Seventeen percent of people currently in jails and prisons are estimated to have a serious mental illness (1). On release, the lack of treatment and income, inability to work, and few options for housing mean that many individuals quickly become homeless and recidivism is likely. A key to breaking this cycle may be linking offenders to the Social Security Administration’s (SSA’s) disability programs and to Medicaid before their release from jail or prison (2–4).
Providing transition services to people with mental illness within a jail or prison setting is difficult for several reasons: the rapid population turnover in jails, the distance between facilities and home communities for people in prisons, the comprehensive array of services needed to address multiple needs, and the perception that offenders with mental illness are not responsive to services. Nevertheless, without addressing transition and reintegration while offenders are incarcerated, positive outcomes are far less likely on their release. SSA’s disability programs, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI), can provide cash and other benefits to persons with mental illness and other disabling conditions who are being released from jails and prisons. The SSI/SSDI Outreach, Access and Recovery program (SOAR), a project of the Substance Abuse and Mental Health Services Administration, is a nationwide technical assistance program that helps people who are homeless or at risk of homelessness to access SSA disability benefits (5).
Many states and communities that have worked to ensure access to benefits upon release have focused almost exclusively on Medicaid. Only four states (Oregon, Illinois, New York, and Florida) provide for Medicaid to be suspended upon incarceration rather than terminated, and few states or communities have developed procedures to process new Medicaid applications before release. Although access to Medicaid is critically important, focusing on Medicaid alone often means that basic needs for income support and housing are ignored.
The SSI/SSDI application process is complicated and difficult to navigate. The SOAR approach is a collaborative effort by corrections and behavioral health systems and the SSA aimed at addressing inmates’ need for assistance to apply for these benefits. SOAR-trained staff learn how to prepare comprehensive, accurate SSI/SSDI applications that are more likely to be quickly approved. On average, staff who receive SOAR training achieve a first-time application approval rate of 71%, compared with a rate of 29% for persons applying without assistance (6).
In 2000, the Eleventh Judicial Circuit Criminal Mental Health Project (CMHP) was established in Miami-Dade County, Florida, to divert individuals with serious mental illnesses from the criminal justice system and into community-based treatment and support services. Staff trained in the SOAR approach screen all CMHP participants for SSI/SSDI eligibility. From 2008 through 2013, 91% of 288 individuals were approved for SSI/SSDI benefits in an average of 34 days. (In 2012, the national average was 98 days.) On release from jail, CMHP participants are linked with community providers who are made aware that SSI approval means access to Medicaid. This reduces the stigma of mental illness and involvement with the criminal justice system, making participants more attractive “paying customers.” An agreement between Miami-Dade County and SSA also reimburses the county (from participants’ retroactive benefit payment) for housing assistance provided between SSI/SSDI application and approval. The number of arrests two years before and two years after receipt of benefits and housing was reduced by 70% (57 versus 17 arrests).
Mercer and Bergen County Correctional Centers
In 2011, with SOAR training and technical assistance, two counties in New Jersey piloted the use of SOAR to increase access to SSI/SSDI for persons with disabilities soon to be released from jail. In each county, a collaborative working group with representatives from the correctional center, a community behavioral health agency, SSA, and the state Disability Determination Service met monthly to develop, implement, and monitor a process for screening and applying for SSI/SSDI for persons in jail or recently released. Applications were assisted by community behavioral health agency staff who were provided access to inmates as well as jail medical records. After one year, 89 inmates were screened in Mercer County, and 35 (39%) were deemed potentially eligible for SSI/SSDI. In Bergen County, 69 were screened, and 39 (57%) were potentially eligible. In Mercer County, 12 of 16 (75%) SSI/SSDI applications filed were approved on initial application; two of those initially denied were reversed at the reconsideration level without the need to go before a judge. In Bergen County, two of three former inmates assisted were approved for SSI/SSDI.
In June 2009, the Georgia Department of Behavioral Health and Developmental Disabilities began a SOAR pilot project at the Fulton County Jail. Staff were issued jail identification cards that allowed access to potential applicants. Staff received referrals from social workers in the Office of the Public Defender, interviewed potential applicants at the jail, completed SSI/SSDI applications, and hand delivered them to SSA. Of 23 applications submitted, 16 (70%) were approved (average=114 days). Using outcome data from the Fulton County Jail, the Georgia Department of Corrections provided SOAR training to 33 correctional officers, who were subsequently assigned by the department to work on SSI/SSDI applications in the state’s prisons.
“Sing Sing” Correctional Facility
The Center for Urban and Community Services was funded by the New York State Office of Mental Health with a PATH grant (Projects for Assistance in Transition from Homelessness) to assist with SSI/SSDI applications for participants in a 90-day reentry program for persons with mental illness released from New York State prisons. With SOAR training, the program at Sing Sing Correctional Facility achieved an 87% approval rate for 183 initial applications, two-thirds of which were approved before or within one month of release.
Oklahoma Department of Corrections
The Oklahoma Department of Corrections and the Oklahoma Department of Mental Health and Substance Abuse Services collaborated to initiate submission of SSI/SSDI applications using SOAR-trained staff. Approval rates for initial applications are about 90%. For those approved for SSI/SSDI, returns to prison within three years are 41% lower than for a comparison group.
