1.5 million people are housed in prisons and 728,000 people in
jails across the United States (Fong, et. al, 2018). The US is at a point that it can no longer
support the mass incarceration rates and radical changes in our country to promote smart
decarceration is overdue. Promoting smart decarceration is one of the 12 Grand Challenges
identified by Grand Challenges for Social Work and Society. This initiative is essential given our
country's high incarceration rate.
According to the Office of Justice Programs, the incarceration rates have continued to
increase the past two decades which includes individuals with drug related offenses in the prison
and jail system. There are two arrests every minute for drug related offenses in the United States
(Aspenridge Recovery, 2021). This is compounded by the lack of proper behavioral health

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treatment both pre and post incarceration continues to influence the increased rate of individuals
in our jail system. Our country is in an era of decarceration that needs new, well-informed,
evidence-based innovations to help the incarceration rates start to decrease (Fong, et.al. 2018).
Our country is stated to be at ground zero for decarceration and looking to catapult a shift in the
mass incarceration nationwide. Part of addressing the Grand Challenge of smart decarceration is
viewing the subpopulation of mild to moderate level of behavioral health needs and the lack of
treatment and resources needed to help them get out of the cycle of multiple incarcerations (So.
County, ND, So. County Drug Court, 2012). The country spends an extraordinary amount to
incarcerate individuals that commit crimes every year while struggling with behavioral health
issues (Mai & Subramanian, 2017).
According to the VERA Institute of Justice, the price to house inmates in Alameda
County jail is almost 4 million dollars per year. The data shows that in this county jail the
average daily population is 3,380, and the cost to house them is 2 billion dollars in Alameda
County for jail related costs and another 2 billion dollars for mental health related health care
which includes SUD treatment (VERA, 2015). No data was found for the other 57 counties in
California including Sonoma County which is the county the design team is focused on; however
it is stated that the average cost per inmate daily is $155 and annually comes to about $64,000
per inmate. Utilizing the data on Alameda County jail and projecting that other counties are
similar, then the state of California is spending roughly 4 billion dollars times 58 counties to
operate county jails annually. The operating costs identified were for jail operations, personnel,
and mental health treatment. This does not include policing, prosecuting, and court costs.
The lack of adequate behavioral health treatment both before and after incarceration
significantly impacts the increasing number of individuals in the jail system (Wakeman & Rich,

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2015). Inmates often encounter challenges accessing behavioral health care while incarcerated,
with studies indicating that only a small percentage receive treatment during their time in jail
(Gerber and Cho, 2023). Only one out of every thirteen people incarcerated received treatment
while in jail or prison for substance use disorder, even though they had a drug dependency
problem at the time of arrest (Howowitz, et.al, Pew Charitable trusts, 2020). This lack of access
to behavioral health services continues post-incarceration, leading individuals to struggle with
their behavioral health symptoms (Grady, 2023). The impact of incarceration on behavioral
health can exacerbate pre-existing conditions, particularly for individuals with histories of
trauma (Grady, 2023). Research underscores the importance of identifying individuals with
behavioral health needs upon intake in correctional facilities to ensure appropriate referrals for
further evaluation and treatment (Zottola et al., 2019). Continuity of care is crucial for
individuals leaving jail, with studies emphasizing the need for engagement with mental health
and SUD treatment services post-release to reduce the risk of re-incarceration (Comartin et al.,
2022). Interventions focusing on positive behavioral support and enhancing behavioral health
literacy among incarcerated individuals can improve outcomes and increase connections to
treatment upon release (Carr & Hillbrand, 2022; Pettus, et al., 2023). Addressing the lack of
behavioral health treatment before and after incarceration is essential to mitigate the challenges
individuals face with their behavioral health symptoms post-incarceration.
According to Saloner and Cook (2013), access to publicly funded substance use and
mental health treatment continues to remain fragmented, underfunded and difficult to access for
individuals who have socio-economic barriers which make them less likely to complete
necessary addiction and mental health treatment. Healthcare accessibility and incarceration have
been treated in separate systems. Healthcare is one system of care, and the judicial system is a

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separate system of care and neither are working together, which contributes to the ever growing
incarceration rates (Ramezani, et al. 2022). To reduce incarceration rates, access to necessary
mental health and SUD treatment is essential. In the county of Sonoma, California, the jail
houses approximately 750-800 inmates every day (SoCo Data, 2023) and is a middle to
maximum security jail. In 2021, it was reported that 45% of the inmate population in the Sonoma
County Jail had been diagnosed with a behavioral health condition. A stated goal of the Sonoma
County Jail is to “release inmates back into the community in better condition medically and
psychologically than when they came into custody” (Civil Grand Jury, 2021). There is currently
only one discharge planner in the county’s jail who is tasked with helping link inmates to outside
resources and treatment after discharge. However, it is reported that this discharge planner only
works with 45% of the population identified as having a behavioral health need. Therefore, 55%
of the population in need of linkage to outside resources and treatment are discharged without
any resources or treatment (Civil Grand Jury, 2021).
The association between substance use, mental health issues and incarceration is strong,
and access to behavioral health treatment during incarceration and after can have a profound
effect on decreasing this population’s incarceration rate (Tsai & Gu, 2019) and extremely high
percentage of overdose after release (Mital, et.al, 2020). This population has a high risk of
relapse and lack of engagement in treatment post-incarceration (Bunting, et.al, 2021), therefore,
during incarceration they need to be provided with a discharge plan that links them up to postincarceration behavioral health treatment before being released back into the community. They
need to be working on their post-incarceration reentry plan that includes necessary social
determinants to sustain a functional life of recovery while they are in jail (Henry, 2019). Post
incarceration these individuals should have an intensive program that provides the support to

