Transition planners' responsibilities include assessing offenders' needs and strengths and facilitating linkages to appropriate community-based services.  Given the special needs of this population, transition planners need to be aware of what services are available in the jurisdictions they serve and which community-based mental health and habilitation services are necessary for the care and treatment of people with mental illness.

While institutional release planning staff reach out to identify resources in the community, it is equally important to establish a working relationship between the offender and a community mental health provider prior to his or her release to ensure continuity of care.  As discussed above, encouraging and facilitating providers' access ("in reach") to the facility will foster community linkages and increase the likelihood that the offender will be engaged and served effectively upon his/her release from the institution.

The case management plan should include dates, times, and locations for follow-up appointments with community supervision agencies and for appointments with treatment providers.  Mental health case managers also can then be on hand to ensure that the releasee is engaged in the planned treatment and service programs and to monitor the initial delivery services.

Since such a large proportion of offenders with mental illness also have histories of substance abuse, it is likely that the community transition and case management plan will also include provision for substance abuse treatment (see Policy Statement 17: Receiving and Intake of Sentenced Inmates, for more on co-occurring disorder statistics in prisons; also see Policy Statement 37: Co-Occurring Disorders).  Substance abuse treatment services may be provided at one site as part of a comprehensive program for dually diagnosed offenders.  If substance abuse treatment is to be provided off site and/or by a separate agency, or if the releasee is to participate in 12-step or other community-based fellowship programs, the community-based case manager should also make arrangements for the offender to receive escort to initial meetings and appointments and ensure that engagement has occurred.  Twelve-step fellowship programs, such as Alcoholics Anonymous and Narcotics Anonymous, provide escort services as part of their regional World Fellowship Networks.  These organizations list local groups and fellowship networks in the white pages of regional phone books.

At a minimum, discharge planners can facilitate case conferences that include participating treatment and social service providers as well as the offender. When face-to-face case conference is not feasible (for instance, due to prohibitive distances between the institution and the home community), it may be conducted as a teleconference. A number of jurisdictions recognize the importance of case conferencing, and have taken steps to make sure that it occurs.