Michigan Department of Corrections
In 2007, the Michigan Department of Corrections (MDOC) began planning a SOAR pilot in the region where most prisoners with mental illnesses are housed. A subcommittee of the SOAR State Planning Group was formed and continues to meet monthly. The subcommittee developed a process to address issues specific to MDOC, such as release before a decision is received from SSA, the amount of time before release that an application could be started, and collaboration with local SSA offices. Since 2007, MDOC has received 72 decisions on SSI/SSDI applications, in an average of 105 days and with a 60% approval rate. Seventeen percent of persons whose applications were denied were reincarcerated in the year after release, compared with only 2% of those with approved applications.
Park Center’s facility in-reach program
Park Center is a community mental health center in Nashville. In July 2010, staff began assisting with SSI/SSDI applications for people with mental illness in the Jefferson County Jail and several facilities administered by the Tennessee Department of Corrections. By November 2012, 100% of 44 applications were approved in an average of 41 days. In most cases, Park Center’s staff assisted with SSI/SSDI applications in the facilities before release. On release, a Park Center staff member accompanies the individual to the local SSA office where his or her release status is verified and SSI/SSDI benefits are initiated. [Additional details about these programs are available in an online data supplement to this column.]
For five years, we have been providing SOAR technical assistance to eight of the nine jail or prison systems reviewed here. Below we describe several best practices. These are in addition to the critical components required by the SOAR model for assisting with SSI/SSDI applications (7).
Identify stakeholders with whom to collaborate.
Jail-related stakeholders include specialized court or diversion judges, social workers in the public defenders’ office, chief jailers, jail mental health clinicians, county or city commissioners, local reentry advocacy leaders, and community SOAR providers. Prison-related stakeholders include the state department of corrections, commissioner, state director of reintegration and reentry services, director of medical or mental health services for the department of corrections, state mental health agency administrator, community reentry project directors, parole officers, and community SOAR providers. Including supported housing programs for persons with mental illness is key to ensuring continuity of care and best overall outcomes after release. Fortunately, these are the same collaborations needed for successful postrelease transitions of offenders with mental illness. Thus access to SSI/SSDI can become a concrete foundation on which to build the overall reentry process.
Establish prerelease agreements with SSA.
Prerelease agreements can allow applications to be accepted up to 120 days before the expected release date. SSA can also establish a contact person to work with and accept paper applications and schedule phone interviews when necessary.
Work with local SOAR providers to establish continuity of care.
Given the unpredictability of release dates, it is important to engage a community-based behavioral health provider either to begin the SSI/SSDI application process while the inmate is still in the facility or to assume responsibility for the individual’s transition and SSI/SSDI application on release.
Collaborate within the jail or prison system.
Identifying persons in the jail or prison who may be eligible for SSI/SSDI will require the collaboration between the jail or prison corrections staff and medical staff. When a person is identified, assistance with SSI/SSDI can be done by staff in the jail or prison with a hand-off occurring on release, or the person can be assisted by community providers who come into the facility for this purpose. Frequently, correctional staff, medical or psychiatric staff, and medical records are administered separately, and collaborations must be established within the facility as well as with systems outside it.
Starting an SSI/SSDI initiative as part of reentry requires a steering committee that meets regularly with a strong and effective coordinator. It is essential that the steering committee include someone who has authority in the jail or prison system and someone with a clinical background who can ensure that the clinical aspects of implementation are accomplished.
Successful initiatives commit resources for staffing to coordinate the overall effort and to assist with SSI/SSDI applications. In our experience, it is very difficult for current jail staff to assist with SSI/SSDI applications because of their competing demands, staffing levels, skill levels of the staff involved, and rapid turnover of the jail population. In the programs where we have worked, few or no applications would be completed for persons leaving jails without the assistance of community providers. Jail staff time may be best reserved for identifying individuals who may need assistance and referring them to community providers, facilitating community provider access to inmates before release, and assisting with access to jail medical records.
Developing and implementing an initiative to access SSI/SSDI as part of reentry require a commitment of at least a year to see any results and at least two years to achieve a fully functioning program. During startup and early implementation, competing priorities can derail the best intentions. We have seen commitment wane as new administrations took office and the department of corrections commissioner changed. We have seen staff struggle without success to find the time to assist with applications. We have seen many facilities willing to conduct training but unwilling or unable to follow through on other key components.
Training for staff in jails and prisons should include those who will identify and refer inmates to the program and who will assist with applications as well as medical records staff and physicians and psychologists. Specific training for each group is needed. However, without the elements described above in place, training is of limited value.
The outcomes of SSI/SSDI application assistance are relatively few and easy to track (number of application decisions received, percentage approved, number of days to decision, and clinical outcomes, such as access to housing, rearrest, and reincarceration). A free Web-based application outcome tracking system is available at https://soartrack.prainc.com.
People with mental illness face extraordinary barriers to successful community reentry from jails and prisons. The SOAR approach has been implemented in 50 states, and there is programmatic evidence that it is transferable to correctional settings. The combination of access to SSI/SSDI and Medicaid and subsequent access to housing is commonly cited by the programs described here as responsible for the reduction in rearrests and reincarcerations. The positive outcomes related to reincarceration produced by SOAR pilot projects in jails and prisons should provide impetus for more correctional facilities to consider this approach as a foundation for building successful reentry programs.