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continue their recovery and allows them assistance through case management to help them
obtain employment, medical care, mental health services, housing, money management, build
community, decrease isolation, etc. in order for them to meet their basic needs which will
promote stability (Borowski, et.al, 2020). They need help building a community that supports
them and provides them with acceptance and resources to help them succeed instead of facing
mountains post-release that they don’t have the knowledge or ability to climb. Not only is it the
humane thing to do, but it is the financially smart thing to do. Tsai and Gu (2019) report that
providing behavioral health treatment is directly associated with monetary benefits. There is a
7:1 ratio to the monetary benefits due to decrease in crimes and incarceration, and an increase in
employment. Inmates who receive and are stabilized by treatment during incarceration are
significantly less likely to re-offend, reducing their likelihood of re-incarceration by an average
of sevenfold.
On January 26, 2023, a new Cal-AIM initiative in California which has one of the carve
outs focused on the incarcerated population. Cal-AIM provides Medi-Cal services while
individuals are incarcerated and helps transition inmates to full Medi-Cal services once released
(CHCF, 2021). Cal-AIMs is tasked with providing justice-involved individuals treatment by
ensuring they have access to essential healthcare services during and after incarceration which
includes mental health and substance abuse treatment. One of the areas that has been a barrier is
helping inmates continue treatment once released to the community. Once released in the
community inmates struggle to engage in services to help them stabilize which can lead to them
relapsing and being rearrested (HCS, 2023). Every county will be required to implement the
new initiative and improve services to health care for the inmate population. Kaiser Permanente
is a managed health care plan that is required to provide services to the KP Medi-Cal population

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which includes working with the jail population coming out of jail. Utilizing the initiative
platform, programs to improve health care including behavioral health will need to be
implemented by January 2026. Efforts to improve Medicaid services through initiatives like CalAIMs can potentially benefit justice-involved individuals by ensuring they have access to
essential healthcare services, including mental health and substance abuse treatment, both during
and after their involvement with the criminal justice system (CHCF, 2021).
Multiple stakeholders were interviewed in the process of understanding the current state
of the problem and what needs are not being addressed. Stakeholders interviewed were jail
mental health clinicians and director, government officials, consumers (incarcerated or
previously incarcerated individuals), and family members of consumers. Throughout the
interview the themes related to transitional care to the community consistently were expressed
(Hicks, et.al., 2022). The jail mental health clinicians and director reported barriers with a broken
system of care, lack of resources, and the community resources working in silos instead of
together with the jail system (Ramazani, et. al. 2022). The director of the jail mental health
program stated that once they leave the jail there is nothing that is provided most of the time to
help inmates connect to necessary treatment and resources to meet social determinants, so they
continue to come back into the jail system (Bowen & Walton, 2015). Inmates or previously
incarcerated individuals continued to report feeling lost with how to navigate the behavioral
health systems and resources coming out of jail, and most of them gave up trying and went right
back to their previous lifestyles. One consumer stated that her “brain addicted to drugs would
equate her drug of choice to breathing air and if you take away her air without giving her an
oxygen mask, she will do anything to get some type of air to survive even if it is toxic”. Every
time she came out of jail, she was instructed to stay clean from drugs, but she was never

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provided with help and released from jail in the middle of the night with nowhere to go so she
would end up at the trap house because she knew they would let her in.
Several factors were identified during interviews with stakeholders that continue to
impact recidivism rates negatively, which suggest potential solutions to consider these factors
when developing new programs (Interviews, 2023). One area identified that inmates that were
discharged without resources to meet their basic needs, and no support in helping them access
resources, led them to gravitate back to their former lifestyle, which included continued
untreated behavioral health issues (Interviews, 2023). Second, discharge planning at the current
level was reported as not being comprehensive and failing to address all barriers to engaging
inmates and helping them stay engaged in behavioral health treatment following their release
(Interviews, 2023). And finally, outside agencies lacking communication amongst each other led
to duplication of services, or a gap in services (Interviews, 2023). Providing discharge planning
and linkage to community behavioral health supports to begin or continue behavioral health
treatment that is started in the jail and continues post release is the main objective of the
proposed project (Ramazani, et. al., 2022).
Bridging the gap between in jail treatment and community behavioral health treatment is
an area that has been identified as the most common barrier to continuing recovery treatment in
the community (Martin, et.al, 2019). Discharge planning has been an area that continues to lack
the effectiveness necessary to help solve the wicked problem. Discharge planning currently has
been reported as providing possible resources in the community and releasing inmates with a
plan for them to then do the work to link up to necessary resources (Hicks, et. al., 2022;
Interviews with jail mental health director). The problem is that inmates lack skills and means to
be able to engage in community resources. One major barrier is lack of transportation, and many

