Housing and Reentry
Frank Mazza
Due to the manifold needs of their residents, County Corrections is the intersection point of all publicly and privately funded systems of support. As a result of deinstitutionalization, individuals experiencing poverty face barriers in access to acute residential mental health and substance abuse residential care facilities. A significant portion of the population frequently using the County Correctional centers in this country are chronically homeless, live in areas with a high police presence, are addicted to substances, have mental illness, chronic health issues, and tend to bump up against frontline law enforcement while symptomatic and/or when high.
Interactions tend to be negative; law enforcement must act in the interest of public safety and remove the person from the community; however, because of the lack of clinical care options, the jail has become the de facto residential treatment provider. In urban areas our county correctional centers have become the most common treatment providers for people living below the poverty line facing addictions and mental health issues. Hudson County recognized this phenomenon more than a decade ago and has reinvented its jail as a hybrid health care, employment and training, and social services resource center that serves the specific needs of its community.
For the chronically ill, reentry, and homeless population, a uniform approach to health insurance assistance, housing assistance, public assistance, health care navigation, and case management is essential. The lack of a unified approach across systems, as well as the lack of recognition of needs that cross all these domains, is the reason for a lack of success in ameliorating the challenges of this target population.
HCDCR’s Reentry Program
Since 2008, Hudson County, New Jersey, has provided a multifaceted and robust reentry program inside the Hudson County Department of Corrections and Rehabilitation (HCDCR). Hudson County provides inmates access to the only New Jersey Division of Mental Health and Addictions (NJDMHAS) certified residential treatment program in a county facility in the state where inmates are provided access to all forms of Medication Assisted Treatment (MAT). The reentry program has a Federally Qualified Health Center (FQHC) operating inside the walls of the Correctional Center as well as an American Job Employment and Training Center that operates college, high school, trades, certificate, and pre occupational programs. The reentry program sends County Welfare Agency (CWA) employees into the jail on a daily basis to make sure benefits, cash, Medicaid, and food stamps are activated on the day of release.
Upon release, everyone enrolled in the Hudson County Reentry program is provided housing, access to a NJDMHAS certified outpatient clinic, a Joint Commission Accreditation for Health Care Organizations (JACHO) certified clinic that provides access to physical and mental health care, a certified Opioid Treatment Program provides continuation of MAT medications in the community, and case managers are assigned to help clients navigate the various systems of support in the community.
The Hudson County model defines specific client goals, removes barriers to coordination among providers, and ensures all systems work in tandem to provide appropriate levels of care and improve the quality of care for patients. The model developed in Hudson County is a public-private partnership. The County Reentry Program serves as the unifying entity that coordinates the public and private entities that work independently to provide services to the reentry population.
During the initial years of the Hudson County Reentry program it became apparent that great success could be achieved if clients enrolled in and completed educational/clinical programs in the jail, and then were immediately linked to services upon release. Furthermore, success in the community was predicated upon a supportive housing model of treatment. When clients were linked to safe and stable housing, reentry interventions demonstrated the highest level of efficacy. Clients were better able to engage with case management, prescribed clinical/educational, and employment-based programs if they were not worrying about where they would sleep that night.
Hudson County developed a strong supportive housing model that provides case management and counseling services tailored to meet the unique needs of each person enrolled in the program. Hudson County built its transitional model based on a continuum from the jail to the community, the foundation of the continuum was housing services combined with support across all domains.
The Warming Center
In 2013, the Hudson County jail, its Housing and Urban Development (HUD) office and its Reentry program collaborated to open a Warming Center with the capacity to serve more than 100 people per night to provide an accessible shelter for homeless individuals during the winter months. The target population was individuals with chronic mental health and addiction issues, who refused to use the County’s network of shelters or engage with the public assistance system and lacked access to shelter during the winter months. In order to promote utilization, the jail routinely sent two large buses and officers in plain clothes to homeless encampments in the County to offer transportation to the Warming Center. HUD funded a heated warehouse to house the population, and the reentry program provided access to food, benefits, and case management services.
