The Connections Program: a NSW integrated approach to care and engagement for prisoners with a history of illicit drug use

The Connections Program: a NSW integrated approach to care and engagement for prisoners with a history of illicit drug use

HIV Australia | Vol. 14 No. 1 | March 2016

By Stephen Ward

Justice Health and Forensic Mental Health Network (JH&FMHN) is responsible for the provision of health services for people in contact with the forensic mental health and criminal systems throughout New South Wales.


Justice Health and Forensic Mental Health Network (JH&FMHN) is responsible for the provision of health services for people in contact with the forensic mental health and criminal systems throughout New South Wales.

The Connections program is managed by JH&FMHN. It takes an assertive approach to release planning and post-release follow-up, assisting illicit drug users with the transition from prison back to the community.

Most participants in the program have extensive criminal histories with multiple incarcerations. They also tend to have complex medical and social situations which, together with drug dependence, contribute to a history of poor engagement with community-based services. This often results in multiple hospital presentations and higher levels of mortality.

Prior to the establishment of Connections in September 2007, patients with illicit drug problems leaving custody were generally provided with appointments to attend community health services with limited practical assistance available.

NSW Health funding has resulted in Connections successfully providing coordinated state-wide comprehensive pre- and post-release assistance to about 800 adults leaving custody each year.

Between September 2007 and December 2015, more than 6,600 participants have been assisted by Connections, of whom 18% (1,179) were female and 28% (1,873) identified as Aboriginal and/or Torres Strait Islander. During the same period, 3.5% (229) had ongoing blood borne virus treatment arranged post release.

Connections has developed strong working relationships and pathways with Population Health in the correctional and community environments; this ensures that patients receiving, or who require specialist treatment services for a blood borne virus have access to treatment as required.

This can be as simple as assisting with the referral process, or transporting and attending an appointment with a participant and then ensuring the participant has adequate storage facilities for medications and accommodation in place. Connections staff are based throughout NSW so regardless of a patient’s geographic location, Connections can provide appropriate support to facilitate access to treatment as required.

Program pathway

The Connections program operates within the JH&FMHN Drug and Alcohol Directorate, and the participation of adult patients in custody is voluntary. It is one of a small number of JH&FMHN programs that operate within both the correctional and the community environments. The program coordinates release planning and links patients with relevant health and welfare service providers post-release.

Connections is available at all Adult Correctional Centers throughout NSW and there is no exclusion criteria based on location or criminal history. Referrals come from a variety of sources including health staff, correctional staff, family, friends and legal representatives.

Following referral, all participants complete a comprehensive assessment and start the process of release planning. The Connections Clinical Support Workers (CSWs) then begin working and advocating with health and welfare staff within the custodial and community environments, to ensure that participants are as prepared as possible for release and their needs are appropriately addressed.

CSWs are based throughout NSW and have developed strong networks and local relationships, which together with formal agreements with community based services, have resulted in a comprehensive and coordinated approach to release planning. Some CSWs are co-located with the Local Health Network and other community-based staff, which has enhanced continuity and the smooth transfer of care.

People released from custody often have complex needs and limited coping skills, requiring an assertive approach to engagement that is not available within existing community drug and alcohol service provision. All Connections participants are assertively followed up in the community by an allocated CSW for a period of four to twelve weeks, addressing identified needs through existing community-based services.

Some participants need minimal assistance, while others require more intensive support e.g. workers attending appointments with participants in order to advocate or support, especially at initial appointments and during crisis intervention, etc. All participants are also assisted in accessing a case manager in the community if needed, with a handover of care arranged prior to ending Connections engagement.

Model of care and aims

The Connections program is focused on social justice and social inclusion, delivering coordinated care to integrate people back into their community. The program aims are to improve the engagement of participants with a variety of health and welfare services to enhance health, reduce drug related deaths and reduce the rate of return to custody. External evaluation of this approach to pre and post-release engagement has demonstrated its success and positive outcomes.

The service operates within the principles of The Personal Strengths Model of Care, as outlined by Rapp (1993)1. This practical social work model from the USA was initially developed to assist patients with mental health problems leaving institutions, and then later modified for working with people with substance misuse problems.

The underlying principle of the model is that everyone has the capacity to grow and learn, and a practical and consistent assertive approach will enhance positive changes and the engagement of participants.

Assistance provided

Connections participants are provided with a comprehensive assessment four weeks prior to release and a release plan is then developed in collaboration with the patient to meet their identified health and welfare needs. Following release, participants require very different levels of support and the Connections program is very flexible in its approach to assist with the transition back to the community.

Some patients may have existing community supports and may just require telephone contact and direction. One of the more common types of feedback Connections receives from participants is that it was good to have someone to talk to, who understood what they were going through and did not make judgments on their ability to achieve planned goals.

Other participants have much more complex needs, and these individuals are sometimes released early with little or no planning for their release in place. JH&FMHN have no control over when someone is released and this can occur for a variety of reasons. As a result a participant may be in a situation where they are homeless, have little if any identification, have no money or access to food and are in need of a lot of immediate practical help.