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resources require inmates to travel to their location to complete an intake or application. Inmates
who struggle with behavioral health issues have not developed skills to live effectively in the
community (Marlow, et.al. 2015). Their goal has been to survive throughout the day usually
being homeless. Expecting that inmates will access services if you provide them with a list of
resources available continues to fail inmates and perpetuate the cycle of behavioral health crisis
and recidivism.
Currently, there are a few programs designed to provide necessary treatment post-release
from the Sonoma County jail (SCDDC, 2012; RDA consulting, 2022). In the jail system there are
SUD and Mental Health treatment programs through an agency called Wellpath that is contracted
to provide inmates with treatment (Civil Grand Jury, 2021). However, severe deficiencies in the
treatment provided in the jail by Wellpath have been reported (SF Chronicle, 2023) and their
ability to link inmates to community resources is limited due to the lack of collaboration among
the agencies in Sonoma County. The Sonoma County courts have developed a drug court to help
support incarcerated individuals through case management, frequent and regular court
appearances, residential or outpatient treatment, individual and group counseling, drug testing,
and self-help meetings (Dependency Drug Court, 2012). There is also a Mental Health court that
provides intensive services to the population with serious mental health issues. This program
consists of pre- and post-booking diversion, community-based supervision, and re-entry
stabilization (County of Sonoma, N.D.). The issue that continues to contribute to high recidivism
rates in Sonoma County is that these programs focus on inmates who have moderate to severe
level of behavioral health problems, not the inmates who have mild to moderate level of need. A
large percentage of inmates who have mild to moderate level of behavioral health problems are
not receiving treatment while in the jail and after release (County of Sonoma, N.D). The bridge

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program is designed to provide necessary behavioral health treatment to the mild to moderate
level starting in the jail and continuing into the community post-release.
Conceptual/Theoretical Framework
The Sonoma County jail system operates in its own silo of booking inmates, housing
inmates, and releasing inmates back into the community. The jail’s mission is to provide “a
secure, safe, and humane environment,” and one of the three goals identified is to “release
inmates back into the community in better condition medically and psychologically than when
they came into custody” (Civil Grand Jury, 2021). There is a direct relationship between mass
incarceration and community public health and behavioral health service accessibility
(Ramezani, et.al. 2022). However, it is reported that they are treated separately and continue to
operate individually providing services instead of collaboratively to ensure that inmates are
provided with comprehensive services provided by multiple agencies. This contributes to
inmates not receiving the appropriate treatment that target all areas of need to remain stable in
their behavioral health needs and increases the rates of recidivism (Owens, et. al., 2018). To
achieve the goals of the Sonoma County Jail they will need to collaborate with the community
system as a whole to access behavioral health resources and meet social determinates postrelease.
The Social Determinants of Health framework explores the structural and systemic
factors that may contribute to the development and persistence of behavioral health issues and
criminal behavior (Delcher et.al, 2022). The influence that socioeconomic status, access to
healthcare, housing stability, employment opportunities, and social support networks has on
behavioral health issues and criminal behavior is significant. Justice involved individuals who
are struggling with behavioral health issues often struggle with social determinants, and struggle

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with accessing resources to help them improve their current situation and improve their
behavioral health needs. If an individual can’t meet basic needs, how will they stabilize in their
behavioral health needs? Addressing these issues requires a multifaceted approach that
acknowledges the interconnectedness of social determinants of health and behavioral health
outcomes (Ramezani, et. al, 2022). It involves not only improving access to healthcare and
mental health services but also addresses housing, employment, access to food, and other basic
needs.
Reducing recidivism rates for inmates struggling with behavioral health issues will
demand a drastic programmatical shift that links multiple community resources and behavioral
health systems with the jail system. Utilizing systems theory which looks at adaptation of
systems to create concepts, ideas, or systems through goal-orientation and feedback loops, the
design team developed a pilot program (study.com). The program was focused on decreasing the
recidivism rates and breaking down the jail and community treatment silos to impact mass
incarceration rates and engagement in behavioral health services through working together as
part of one system with a common purpose. Through bringing both systems together, along with
other county systems in a coordinated effort, to start treating inmates’ behavioral health issues
both in jail and post release we will start to shift the growing need in the community of
individuals struggling with behavioral health issues that lead to incarceration (Ramezani, 2022).
Methodology
Addressing the complex issue of smart decarceration, particularly focusing on bridging
incarcerated individuals with behavioral health needs to post-release treatment through KPSRO,
presents a significant challenge. Utilizing the design thinking process—empathize, define, ideate,
prototype, and test—a program was developed to facilitate this transition between the

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correctional system and KPSRO.Starting the design thinking process of empathize the design
team utilized various forms of research were designed to employ an understanding of the needs
of the incarcerated population within the jail system who struggle with behavioral health issues.
Peer-reviewed journals were accessed to review both current and past research pertinent to the
specific problem under examination. Interviews were conducted with approximately 30
stakeholders in the community, as well as in other communities, to gain diverse perspectives on
how stakeholders perceive the problem. The design team looked about communities in
Massachusetts and the impact of the recent legislation requiring inmates be provided with
Medical Assisted Treatment (MAT) while incarcerated and linkage to continue the treatment after
release (Pivovarova, et.al, 2022). Inmates or previously incarcerated individuals played a
significant role in explaining the needs of the affected population. By listening to their
experiences and understanding their perspectives on what they require and what has assisted
them in achieving stability, we centered the development of the program around their insights.
Research into the needs and issues persisted throughout the development of the prototype
to verify the accuracy of user needs and problems, as well as the effectiveness of the solution
under development. Interviews with various stakeholders were consistently conducted and
proved essential during the ideate stage which focused on challenging assumptions and creating
ideas. Directors of jail programs in Sonoma County and Massachusetts, KPSRO leadership,
government officials, and county leadership participated in gathering information to generate
innovative ideas to help solve the problem. Ideas were discussed in collaboration meetings with
the program design partners which consisted of KPSRO leadership and Wellpath (jail MH
program) leadership. During collaboration meetings, ideas were presented, explored, and the
limitations of both organizations were discussed, bringing the design team closer to the

