Behavioral Health Transition Plans

Treatment Coordination Case Managers

The Treatment Coordination Case Managers (TCCM) are staff within the Approved Treatment Provider (ATP) Client Choice Program in the Division of Adult Parole.  As part of the transition from the former TASC contract, the Division reallocated these positions to take on the important work of continuity of care between facility to community for releasing individuals needing treatment services. 

The goal of this unit is to ensure releasing individuals who have psychological (>P3), substance abuse (>SA3), or offense-specific (S5) treatment needs (>P3, >SA3, or SO5) are referred to a treatment provider for assessment/ intake within 14 days of their release to the community and post release at the parole officers request. The referrals include coordination with facility case managers to identify client choice in treatment agency, providers in the community, and the various Regional Accountability Entities (RAE’s) for those who are Medicaid eligible.  They also may include coordination with the Parole MH Clinicians either pre or post release for those HRHNDO or higher risk/ need individuals.  They are responsible for identifying and working with various providers in the community to expand and align our provider network with that of Medicaid, maintaining our Provider Handbook, and Provider Directory. If you are a provider that is in need of more consistent referrals and interested in joining this new and exciting transition, please contact the ATP Coordinator for more information. We strongly encourage providers that are dual billable to ensure continuity of care in cases where the parolee flow between billing sources or discharges their sentence and can no longer be funded by CDOC.

As we look to continue to expand the role of these positions, they will have access to treatment notes/ progress summaries/ ROI’s in eOMIS and will create referral packets with ROI’s for providers and RAE’s. They will also have PEAK Pro Access for existing parolees to check eligibility and benefit status.  They will become more involved in the referral process for residential treatment programs, both our traditional IRT/STIRT/RDDT and the new Medicaid wavier for residential treatment.  And last, but not least will be assisting with Medication Assisted Treatment (MAT) service coordination from facility to community and when needs are identified in the community.

In the short time this unit has been staffed, they have worked hard to meet the objectives of our Departments 2020/2021 WIG #2 Strategy: Increase (to 80%) the number of eligible inmates referred to post-release substance abuse services prior to release. As of February 1st, 2021 they have referred 72% annualized (June-December) and were at 85% for October, 96% for November, 85% for December, and 92% for January. Their work is directly contributing to the increase in overall engagement numbers for the Regional Accountability Entities (RAE’s) and releasing individuals access to care.

Regional Accountability Entities (RAE’s) map

Continuity of Care Referral and Treatment Coordination Framework

Contact a TCCM

Parole Mental Health Clinicians

The Department of Corrections Office of Clinical and Correctional Services provides the Parole Division with four Parole Mental Health Clinicians and one Supervisor. These clinicians are assigned to Parole offices throughout the state by geographic region, and are tasked with identifying specific, persistently mentally ill and dual diagnosed offenders pending release from prison to Parole supervision. The Parole Mental Health Clinicians work collaboratively with Facility Clinicians, Case Managers, Facility-based Community Parole Officers, and offenders to create transition plans and address the wide range of behavioral health needs for their assigned groups. They also work in conjunction with Community Mental Health Agencies and Parole approved treatment providers to help ensure that identified parolees receive appropriate and adequate services while on Parole. Additionally, Parole Mental Health Clinicians provide crisis intervention services, complete risk assessments, initiate mental health holds, and help ensure that offenders receive emergency psychiatric services if needed. These clinicians serve a small, targeted group of pending releases and active parolees, therefore, most offenders releasing to Parole and in need of treatment referrals and/or connection(s) will be assisted by other Parole staff known as Treatment Coordination Case Managers. 

Read more on transitioning to the community 

Laura Caile, Mental Health Supervisor, (303) 426-6198 Ext. 4117, Email: laura.caile@state.co.us

Kathy Sullivan, Mental Health Specialist, (719) 633-1469 Ext. 2352, Email: kathy.sullivan@state.co.us

Karen Reinersten, Mental Health Specialist, (970) 255-9126 Ext. 4157, Email: karen.reinersten@state.co.us

Carly Lembke, Mental Health Specialist, (303) 763-2420 Ext. 3028, Email: carly.lembke@state.co.us

Community Care Case Managers

Community Care Case Managers (CCCM) assist with social services benefit program navigation and access, pre-release transition planning and tracking, and assisting with long-term care enrollment. CCCMs are involved in community outreach to develop new partnerships to increase, improve, and/or refine service delivery to complex needs individuals. This team also participates in special projects as needed or assigned in a continual effort to improve service delivery. CCCM responsibilities include:

Long-Term Care Placement Assistance: Assist in identifying long-term care candidates either prior to release or under supervision by Parole; providing application support, locate and complete referrals to appropriate level care including home healthcare, assisted living, skilled nursing, group homes, and hospice; serve as liaison between DOC facility or community staff and care providers; work to facilitate sustainable placements by providing short term intensive case management to individuals placed and supporting care providers.

Community Outreach:  Attend community meetings and travel to network with outside resource and service providers, locate new resources across the state, identify ways to improve or refine service delivery to complex needs individuals, collaborate with other government agency partners, and share information specific to working with the justice involved. 

Social Services Benefit Program Access:  Maintain specialized eligibility knowledge for federal, state and local social services programs.  Increase access to programs for target population to include providing advocacy, acting as authorized representatives, completing required forms, navigating eligibility determinations, interpreting notices of decision, and maintaining communication with staff and the applicants throughout the process.  Sharing program knowledge by providing benefits education workshops to offenders, consulting with other staff on complex cases during multi-disciplinary meetings, and recommending policy or process changes to leverage benefits as a re-entry resource.

Pre-Release Transition Planning and Tracking:  Begin tracking upcoming releases with offenders having moderate to severe medical, mental health, or intellectual/developmental disability needs up to 180 days before they return to the community.  Recommend specialized resources in proximity to release area, identify care needs for chronic conditions; connect offenders with Medicaid care coordination, durable medical equipment, or other specialized services such as brain injury resources.  Act as a liaison when needed to increase collaboration between facility, headquarters, parole, clinical services, and re-entry staff.  Upon release meet with offenders to help them in identifying health related goals, developing an action plan to address barriers related to their personal health or impairments, and support the offender in accessing care. 

Contact a CCCM

Read more on transitioning to the community.