Recently, I conversed with a colleague who provides critical support and services to men and women who have been recently incarcerated. When I asked her about how she connects individuals to behavioral health services, she opened her filing cabinet and pulled out a stapled sheet of paper with a list of mental health providers. When attempting to link an individual to behavioral health or substance use disorder services, she would use this paper she compiled with often outdated information. It was the best tool she had available.
I was floored that there isn’t a better system in place at one of the most advanced service providers in my state to support linkage to critical services such as behavioral health and substance use disorder that are shown to reduce recidivism. Individuals with mental illness and substance use disorders are among those who experience the highest recidivism rates. Treatment and prevention programs are severely underfunded and unavailable, though they are proven tools that aid better health and recovery. Many individuals who cycle through the justice system have never had access to quality mental health care coordinated as a part of their whole health.
This conversation illustrates the glaring inadequacies in the way our health, justice, and social systems work together, particularly for those in underserved and marginalized communities. It also exposes the high burden placed on phenomenal clinicians like my colleague to navigate systems without the necessary tools and resources to support the health of populations.
If we begin to better coordinate all our systems of care; health care, behavioral and substance use, social services, and the justice system, we can have the impact of addressing disproportionately underserved populations while also reducing the burden on our systems. Let’s be clear; a disorganized system isn’t just inefficient; it often has a clinically significant negative impact. These impacts can include retraumatization, loss of trust of providers, and lack of confidence in an individual's own ability to manage their care.
What might our system be like, if instead of individuals having disconnected care between their providers, we were able to wrap around support for them by providing a community care record?
Here are some practical ways communities can work towards a more coordinated care system:
- Build longitudinal community care records
Community care records will allow organizations in a community to view an individual’s care history, current needs, and facilitate whole person care.
- Provide alerts when significant events occur
When an event occurs, whether it be an arrest or a hospitalization, organizations in the community who are providing care to the individual should be alerted and help the individual through their process. Likewise, the responders to that event should be able to access information and track down the individual’s care team.
- Share data between providers
Critical to providing positive health outcomes, shared data between providers allows for trauma-informed care and a better patient experience, which can help reduce readmissions.
- Create community-wide resource directory listings that are regularly updated
With a consistently up-to-date resource directory, providers can connect their clients to the best possible service that will match their needs.
As a mental health provider, I am in awe as I think about the resilient and powerful men I've seen recently reenter society and have somehow navigated those care systems. There’s a lot of work to be done to support our underserved communities and the clinicians who work tirelessly against the tide of systems that make their challenging work nearly impossible. Creating more equitable access to health and social care is necessary, possible, and cannot wait another day.
It’s important to stay up-to-date on important topics like these. We recommend subscribing to newsletters from companies such as The Vera Institute of Justice, SAMHSA’s Gains Center for Behavioral Health and Justice Transformation, and the Crisis and Recovery Enhancement newsletter, to name a few.