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development of the prototype. Through continued collaboration the design team developed and
redesigned several versions of the prototype in order to get a prototype that was ready to be
implemented by both the jail and Kaiser side of the bridge program.
The prototype for the bridge program has evolved multiple times based on presentations
to key players that will be part of the implementation of the program. Key players that were
essential to the development and refinement of the prototype were managers and clinical staff
from both KPSRO and Wellpath. Every time the prototype was presented new refinements were
identified based on different job functions, resources available, policies for both organizations
and logistics of the bridge (prototype). After numerous revisions of the prototype, a bridge
program was established from the Sonoma County jail to the KPSRO Mental Health department.
This program incorporated all the challenges and limitations of the organizations and addressed
the primary needs identified by users in navigating the complex behavioral health system and
linkage to essential resources.
Testing the prototype has been a challenge due to the understaffing of the Wellpath jail
system. Without the staff available, the bridge program will not be able to be fully implemented.
That being said, there is a very small pilot group of inmates that has been identified in the jail.
This pilot group will test the prototype. The first inmate to test the prototype does not have a
release date until after their upcoming court date therefore the program is waiting for the release
date before the testing will be implemented. Once the testing starts, the design team will meet
regularly for feedback on the prototype and identification of changes needed to the bridge
program design.
Utilizing design justice principles of “we center the voices of those who are directly
impacted by the outcomes of the design process”, the bridge program was designed, developed

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and is in the process of being implemented. The current organizational systems in place worked
together to build a community collaborative system that helps consumers heal from the
behavioral health challenges and empowers them to take steps to improve their lives. Both
systems are well-established, and resources are in place, but the collaboration and bridge
between the systems needed to be developed to overcome the challenges that continue to keep
inmates in a cycle of incarceration and behavioral health crises. Learning each system’s
processes and limitations was a strategic plan which was accomplished by the design team
integrating themselves into both systems which was accomplished by firsthand experience of the
work. For two years the design team worked within each system to study how the systems can
collaborate under the current limitations and restraints. Through the process of studying the
programs and understanding of how to innovatively coordinate services utilizing the current
systems was developed. Utilizing both systems that are already working to provide essential
services and bridging the two to create a collaborative treatment plan to ensure inmates continue
to receive essential services post incarceration. The design team focused on the principle of
“before seeking new design solutions, we look for what is already working at the community
level and we honor and uplift traditional, indigenous and local knowledge and practices”
(Costanza-Chock, 2020). During collaboration meetings both organizations used the systems that
were already working and built a partnership to help mutual clients engage in treatment postrelease to help change their cycle of destruction. The team also honored users’ needs and
incorporated those needs into the process of collaboration and design. Users are experts on their
needs based on their lived experiences and should be at the center of designing a program to
meet those needs.

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Multiple systems exist providing behavioral health services within Sonoma County;
however, they are providing services that are disconnected from one another. Coming together in
a coordinated effort is essential but will take significant financial resources as well as crossagency partnership. Developing comprehensive treatment for inmates struggling with mild to
moderate behavioral health issues will be best achieved utilizing existing programs and
restructuring them to provide a comprehensive bridge from the jail system to community-based
treatment.
Project Description
Considering the three themes identified in interviews that were conducted, the proposed
solution must have comprehensive discharge planning process from the jail that includes meeting
inmates’ basic needs as well as their behavioral health needs. The current systems of the jail,
county, and community must have a cohesive and collaborative process for meeting the needs of
inmates upon their release. Sonoma County does have programs that meet these criteria;
however, they only focus on providing resources to the moderate to severe level of need inmates.
There are no identified programs in Sonoma County that meet the needs of inmates diagnosed
with mild to moderate behavioral health issues to help them break the cycle of recidivism and
into sustained recovery (Drug Dependency Court, 2012, County of Sonoma, N.D.). Utilizing the
Cal AIMs initiative in collaboration with the jail, Wellpath (a jail behavioral health program),
Sonoma County and Kaiser Permanente behavioral health services can be coordinated to provide
services for those inmates diagnosed with mild to moderate level of behavioral health issues
among the Kaiser Permanente Medi-Cal population of inmates. CalAIMS is focused on
expanding Medi-Cal services and the goal of the proposed program will focus on providing

