University of Southern California Dissertations and Theses

A bridge program from jail to community behavioral health treatment

A bridge program from jail to community behavioral health treatment [summary]

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A bridge program from jail to community behavioral health treatment [summary]

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Content Jail to Community Behavioral Health Treatment
Capstone Project Executive Summary
Heather Dunn
University of Southern California
Suzanne Dworak-Peck School of Social Work
DSW Program
Professor Renee Smith-Maddox
June 21, 2024

The United States has the highest incarceration rate globally, with mass incarceration
rising 45 years ago and persisting. Currently, 1.5 million people are in prisons and 728,000 in
jails (Fong, et al., 2018). The U.S. can no longer support these rates and needs radical changes to
promote smart decarceration, one of the 12 Grand Challenges for Social Work and Society.
Incarceration rates, including for drug offenses, have increased over the past two decades, with
two drug-related arrests every minute (Aspenridge Recovery, 2021). Inadequate behavioral
health treatment before and after incarceration contributes significantly to recidivism (Wakeman
& Rich, 2015). High costs are associated with incarceration; for example, Alameda County
spends nearly $4 billion annually on jail operations and mental health care (VERA, 2015). Only
a small percentage of inmates receive necessary treatment during incarceration (Gerber & Cho,
2023). Post-release, many struggle to access behavioral health services, exacerbating their
conditions (Grady, 2023). Effective interventions and continuity of care are crucial to reducing
re-incarceration (Comartin et al., 2022).
Access to mental health and substance use disorder (SUD) treatment is fragmented and
underfunded, especially for socio-economically disadvantaged individuals (Saloner & Cook,
2013). The lack of integration between healthcare and judicial systems further exacerbates the
problem (Ramezani, et al., 2022). For instance, in Sonoma County Jail, 45% of inmates have
behavioral health conditions, but many are released without adequate post-incarceration support
(Civil Grand Jury, 2021). The Cal-AIM initiative in California aims to provide Medi-Cal
services to inmates during and after incarceration, addressing healthcare access issues (CHCF,
2021). Interviews with stakeholders revealed systemic barriers, including broken care systems
and inadequate discharge planning, leading to high recidivism rates (Interviews, 2023). Effective
discharge planning should link inmates to community resources and support their reintegration

(Ramazani, et al., 2022). Current programs like Wellpath in Sonoma County offer SUD and
mental health treatment but face criticism for their effectiveness and lack of collaboration (SF
Chronicle, 2023). The Bridge Program aims to address these gaps by providing continuous
behavioral health treatment for inmates with mild to moderate needs, starting in jail and
extending post-release.
This bridge program focuses on smart decarceration concentrating on the mild to
moderate level of behavioral health needs of the jail inmate population. Sonoma county was the
county researched and focused on by the design team. This county currently houses 750 inmates
everyday with 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 (Civil Grand Jury,
2021). The 40% being provided with discharge planning have a severe level of behavioral health
needs and programs designed post release in Sonoma County focus on the severe level of BH
need inmates, leaving the mild to moderate level of BH need inmates without any treatment or
resources post release. Therefore, after through research the huge gap in treatment was identified
and a bridge program from the jail to Kaiser Permanente Santa Rosa was developed to help
inmates stabilize post-release leading to decrease in incarceration rates.
The Sonoma County jail operates independently, focusing on booking, housing, and
releasing inmates. Although its mission includes releasing inmates in better medical and
psychological condition, the jail and community health services function separately, leading to
inadequate treatment and high recidivism rates (Civil Grand Jury, 2021). Addressing social
determinants of health, such as socioeconomic status, healthcare access, and housing stability, is