Over its first year of operation, the Warming Center consistently served more than 100 homeless individuals each evening. There were anecdotal reports from all systems that everyone using the Warming Center was a frequent utilizer of the emergency rooms, shelter, and housing system. As a result, the county decided to collect information from each individual using the Warming Center and provide it to all the systems of support in order to understand the characteristics and needs of these frequent utilizers. When an individual entered the Warming Center, with their consent the county would input their information into the homeless information
system, including identifying information, clinical, and social determinants of health/health-related social needs information. This allowed the network of community housing and care providers to have future access to information about the client’s needs, creating a no wrong door system.
Frequent Utilizers
A preliminary data match was completed, which identified approximately 2,000 individuals who had both been incarcerated and had experienced homelessness in the last five years. The County worked together with the Corporation for Supportive Housing and the John Jay College of Criminal Justice to further analyze this data. Ultimately, the group created a definition of a frequent utilizer for Hudson County (i.e., a person who has been incarcerated four times in five years).
Once the list had been narrowed to these frequent utilizers of the jail who had experienced homelessness, the Department of Corrections did further analysis using the assessment data from the Correctional Offender Management Profiling for Alternative Sanctions (COMPAS) Risk Assessment tool. All individuals who were incarcerated in the jail are assessed using this tool, which takes a comprehensive look at the individual’s unique situation, needs, and the motivation behind the criminal behavior that resulted in incarceration. The tool provides an assessment score of high, medium of low for the individual’s risk for recidivism. Those scoring low on the COMPAS assessment were removed from the list, with the medium and high scoring cohort moving on.
The County engaged the New Jersey Department of Community Affairs (DCA) to secure 100 HUD permanent housing vouchers for the 100 most frequent users of the various systems of support and the jail. The jail dedicated one million dollars to hire two nonprofits, the Garden State Episcopal Community Development Corporation (GSECDC) and the Community Support Program of New Jersey (CSPNJ) to provide health care navigation, case management, transportation, and other services to those frequent users linked to permanent housing vouchers.
A list of the remaining frequent utilizers, those who had experienced homelessness and scored high or medium for their risk of recidivism, was passed on to the GSECDC and CSPNJ for outreach and engagement and potential connection to the DCA voucher program.
In 2015, 86 individuals were linked to DCA housing vouchers, which fell 14 people below the County’s goal of 100. Out of the 86 individuals linked to DCA housing vouchers, 81 were placed in housing, and five clients were lost to long term prison sentences.
As of October 2023, 74 percent or 60 out of the 81 individuals placed in long term housing, who were provided access to all Reentry Program services, case management, and health care navigation have successfully remained in housing. Prior to placing these 60 individuals into permanent housing and supportive programming, as a group they had used the jail 829 times and had served more than 47,000 total days in county corrections over their lifetimes. Narrowing down the data to only the previous years of the program, this group was in the jail 296 times and spent 13,000 days in the County Correctional Center.
After enrolling the group into the supportive housing program, 42 individuals or 69 percent, have never returned to any county correctional center. Nine individuals or 15 percent returned to jail only once since the start of the program. Seven individuals or 11 percent returned to jail twice, one person returned three times, and one person returned five times. However, none of the clients who returned to corrections committed a serious offense that would have caused them to be incarcerated for an extended period and lose their housing voucher. The most encouraging outcome is that the 13 most frequent users of the system never returned to corrections, and the most frequent user, who was in the correctional center 49 times in the previous five years, has not returned.
Data indicates that all the individuals in this group have chronic health problems, and prior to the supportive housing program, the group used the Emergency Room (ER) as their primary care provider and used the ER only when in crisis. This was an unnecessarily expensive way for both the hospitals in the County and the federally funded Medicaid system to furnish care to individuals with chronic disorders. Furthermore, the ER is an inefficient way to treat chronic illness, and this leads to unnecessary hospital admissions. All 60 clients were linked to the Reentry Program’s FQHC primary care provider, and through their case management program, they are routinely in contact with their primary care provider. This has driven down the cost of delivering health care and has increased the quality of care for the population.
Prior to the introduction of the supportive housing program, the Reentry Program was a reaction to crime and incarceration. The Hudson County Reentry program demonstrates that diversion is possible. Diversion can be achieved by repairing the fractured nature of our systems of support, and instituting collaboration across systems. When disparate systems communicate with each other, we can intervene at the various system entry points of our most vulnerable populations. From there, we can build early intervention services that can avert the potential for future criminal behavior and incarceration.