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services to the Kaiser Permanente inmate population with either Medi-Cal or straight Kaiser
Permanente (KP) insurance (HCS, 2023).
With all the agencies working collaboratively together, inmates can be identified upon
their initial booking into jail and the discharge planning can start from the beginning. Wellpath
Mental Health Professionals already assess for mental health codes for all inmates coming into
booking. During the assessment inmates who meet behavioral health need criteria are assigned
and IBC code based on their level of symptoms. IBC codes range from E, D, C, A, and Z
(appendix C). E is the most severe level of symptoms to Z the mildest level of symptoms. The
next step after initial assessment and IBC assignment would be for Wellpath discharge planner to
incorporate, as part of their initial meeting with the inmate, a question to identify Kaiser
Permanente justice involved members who have an IBC code of C, A, or Z. The discharge
planner will add the inmate to the list of KPSRO inmates to continue to monitor for release dates.
Once a release date is identified the discharge planner will schedule with KPSRO triage clinician
a teams (Microsoft virtual meeting platform) meeting to facilitate a screening the day before or
the day off release. During the screening the KPSRO triage clinician will schedule an initial
intake in the office within 5 days of release. During the intake meeting the KPSRO clinician will
identify treatment needs and level of case management needed, and book follow up appointments
to start treatment. KPSRO will provide mental health services that include medication
management, individual and group therapy, and intensive outpatient services may/can/will be
provided by Kaiser Permanente and SUD treatment based on their Kaiser coverage. If other
needed services are identified such as housing, case management, employment, SUD treatment
outside of KPSRO, an appointment to meet with a KPSRO case manager will be scheduled to
start linking the member to community resources.

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Resources and services that will be used by the proposed program exist and are active.
The agencies would not necessarily need to create new programs, because they would utilize the
existing programs and adapt them to the proposed collaborative program to serve the inmates.
The proposed bridge program utilizes all systems in place and helps them come together in a
collaborative problem-solving approach to ensure that inmates are released with the proper
supports to facilitate treatment and re-entry into the community. By building on the currently
existing programs and helping them work together cohesively, this proposed bridge program is
feasible and can be successful in helping the inmates with mild to moderate behavioral health
problems. Currently this population does not have a comprehensive program designed to link
them to wrap-around comprehensive services. The agencies that can provide portions of these
services do not have the infrastructure currently to communicate and work together. Therefore,
there is a clear need to create an infrastructure that will help inmates with mild to moderate
behavioral health issues to engage in necessary treatment.
Short, mid-level and long-term outcomes for the proposed program incorporate multiple areas.
Short term outcomes of the proposed program were:
a) to develop program workflows,
b) develop a committee of stakeholders to develop the program,
c) restructure the discharge planners initial meeting questions to include insurance carrier
which identified inmates that meet criteria, and
d) develop a list of resources in the community for treatment and develop a tracking system
to track Kaiser justice involved members and their release dates.
Mid- term outcomes consist of:

22
a) identifying inmates that meet criteria for the program,
b) starting the discharge planning at the beginning of incarceration between the jail,
Kaiser, and county agencies,
c) establish initial appointment with Kaiser pre-release from the jail, and
d) follow-up with inmates by Kaiser post-release to increase engagement in treatment.
Long-term outcomes of the program will be:
a) to reach and provide services to all inmates that meet criteria,
b) increase the engagement in treatment for inmates’ post-release,
c) increase quality of life for inmates,
d) change the cycle of inmate’s incarceration cycle, and
e) decrease the recidivism rates.
The systems that currently exist will need to shift to working interdependently to provide
wrap-around services to meet the needs of this population. Wrap-around services should start
with booking, continue throughout incarceration and discharge and into the community where it
will continue post incarceration with critical community supports. Throughout the process, each
part of the system must continue to communicate until the inmate is linked to community
services and pursuing a plan to become a contributing member of society. Throughout the
incarceration process the discharge planner will be in communication with KPSRO triage, and
the design team will continue to meet regarding the program with the goal of ensuring
sustainability and collaboration. These important and necessary supports will provide the
impetus to positively impact the incarceration and recidivism rates of Sonoma County.

23
Sonoma County has many resources (e.g. housing, food banks, employment) available
that are currently providing needed behavioral health treatment to the community. Inmates that
are suffering from a mental health diagnosis, which includes substance use disorders, need help
accessing those treatments in the community post-release. Looking at the current landscape of
existing solutions, there are programs that currently provide services to the moderate to mild
behavioral health need inmates both in the jail and in the community. Utilizing the current
program in the jail, Wellpath, will allow the jail system to identify the inmates with mild to
moderate level behavioral issues that are not currently being provided with services, and link
them to community services and resources already in place. Kaiser Permanente is already
providing many of the proposed services (e.g., therapy, group therapy, medication management,
case management) to their members, and by building on the services already in place, this would
provide sustainability to the proposed program.
The successful implementation of the Bridge Program will mean that justice-involved
Kaiser members will engage in comprehensive treatment for six months, leading to decreased
behavioral health symptoms and improved social determinants of health. Participants will receive
targeted services designed to break the cycle of behavioral health crises, and to help them
overcome barriers to stability in various areas of their lives. A key objective of the program is to
reduce recidivism rates, aiming for participants to have no new arrests during and following the
treatment period. Providing the bridge to gap services is a new bridge that has never been
developed and the hope is that this bridge will drastically reduce the recidivism rates that are
seen in Sonoma County.

