ABLE is currently the only person or program at either Warren or Washington county jails to help incarcerated folks plan for reentry or set up services or appointments. At Warren County jail Amanda is the only person in the jail allowed to contact anyone outside the jail on behalf of people incarcerated there.

  

Warren County jail (and Washington County jail before March 2020) allows ABLE to operate there, allowing Amanda to meet with people while they are incarcerated. However she is not an employee of the jail - she goes into the jail as an outside visitor or volunteer. She sets meetings with some of the jail staff when she wants to, but there are no regular meetings with jail staff or regulation, control, or oversight by the jail administrations. She runs the program herself as an employee of the Baywood Center, and her supervisor in her role at Baywood also supervises and supports ABLE.

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            Who does ABLE serve? The vast majority of ABLE clients are incarcerated in Warren County jail, but the program is also offered to people incarcerated in Washington County jail and anyone in the community with a history of incarceration. Unfortunately, Washington County jail has been mostly shut down to visitors during the COVID-19 pandemic, so ABLE has not been able to see many people there since March 2020.

  

• Amanda does not charge for ABLE services, and Baywood pays her salary. Baywood also doesn't require ABLE to focus on any specific population, like some grants or agencies might (some reentry programs can only work with, for example, people who are sentenced). So, she has the flexibility to offer case management services to this wide population! She's sometimes asked by clients at Baywood or other service providers about resources too - she always offers what help she can in the moment. 

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         What is case management? A model of healthcare where a professional helps a client make a plan to coordinate services to meet their needs. It involves assessing what they need, figuring out the best ways to meet those needs, and helping the person connect with, and follow through on, services.

 

            What does this look like at ABLE? The bulk of ABLE is Amanda's case management work with people who are incarcerated in Warren County jail to help them figure out what they might need or want when they're released from jail, to identify services or resources that will help them meet their needs, and to connect clients with those services and resources. If/when the person is released from jail Amanda can continue working with them, checking in on how they're doing, and providing case management, providing continuity of care!

  

• Assessment and Releases: She meets with new clients in-person to conduct a biopsychosocial assessment to understand their background, figure out what services a client might be interested in, and what might be helpful or a problem for them in the future. For example, if someone has Sex Offender status they are barred from a lot of housing options and government services. Or if their parent passed away, they may be eligible for different types of Survivor's Benefits. Really getting to know the client and their background is important for building a reentry plan that will work the best for that person and doesn't miss anything in their life that will affect their success. Then, she asks the person to sign some 'releases' to allow Amanda to talk to other agencies and people about the person.

  • Amanda's role is "HIPAA compliant", meaning she legally cannot share information about her clients with someone unless she has a Release of Information signed by the client to share information with that person or the agency they work for (under a federal law about privacy of health insurance: read more at HIPAAcompliance.org). That means, for example, to call a client's mom and tell her about the clients' plan, or to call a substance abuse clinic to set up an appointment, Amanda has to have a signed Release of Information stating that she can share information with that specific person or organization.

 

• Gathering info: Then, Amanda gathers information on the agencies and people that might be able to fulfill these needs, makes phone calls, sets up appointments, and gets applications ready.

   

• Meeting again: She'll meet with the client again to fill out applications or forms (like a Department of Social Services application for different government benefits), to discuss the options for agencies and resources and decide on the right one, discuss other needs the person has, and keep track of their case and release date. For the rest of the time before someone is released, she keeps checking on them, discussing the reentry plan and anything else happening with their case or anything else they're worried about with reentry.

   

• Follow-up in the community: After they're released, Amanda tries to provide a continuity of care by offering to meet with clients in the community after they're released. Before COVID-19, she would often set a meeting time and place with clients in the first few days after they're released to check in, see how they're doing, and see if there is anything else they need. 

  • Providing Continuity of Care: Clients have ABLE's contact information and can reach out anytime in the future if they want or need more help. If she doesn't hear from a client after they're released, Amanda will reach out if she has contact information to see how they're doing, if they made it to their appointments, and if they would like any more help or just to talk things out. She will also reach out to service providers the client is connected to (if she has a signed Release of Information to do so) to see if the client went to their appointments. 

  

• However, a lot of people do 'drop off the map' so to speak - they don't reach out once they're released, the contact information for them doesn't work or it's for a family member who hasn't heard from them either. This can be because the person is homeless and bouncing around shelters and DSS-provided hotel rooms, because they returned to crime or drug use, or any other reason. Amanda reaches out as much as she can, and hopes the person will call if they want help again.

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                 How do people connect with ABLE to get services? Usually people get involved with ABLE through referrals. Referrals for new clients can come from:

  

• Warren or Washington County Jail Social Workers - if any of the jail social workers hear an inmate might need services set up, or are lacking basic needs (ie they're homeless, or need transportation), they give the person an ABLE referral form

• Warren County Department of Social Services - if someone comes into DSS with a history of incarceration or is recently released, and needs services, they may refer them to ABLE

• Warren County Probation - a probation officer may refer a client

• Local Service Providers - another counselor at Baywood, a case manager at another agency, or any other local service provider may refer a client with a history of incarceration, or a client who is going to be incarcerated in Warren or Washington jails

• Self-Referrals - a person in the community or in the jail may hear about the program and either ask the COs or the jail social workers for ABLE services, or if they're in the community call ABLE directly

  • News of ABLE and what they do spreads in the jails through word-of-mouth among inmates, by the social workers, and sometimes even Corrections Officers!

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             Weekly Recovery Group: Amanda also runs a recovery group in Warren County jail as part of ABLE. The group is an hour-long once a week, and there's one group for women and one for men. The group is open to anyone in the jail to request to join, but they must be approved by the jail for security reasons. The jail requires people receiving MAT to attend every week to maintain their MAT.

  

• There's a wide range of topics, but Amanda maintains a focus on how to work on recovery once released back to the community, with discussions of coping skills and building a healthy life.

• The men's group brings together inmates from different pods into the visiting room. Amanda sits at the front of the room at one end of the visiting room table, and the men are spread out around the room distanced from Amanda. At least one CO is required in the room for every 5 inmates in the group, standing around the room watching the men.

• The women's group takes place in the group room inside the pod. There are no COs in the room, but the door that leads to the pod has a window facing the COs stationed in the pod. Amanda sits at one big table with the women.