Specifications include, but are not limited to: • To clinically screen and evaluate the risk and needs of the chronically and persistently mentally ill (SPMI) or other high-risk individuals with mental health issues currently incarcerated individuals who are scheduled for release/re-entry to the community from the Rhode Island Department of Corrections. • To develop an individualized discharge plan for each person who meet the criteria for SPMI or other high-risk patients with mental illness that addresses the individual service which must include identification, referral, and coordination with community providers for mental health services. A written Re-entry plan will be developed, for all individuals referred to the discharge planner, to address the individual’s short and long term needs along with specific steps and activities they need to take to address them. • A Discharge Planner will provide a warm hand-off to the Case Manager (or similar position) who, when feasible, will be present at the time of release to assist the individual with the transition back into the community. The Case Manager will be provided with a copy of the Re-entry Plan developed by the Discharge Planner, to include program contact information and scheduled appointments in the community. • The Case Manager (or equivalent) will plan continued contact with the individual in the community for 90 days (or more if needed) through phone calls and home visits to continue supporting their transition and follow through of established goals. • Additional tasks may include: o Coordinate services for mental health and substance use treatment, job skill assessment and training, community behavioral-health counseling services, housing needs o Serve as client liaison between program and other support agencies o Provide resources that are both gender and time specific. Services for the awaiting trial population, which will be abbreviated, are to provide as comprehensive a referral plan as possible. o Develop a transportation plan for individuals who do not have their own transportation to appointments and other events under this program o Develop a plan for transitional housing when needed o Provide medication and/or prescriptions to patients on a short-term basis as needed