24
Implementation Plan
Once the prototype and workflows have been created, the committee will present it and
train the agencies and personnel who will be implementing the linkage. The plan is to start off
with a pilot program and follow the process closely to ensure that workflows are adjusted as
needed and any gaps in the process of the bridge between Sonoma County jail and KPSRO that
were not identified are closed. Currently there is one inmate identified as meeting criteria for the
program. She is mild to moderate in her behavioral health treatment needs and a Kaiser member.
The design team continues to monitor her release date which should be scheduled within the next
month. Once the release date is scheduled then the bridge program will be implemented. During
the implementation process the design team will meet to provide updates and feedback to the
process and identify any gaps or barriers that need to be address in the bridge program. The
stakeholders that will be invited to the meeting is the jail discharge planner, jail mental health
director, KPSRO manager of triage team, KPSRO manager of acute care services, KPSRO
clinicians’ working with inmate and KP MH director.
Looking at the current state of the bridge program without the implementation process
being fully tested a few gaps have been identified that will need more resources to address. First
potential barrier is that the jail only has one discharge planner for the whole jail. To provide the
best level of discharge planning, investment in more discharge planners is needed. The current
Sonoma County data that we are using focuses on the jail capacity which is approximately 750-
800 inmates and 45% of inmates have a behavioral health need. Of the 45% only 40% receive
discharge planning services leading to 60% still in need of discharge planning services (Civil
Grand Jury, 2021). Therefore, if the current discharge planner who works full time can only
service 40% of the inmates being released, the jail program will need to increase their workforce

25
to include 1.5 FTEs for discharge planning. Currently there is no data available regarding how
many inmates with behavioral health needs also have KP insurance, which is a variable that
could also influence the potential need to increase in KP resources to meet the needs of justice
involved KP members. Without the data to report how many intakes are needed from the jail, KP
cannot adequately prepare for the effects the bridge program may have on outpatient treatment.
The biggest unknown factor is what percentage of inmates will attend their first communitybased appointment with KP. This is a variable that will be tested in order to understand the
success rate of inmates engaging in post-release treatment. A potential need if the percentage is
low for engagement is the need for peer support specialists that can help assist inmates in making
it over the jail bridge to KPSRO services. This position would need to have added funding
resources either from the jail or KPSRO.
Other stakeholders in the community are agencies (e.g. Catholic Charities, Sonoma
County Behavioral Health, Vet Center) focused on providing services to meet social determinants
which Kaiser case managers would be referring justice involved members to. Moving forward
with ensuring that the released inmates are engaging and utilizing community resources would
mean extending and developing a collaboration between KPSRO and the community
stakeholders to develop the next step in the bridge process which is a KPSRO to community
support bridge. Current state is a loose collaboration and referral process of KPSRO case
managers utilizing the resources list available and referring members to services, however,
ensuring they are engaged does not have any formal collaboration process and is reliant on
informal collaboration initiated by individual case managers. Development of a formal
collaboration process with structured meetings will be the next focus of the implementation
process once the initial bridge from the jail to KPSRO is completed and effectively implemented.

26
Evaluation Plan
KPSRO will be utilizing their current system of data collection to pull data regarding the
percentage of justice involved members who attended their initial appointment post release and
then follow up data on those justice involved members who continued engagement in services
for 6 months post release. Assessments will be conducted with justice involved members in the
form of an Adult Outcomes Questionnaire (AOQ) before every treatment session with Kaiser
Permanente to track increase or decrease of symptoms. The AOQ is an assessment tool that rates
the level of anxiety, depression, substance use, suicidal ideations, and homicidal ideations. This
assessment questionnaire is already implemented for all Kaiser Permanente members before their
behavioral health appointment, so implementing the assessment tracking tool into the new
program will have a high probability of success. AOQ data will be monitored at the one-, three-,
and six-month mark for every justice involved member. KPSRO will be measuring impact of
treatment on their symptoms and stabilization in the community. Utilizing the data collected the
design team will be able to track effectiveness of the post-release treatment in justice involved
members who are attending their initial appointment and who are continuing to engage in
treatment post release for the 6 months. Further development of a tool for measuring recidivism
rates will need to be developed and implemented in the jail system which will provide the design
team with data on the effectiveness of the bridge program on the recidivism rates for justice
involved members.
Within the KP electronic health record there is a system that KP data analysist can utilize
to generate data reports on multiple variables identified for the data report. The data analyst can
pull data regarding percentages of justice involve members engagement in KP services based on
appointment type and trigger phrase that identifies the involvement of the bridge program. A

27
trigger phrase identifying that the member attended the initial appointment and a separate trigger
phrase that identifies “no shows” to initial appointment will be developed for the initial
appointment and will need to be imbedded into the clinical documentation in order for the data to
be pulled from the electronic health record. We will compare the attendance of initial
appointment with the no show rate to gather percentage of inmates that are attending their
scheduled post-release KPSRO appointment. There will also be a trigger phrase developed for
continued engagement within the clinical documentation which will have the data analyst track
percentage of inmates who continue treatment after initial appointment. The data will be
important and necessary for supporting the bridge program goals and objectives and helping the
program identify gaps that need to be address in order for success in the bridge program.
Challenges/Limitations
Bringing two large organizations together to collaborate and build an integrated system
has been challenging and many obstacles have been overcome, however there continues to be
limitations to the bridge program between KPSRO and the jail. Both organizations operate under
regulations, budget constraints, and policies that limit the services they can offer. When the
design team envisioned the ideal bridge program, they found that the constraints of both
organizations made it impossible to achieve that ideal state. Consequently, the design team had to
take these limitations into account and develop a more realistic program. The primary challenge
posed by the current operational hours of the KPSRO triage (Monday through Friday, 8 AM to 5
PM) is the limitation it imposes on conducting phone screenings for justice-involved members
before their release from jail. Since inmates are released at various times throughout the day and
evening, restricting phone screenings to regular business hours means there are significant gaps

