Module 4: Coordinating and Integrating Systems

1. Ensuring Continuity of Care

The ability of youth to make use of the gains they have made while in a secure or residential setting is dependent on the development and staging of a wraparound community transition plan. Simply making available medications, supports, and treatment services is not enough to ensure successful transitions from institutions to the community. Successful reentry for youth with mental health disorders requires mechanisms to ensure continuity of care.

This section provides information on ways to ensure continuity of care through the establishment of community-based linkages and development of pre-release plans that address all systems from which a youth requires support and monitoring. Decisions on specific aftercare or continuing care services to be provided take into account the risk youth place on the community and to themselves, as well as the youth's strengths and needs. Juvenile justice supervision of aftercare is particularly important during the first three months of community reentry when relapse is likely to occur. Effective communication from the juvenile justice system regarding correctional treatment will provide critical information to mental health and substance abuse treatment professionals. Coordinated case management links youth with appropriate resources, tracks their progress, and monitors their compliance with any conditions imposed by any of the systems. For additional information you may request the Young Offenders Background Paper by contacting the National Gains Center at 1-800-311-4246 or gains@prainc.com.