Connections CSWs can assist by transporting participants to service providers if required, and can advocate for access to ensure their initial basic needs are met and the conditions for the foundations of community integration are in place.

Connections has developed strong links with service providers and put in place agreed processes between government and non-government health and welfare services throughout NSW that have resulted in improved and enhanced access to services. This ensures that follow up appointments with primary health, drug and alcohol services, mental health services and specialist physical health services are in place with release, and that ongoing medication regimes are arranged prior to release.

Practical assistance provided includes obtaining identification, accessing housing, education, employment, food, clothing and transporting patients to health and welfare appointments as appropriate while actively advocating and negotiating access to services.

Program evaluation and Connections’ contribution to the NSW targets ‘NSW 2021’

Goal 11: Keeping people healthy

A 2009 evaluation of Connections completed by the National Drug and Alcohol Research Centre (NDARC) found that completing Connections was associated with improved health among participants. A further internal analysis found participants who remained engaged during the four weeks follow up period reported significantly improved general health (p<0.001), mental health (p<0.01) and social functioning (p<0.001).

In NSW between 1988–2002, the conservative death rate for a prisoner within four weeks post release was 104 (2.2%); within the first year this increased to 721 (14.9%).2 Since 2007, Connections are aware of 38 (0.6%) deaths of participants compared to an expected 147 (2.2%) deaths within the first four weeks of release.

Goal 12: Increase patient satisfaction

Over 87% of respondents (2,435) reported being better prepared for release and 86% (2,395) reported having an easier transition to the community as a result of Connections, with over 97% (n=2,707) reporting that they were satisfied or very satisfied with the help received from Connections.

Participant quotes:

  • ‘If I wasn’t on Connections I would have kept going after the lapse and would have not cared.’
  • ‘You’re there to help with anything. We use (sic) to get release papers but now it’s different we get Connections.’
  • ‘This is one of the best things, should have happened years ago, there would be less people in gaol.’
  • ‘You do the job not like some services, they are all just talk.’
  • ‘I think I have a chance of staying out of gaol.’

Goal 13: Reduce the number of people who are homeless:

Connections developed numerous close working relationships and partnerships with both government and non-government organisations, ensuring that participants have greater opportunities to obtain stable accommodation. When accommodation is identified, Connections assertively works with an array of welfare services to obtain furniture, clothing, food and the basic necessities.

Connections was Highly Commended in the 2012 National Homelessness Service Achievement Awards.

Goal 17: Reduce the recidivism rate

Recidivism is defined by the Attorney General’s Department as returning to custody within two years following release from prison. NSW Governments have recently been targeting a reduction in recidivism. A 10% reduction by 2016 was a goal of the 2006 State Plan. In the more recent NSW 2021 plan, the government has a target of 5% reduction in re-offending by 2016 and a below average Australian recidivism rate.

In December 2015, a review of data found that prior to Connections participation only 9% (473) of people released from custody reported managing to remain in the community for two years or more before returning to custody. Following Connections participation, 33% (1,712) of participants had continued to remain in the community at two year’s review.

Programs specifically designed to reduce recidivism have difficulty achieving reductions in recidivism. The significant change in recidivism following Connections participation would suggest that a flexible health-based approach to assertive support is worth further external analysis.

External recognition

The Connections program has received recognition for the outstanding results it has achieved in improving health outcomes as well as reducing return to custody rates. It has previously been a finalist in the NSW Premier’s Awards, the NSW Health Awards and the National Homelessness Awards.

In 2013, Connections was a winner of both the National Drug and Alcohol Awards and the National Crime and Violence Prevention Awards. In 2014, it was Highly Commended at the Treasury Managed Fund Awards in the Innovation Category.


As a result of working within a broad definition of health and including the social determinants of health, Connections has implemented a whole of government approach to transitional care. The outcomes achieved by the Connections program continue to contribute to a number of NSW and Commonwealth Government strategies.

In the 2014/15 financial year there were 15,003 discharges from NSW adult correctional centre. The Connections program has a current capacity to assist 800 of those discharges (5% of the total) with the potential demand for the program far exceeding current resources.

The outcomes of the Connections program are currently being externally researched by the University of Technology Sydney following a recently allocated grant from the National Health and Medical Research Council.


1 Kinner, S. Preen, D. Kariminia, A., Butler, T., Andrews, J. Stoove, M., Law, M. (2011). Counting the cost: estimating the number of deaths among recently released prisoners In Australia. Medical Journal of Australia, 195(2), 64–68.

2 Rapp, C. (1993). Theory, principles and methods of the strengths model of case management. In Harris, M. Bergman, H. (Eds)., Case Management For Mentally Ill Patients: Theory And Practice. Harwood Academic Publishers, Langhorne, 143–164.

Stephen Ward is Manager of Drug and Alcohol Release Planning at Justice Health and Forensic Mental Health Network.