crucial for improving behavioral health and reducing criminal behavior (Delcher et al., 2022;
Ramezani et al., 2022). A programmatic shift is needed to link community resources with the jail
system, treating behavioral health as part of one integrated system. A pilot program was
developed using the design thinking process, incorporating feedback from various stakeholders,
including inmates, jail staff, and community leaders. The program aims to bridge the gap
between jail and community treatment services, focusing on continuity of care (Ramezani,
2022).
The prototype for the bridge program was refined through collaboration with key players
and is currently being tested with a small pilot group of inmates. Challenges include
understaffing in the jail system, but ongoing feedback will help improve the program. The design
process emphasized existing successful community practices and user-centered design,
integrating lived experiences into the program development. The goal is to create a coordinated
system to support inmates' behavioral health needs post-release, utilizing existing resources and
fostering cross-agency partnerships.
The proposed solution addresses the need for comprehensive discharge planning from
jail, including meeting inmates’ basic and behavioral health needs. A cohesive and collaborative
process involving jail, county, and community systems is essential. Sonoma County currently
has programs for inmates with moderate to severe needs but lacks programs for those with mild
to moderate behavioral health issues, contributing to recidivism. The solution involves utilizing
the Cal AIMs initiative, in collaboration with Wellpath, Sonoma County, and Kaiser Permanente,
to provide services for inmates with mild to moderate behavioral health issues, particularly those
with Medi-Cal or Kaiser Permanente insurance. Upon initial booking, Wellpath Mental Health

Professionals will assess inmates and assign IBC codes based on their symptoms. Inmates
identified as Kaiser Permanente members with mild to moderate symptoms (IBC codes C, A, or
Z) will be added to a monitoring list. Discharge planners will then schedule virtual meetings with
KPSRO triage clinicians for screenings before release. Follow-up appointments and treatment
plans will be arranged, including mental health services and other necessary supports like
housing and employment.
The program leverages existing resources and services, adapting them for a collaborative
approach to support inmates' re-entry into the community. By building on existing programs and
fostering collaboration among agencies, this program aims to provide comprehensive support for
inmates with mild to moderate behavioral health issues, a currently underserved population.
There is a clear need to create an infrastructure to facilitate communication and collaboration
among agencies, ensuring inmates receive the necessary treatment and support.
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 inmates incarceration cycle, and
e) decrease the recidivism rates.
The goal was to address the unmet needs of inmates with mild to moderate behavioral
health issues, as Sonoma County already provides services for severe cases. KPSRO, which
serves mild to moderate behavioral health needs, had not been utilized for justice-involved
members. The bridge program aims to connect these inmates to community-based behavioral

health treatment, increasing their engagement from minimal to comprehensive wrap-around
services. By providing coordinated, comprehensive services, the program seeks to improve
treatment outcomes and reduce recidivism rates for this population (Saloner & Cook, 2013,
Bowen & Walton, 2015). Improved treatment outcomes will enhance inmates' lives, help them
break the cycle of incarceration, and decrease the use of crisis services such as emergency rooms
(Martin, et.al., 2019; Easter, et.al., 2023).
Once the prototype and workflows are developed, the committee will present and train
the implementing agencies and personnel. The plan starts with a pilot program, closely
monitoring and adjusting workflows to address any gaps. Currently, one inmate, a Kaiser
member with mild to moderate behavioral health needs, is identified for the program. The design
team monitors her release date to implement the bridge process, providing updates, feedback,
and identifying gaps. Key stakeholders include the jail discharge planner, jail mental health
director, KPSRO managers and clinicians, and the KP Mental Health director. Community
stakeholders include agencies providing services for social determinants. Collaboration between
KPSRO and community stakeholders needs formal development to ensure inmates utilize
community resources. The current informal process relies on individual case managers. Formal
collaboration with structured meetings will be the next focus once the initial jail-to-KPSRO
bridge is successfully implemented.