28
in conducting the necessary phone screen to schedule the initial appointment. This limitation
means that some inmates could be released and not linked to KPSRO services post-release.
Another challenge that the bridge program might face is staffing issues if the only
discharge planner is not available to conduct the screening post release. Working closely with the
jail staff to identify an alternative clinician to complete the screen will be necessary. The design
team was able to identify a jail clinician who could step in and complete the screening call with
KPSRO triage. The identified jail clinician will need to be knowledgeable about the objectives of
the bridge program and process and trained to ensure that the collaborative behavioral health
project can be implemented as designed.
The current bridge program is aimed only at providing services to Kaiser members. This
excludes inmates who do not have Kaiser insurance and leaves them continuing to lack the
continued treatment resources when reentering the community. The hope for the future is that the
design team would expand to include other managed health care and county services so that the
bridge program is provided to all inmates regardless of insurance type. An important inclusion
criterion is willingness to participate in the bridge program which could also impact inmates that
are not willing to participate. If inmates are not willing to participate then services will not be
provided leaving them to continue in the cycle of potential recidivism due to their behavioral
health needs.
Conclusion and Implications
Throughout the collaborative problem-solving process there were several lessons learned
that needed to be identified before the bridge program could be fully developed. First, the
process needed to have end user’s voice as the center of the development. Coming into the

29
process with a preconceived notion of what the justice-impacted individual needed was a barrier
to actually developing a program that would meet their needs. The preconceived notion that was
presented at the beginning was the need for Medical Assisted Treatment (MAT) access to inmates
and continued MAT treatment post release. This continues to be an area of need and can impact
success rates, but users identified needing more than just MAT and actually reported that linkage
to community treatment was the biggest barrier to them continuing to stabilize once released
from jail. The design team shifted their focus based on feedback from end users, who identified
the primary challenge as difficulty navigating the behavioral health system and connecting to
treatment and case management after their release. As a result, the bridge program was
redesigned to better connect individuals from the jail to KPSRO.
The second area of learning emphasized the importance of thoroughly understanding
both KP and Wellpath system structures. For two years the design team studied the systems from
both organizations and developed a deep understanding of the limitations of both systems and
their resources available. Through gaining knowledge about both systems, the collaborative
process identified barriers and provided creative solutions to overcome the collaboration barriers.
Understanding what both systems needed to implement the bridge program was invaluable to the
process. Without taking the time to study the systems, the innovative and creative design of the
bridge program could not have been developed.
The goal was to provide services that were not already being provided. Therefore,
understanding what services are currently being provided and for which portion of the population
was essential. Sonoma County provides services already to the severe level of behavioral health
need inmates therefore duplicating or creating a new service for this population would continue
to leave a significant hole in the mild to moderate level of need inmates. Understanding that

30
KPSRO serves the mild to moderate level of behavioral health was a resource that had not been
tapped into, and it was the area of most need for our justice-involved KP members. The bridge
program is the first program to collaborate with the jail to provide a bridge for inmates to
community based BH treatment. Currently, the level of services for inmates with mild to
moderate level need is minimal, but with the implementation of the projected program there will
be an increased level of engagement in services for this population from minimal to wraparound. Increasing coordinated services to provide comprehensive wrap-around service will
provide opportunities for this population to increase their involvement in community treatment.
When individuals are provided with comprehensive services it has been reported they have
improved treatment outcomes in the community (Saloner & Cook, 2013, Bowen & Walton,
2015). Improved treatment outcomes will help decrease the recidivism rates for the mild to
moderate inmates, which will improve inmates’ lives, help them break the cycle of incarceration
(Martin, et.al., 2019), and decrease the utilization of crisis services such as the community
emergency rooms (Easter, et.al., 2023).
The next step to fully implementing the bridge program is testing the design out with an
inmate. An inmate has already been identified and the design team is waiting for them to go to
court where a release date will be scheduled. Once the design team has the release date then the
bridge program will be implemented and followed closely to identify any gaps, barriers, and
structural changes that are needed. Design team meetings will be conducted to refine the process
based on the testing findings. After revising the program, then a small group of inmates will test
the refined process out to ensure that it runs smoothly. The design team will continue to meet and
refine the bridge program. Once the team feels confident that the bridge program is ready, it will
be fully implemented.

31
Alongside the refinement process, the capstone paper will be provided to the Mayor of
Santa Rosa who has stated she is very interested in supporting the program and will be providing
the information to the Sheriff who oversees the jail. Through the support of elected officials, the
hope is that more resources will be identified to enhance the bridge program. The bridge program
will also be presented to the National Association of Social Workers in August 2024 in hopes
that other social workers might be inspired and work toward developing bridges in communities
across the United States. This problem is not unique to just Sonoma County. Mass incarceration
is indeed a critical issue facing many counties in the United States. Overcrowded jails and the
high cost of incarceration have long been recognized as unsustainable and counterproductive,
especially for individuals with behavioral health (BH) needs. Establishing bridges to community
BH treatment is crucial for addressing this problem effectively.

