Tai M. Paquin, LADAC, MSW

BH2I grantees can support individuals reentering the community after incarceration. This article offers some strategies for care coordination, integrating cultural elements, and collaborating with court systems. One model I’ve been involved with is the Tribal Healing to Wellness Court, which is a good example of the potential of a culturally grounded and integrated approach that brings together judicial and health care partnerships.

As mentioned in the previous article by Dr. Middlebrook, AI/AN individuals have disproportionately high incarceration rates and frequently enter and reenter their communities with complex behavioral health needs. The period after release is a particularly vulnerable time when individuals may face increased risk of relapses, overdose, mental health crises, and housing instability. However, this transitional time presents a good opportunity to reconnect individuals with support networks, services, and cultural support. And BH2I programs are in a great position to support judicial programs through the following services.

  • Use of warm handoffs to behavioral health and primary care services.
  • Use of medication-assisted treatment (MAT) and substance use care.
  • Engage peer support, health education, and case management services.
  • Reconnect individuals to cultural and traditional healing practices.

How Can BH2I Support Reentry?

Using one or more of the following ideas will help with integrating the Indigenous individuals who are returning to the community.

Collaboration with Tribal Justice Systems

BH2I program staff can work alongside tribal justice programs, such as tribal/local/state probation/parole offices, jail/detention facilities, reentry teams, tribal courts, and/or tribal officials to develop supportive care plans for individuals transitioning from incarceration back into the community. BH2I teams can also offer mental health screening, referrals, and ongoing care.

Initiating Services Before Release

BH2I staff can engage individuals’ pre-release with the following activities.

  • Probation/Pretrial recommendations to court for BH or care coordination assessments.
  • Regular BH screenings as part of the intake process.
  • Cultural assessments during incarceration.
  • Support groups on several topics such as anger management, parenting, domestic violence, smoking cessation, etc.
  • Plan for treatment, housing, and social support.

Offer Holistic, Culture-Based Services

Healing involves more than physical clinical care. BH2I programs can work with cultural leaders, elders, and community members to offer services that reflect the values and traditions of each community. This might include talking circles, ceremonies, land-based healing, or language preservation, alongside evidence-based interventions to build trust and improve outcomes.

Continuity Through Care Coordination

BH2I program staff can build relationships with local jails, detention centers, and court personnel to ensure real-time communication and continuity of care. This may include developing MOA/MOUs, if needed. Regular use of shared care plans or regular team meetings to coordinate services will help the process and sustain momentum for helping these groups.

The Challenges and Solutions

Challenge #1: Siloed communication between justice and health systems.

Solution: Schedule case meetings or team huddles with individual departments or as an interdisciplinary team.

Challenge #2: Individuals’ drop-off in post-release care.

Solution: Assign peer support specialists or care coordinators to conduct check-ins after release.

Challenge #3: Cultural mistrust or resistance.

Solution: Include family, traditional healers, or peer supporters in care or education opportunities.

Challenge #4: Limited funding for post-release services.

Solution: Leverage cross-agency partnerships and explore grant opportunities together with justice partners.

Healing to Wellness as an Example

One program that demonstrates successful integration is the Tribal Healing to Wellness Court. These courts involve BH staff in interdisciplinary teams that can include tribal courts, probation, social services, prevention programs, CHWs and tribal/cultural liaisons, who participate in creating care plans that honor culturally specific practices like ceremony, talking circles, and elder mentorship.

In my own work with a Tribal Healing to Wellness Court, I witnessed how ceremony, language, clinical support and accountability worked together to help individuals reclaim their sense of identity and purpose; all in effort to create real change. Participants often experience a shift not just in behavior, but in belonging. One participant who had been disconnected from community and self for years said that the court gave them “a reason to try again.” That’s what integrated, healing-focused justice can do.

For court-involved individuals, care doesn’t stop at the jail door, it continues into clinics, ceremonies, and families. BH2I programs can be an essential partner in building coordinated systems of care that support wellness at every stage of the reentry process.

Whether you’re a clinician, care coordinator, court partner, or administrator, you have a role in creating culturally affirming, integrated pathways for healing and reentry. Programs like Tribal Healing to Wellness Courts provide a compelling example of how it can be done, and the approach can be adapted and expanded across many settings and tribal communities.

References

Tribal Law and Policy Institute. (2023). Healing to Wellness Court Resources. https://www.wellnesscourts.org