References:
Aspenridge Recovery (2021). Drug Incarceration Statistics. Aspenridge Recovery. Drug
Incarceration Statistics | Relapse After Jail? | AspenRidge (aspenridgerecoverycenters.com)
Bowen, E. & Walton, Q. (2015) Disparities and the Social Determinants of Mental Health and
Addictions: Opportunities for a Multifaceted Social Work Response. Grand challenges
for society: Evidence-based social work practice (pp. 64-70)
Civil Grand Jury (2021). COVID-19 Mitigation at the County Jail And Its Unexpected
Consequences. Civil Grand Jury. files (ca.gov)
CHCF. (2023) CalAIM Explained: A five-Year Plan to Transform Medi-Cal. California Health
Care Foundation. www.chcf.org/publication/calam-explained-five-year-plan-transformmedi-cal/#what-is-calaim
Comartin, E., Burgess-Proctor, A., Hicks, M., Putans, L., and Kubiak, S. (2022). A Statewide
Evaluation of Jail-Based Mental Health Interventions. Psychology, Public Policy, and
Law. Vol. 28. No, 3, 433-445 (2022)
Delcher, C., Harris, D., Anthony, N, Stoops, W., Thompson, K., & Quesinberry, D. (2022)
Substance use disorders and social determinants of health from electronic medical
records obtained during Kentucky's “triple wave”. Pharmacology, Biochemistry and
Behavior. https://doi.org/10.1016/j.pbb.2022.173495
Easter, M., Schramm-Sapyta, N., Tackett, M., Larsen, I., Tang, B., Ralph, M., & Huynh, L.
(2023) Reliance on Community Emergency Departments by People ever Detained in Jail:
Retrospective Cross-Sectional Study. Journal of Correctional Health Care. Vol. 29, No.4
Fong, R., Lubben, J., & Barth, R. (2018) Grand Challenges for Social Work and Society. Grand
Challenges for Social Work. Oxford University Press.
Gerber, J. and Cho A. (2020). Mental health issues experience by jail inmates in Texas: An
overview of diagnostic problems. Nowa Kodyfikacja Prawa Karnego. 53, 2019
Grady, M., Tripodi, S., Herod, L., and Rudzinski, M. (2023). Behavioral Health Interventions for
Incarcerated Adults With Histories of Trauma: A Scoping Review. Research on Social
Work Practices. Vol. 34 (4) 415-432, 2024.
Martin, R., Gresko, S., Brinkley-Rubinstein, L., Stein, L., & Clarke, J. (2019) Post-release
treatment uptake among participants of the Rhode Island Department of Corrections
comprehensive medication assisted treatment program. Preventive Medicine.
https://doi.org/10.1016/j.ypmed.2019.105766
Ramezani, N., Breno, A., Mackey, B., Viglione, J., Cuellar, A., Johnson, J., & Taxman, F. (2022)
The relationship between community public health, behavioral health service
accessibility, and mass incarceration. BMC Health Services Research.
https://doi.org/10.1186/s12913-022-08306-6

Saloner, B. & Cook, B. (2013) Blacks and Hispanics are Less Likely Than Whites To Complete
Addiction Treatment, Largely Due To Socioeconomic Factors. Health Affairs, January
2013 32:1
San Francisco Chronicle. (2023) Its patients are ‘literally a captive market.’ Is this California
health giant failing them?. San Francisco Chronicle. California health care giant Wellpath
fails patients, critics say (sfchronicle.com)
Wakeman, S. & Rich, J. (2015). Addiction Treatment Within U.S. Correctional Facilities:
Bridging the Gap Between Current Practice and Evidence-Based Care. Journal of
Addictive Disease. Addiction Treatment Within U.S. Correctional Facilities: Bridging the
Gap Between Current Practice and Evidence-Based Care: Journal of Addictive Diseases:
Vol 34, No 2-3 (tandfonline.com)
VERA (2015). The Price of Jails: Measuring the Taxpayer Cost of Local Incarceration. VERA
Institute of Justice.

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 [summary]

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 UC1139991YT

Identifier etd-DunnHeathe-13400-summary.pdf (filename)

Legacy Identifier etd-DunnHeathe-13400-summary

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)

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