32
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Appendix A

38

39
Appendix B
Logic Model for Capstone Project
Name: Heather Dunn
Date: 6/21/24
Problem: Inmates in Sonoma County jail with mild to moderate level of behavioral health needs do not have treatment programs to
help them stabilize once they are released back into the community.
Proposed Solution: Build a bridge to link inmates with mild to moderate level of BH need to Santa Rosa Kaiser Permanente’s BH
department before they are released from jail.
Target Population: Inmates with mild to moderate level of BH needs in the Sonoma County jail.
Assumptions Resources Activities Outcomes Impact
Why does your Capstone
Project need to exist?
What resources are needed to
pilot, implement, and assess
the effectiveness of the
project?
What activities will ensure
that the project’s goals are
met?
What changes are expected?
How will end users benefit?
How will you know if the
project has had a positive
impact? What changes in
policies, practices, and/or
processes might occur?
Identification of Kaiser
Medi-cal members in
the jail.
Discharge planners initial
meeting with inmates
that have a BH IBC code.
Adding a question
regarding insurance
type to the existing
initial discharge
planning meeting to
identify insurance and
dx.
Identification and
starting collaboration
upon booking into the
jail system. Increase
access to tx in the
community.
Every Kaiser member
in the jail with mild to
moderate level
behavioral health
need will be provided
the option to have
linkage to community
BH tx with Kaiser.
SUD and/or MH dx MH professional in the
jail will assessment
inmate for MH needs
and assign them an IBC
code.
Jail MH professional
continues to conduct
assessments as is the
current workflow.
Early identification of tx
needs
Discharge planner will
start to track release
date in ensure
adequate time to
coordinate release
date and linkage to
Kaiser.

40
SUD and MH tx in the
jail
Tx program in the jail Work with jail program
to ensure tx is started in
jail.
Early engagement in
treatment.
Starting the process of
providing any BH tx in
the jail can lead to
them wanting to
participate in
community tx.
Collaboration
between jail, Kaiser
and outside agencies
Continued collaboration
meetings.
Established
coordination of care
meetings.
Starting discharge
planning early into
incarceration with
collaborating
stakeholders so that a
bridge is created to
transition inmates to KP
BH tx.
Ensure that the screen
process with Kaiser is
completed before
inmate is released.
Linkage to continued
treatment before
release from the jail
Communication with jail
discharge staff and
Kaiser
Direct workflow for
referral from the jail to
KP Santa Rosa and
appointments
established before
release
See above Ensure that there is an
initial appointment
with Kaiser before the
inmate is released and
the inmate has all the
information to
successfully attend
initial appointment
Engagement in
community treatment
Follow up with inmates
after being released
Kaiser will follow up
with released inmates.
Continued treatment
that was started in jail
to help continue to
engage in recovery.
Continued treatment
in the community to
help stabilize BH sx
and needs and linkage
to resources to meet
social determinant
which can result in
decreased
incarceration leading

41
to the promotion of
smart decarceration.

42
Appendix C
IBC code Description
IBC Z Currently taking psych medication and have been stable for an extended period of time. Not having
any symptoms of Mental Health diagnosis.
IBC A Stable psychiatric inmate who: Mix well, medication compliant, good hygiene.
IBC C Obvious psychiatric symptoms, may be violent, may not be medication compliant, needs staff’s
directions in order to maintain good hygiene.
IBC D Obvious psychiatric symptoms, moderate risk for violence, most often refuse psych medications,
poor hygiene.
IBC E Obvious psychiatric symptoms, high potential for violence, most often refuses psychiatric
medications, poor hygiene

Abstract (if available)

Abstract Conventional light imaging in living tissues is limited to depths under 100um by the significant tissue scattering. Consequently, few commercial imaging devices can image tissue lesions beneath the surface, or measure their invasion depth, critical in dermatology. We present 3D-Multisite Diffused Optical Imaging (3D-mDOI) a novel approach that combines photon migration techniques from diffuse optical tomography, with automated controls and image analysis techniques for estimating lesion's depth via its optical coefficients. 3D-mDOl is a non-invasive, low-cost, fast and contact-free instrument capable of estimating subcutaneous tissue structures volumes through multisite-acquisition of reemitted light diffusion on the sample surface. It offers rapid estimation of Breslow depth, essential for staging melanoma.
Building upon 3D-mDOI, we designed an improved machine learning solution called multiplexed Diffused Optical Imaging Network (mDOI-Net) to estimate the depth of tissue lesions. mDOI-Net has an interpretable structure and provides depth information on tissue lesion depth in diverse circumstances. Its training is performed with customized synthetic dermatology datasets that we generate from publicly available datasets, ensuring data diversity and adaptability. The network reconstructs the 3D optical properties of the tissue from 2D diffuse images by introducing physical modeling of steady state diffuse optical imaging to the network. Our solution is posed to be more flexible, interpretable and predictable than current end-to-end, black-box neural network benchmarks.

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Asset Metadata

Creator Dunn, Heather (author)

Core Title A bridge program from jail to community behavioral health treatment

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2024-08

Publication Date 08/15/2024

Defense Date 07/31/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag 3D reconstruction,diffuse optical imaging,low-cost,non-contact,structured illumination

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Smith-Maddox, Renee (committee chair), Nielsen-Jones, Shelly (committee member), Rank, Michael (committee member)

Creator Email heatherdunnlcsw@gmail.com,lmurata@usc.edu

Unique identifier UC1139991YS

Identifier etd-DunnHeathe-13400.pdf (filename)

Legacy Identifier etd-DunnHeathe-13400

Document Type Capstone project

Format theses (aat)

Rights Dunn, Heather

Internet Media Type application/pdf

Type texts

Source 20240819-usctheses-batch-1199 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu