Discharge Planning

Comprehensive discharge planning for soon-to-be-released inmates, or reentrants, with TB infection or disease is an essential component of TB control efforts, both within correctional facilities and in the communities to which inmates return (Hammett, Gaiter, & Crawford, 1998). Effective discharge planning facilitates improved postrelease utilization of medical services (Frieden et al., 1995) and reduced recidivism (Flanigan et al., 1996). In addition, continuity of care postrelease is imperative for reducing secondary TB transmission and preventing the development of drug resistance (Glaser & Greifinger, 1993). Failure to complete a diagnostic evaluation for TB disease can result in undiagnosed reentrants exposing their families, friends, and community members to TB. Treatment interruptions or cessation before completion can also have serious consequences. Individuals with LTBI who do not complete their treatment are at risk for developing TB disease, particularly if they are co-infected with HIV or have other risk factors for progression. Inmates with TB disease who are unable to complete their treatment regimen are at risk for developing drug resistance and relapsing to symptomatic and infectious disease. Recidivists with incompletely diagnosed or untreated TB disease can reintroduce TB into a correctional facility upon admission and place other inmates and correctional staff at risk. Thus case management and discharge planning efforts must be made to ensure timely completion of TB diagnostic evaluation and treatment both during and after incarceration, to prevent potential health risks to both reentrants and the larger community.

Correctional facilities should conduct prerelease case management and discharge planning for all inmates with suspected or confirmed TB disease and those with LTBI who are at high risk for progression to TB disease (CDC, 2006a). For inmates with LTBI who are at low risk for progression to TB disease, correctional facilities should collaborate with appropriate public health agencies to develop feasible discharge planning policies. Regardless of risk of progression, all inmates with LTBI who are started on TB preventive therapy during incarceration should receive discharge planning to ensure uninterrupted treatment after release.

Correctional facilities should have designated staff assigned to conduct TB discharge planning and to notify the appropriate public health agency of inmates with suspected or confirmed TB disease and inmates receiving treatment for LTBI or TB disease (CDC, 2006a). Designated staff may be correction personnel, medical or administrative staff working in the facility, or public health department staff that work on-site. Such personnel should also be responsible for communication with other correctional facilities or community service providers if inmates are transferred or released mid-TB evaluation or treatment. Correction and medical staff within correctional facilities should work with the designated discharge planning staff to develop timely and thorough discharge plans. Planning should address TB diagnosis and treatment efforts begun in jails or prisons and provide for their continuation postrelease. Correctional facilities should ensure that their discharge planning process is comprehensive, is tailored to the needs of the individual, and is conducted in collaboration with public health and community partners.

Collaboration between Correction, Public Health, and Community Partners

Both effective TB case management and discharge planning require and benefit from collaboration between correction, public health, and community partners (Lobato, Roberts, Bazerman, & Hammett, 2004). Such collaboration and coordination maximize the effectiveness of TB control efforts begun in correctional facilities (Hammett, Roberts, & Kennedy, 2001). TB diagnostic evaluation or treatment initiated during incarceration can be completed postrelease by public health or community partners, thus ensuring continuity of care and improved health for the inmate and reducing the likelihood of TB transmission in the community. In addition, collaboration with public health and community partners can assist correctional facilities in overcoming barriers encountered during discharge planning such as brief inmate lengths of stay, unscheduled releases or transfers from the facility, and limited available resources for recommended TB prevention, screening, treatment, and discharge planning services (CDC, 2006a). Public health agencies and community-based organizations may have financial, programmatic, or personnel resources that they can offer to correctional facilities. Public health staff can provide TB medical expertise and assistance with case management, contact investigations, administration of DOT, and accessing community TB-related resources (e.g., local TB clinics for follow-up appointments). In addition, public health departments often maintain TB registries containing diagnostic and treatment-related information on all persons with TB within their jurisdictions. Correctional facilities and public health departments can work together to use TB registry data to find inmates with TB infection or disease and obtain the TB history. Registry information including TB diagnostic test results, drug-susceptibility patterns, and treatment history can be helpful to correctional facilities in case management and discharge planning. Use of TB registry data in correctional settings may also enable health departments to locate persons with TB who have been lost to follow up in the community. Correctional facilities can assist public health departments by promptly reporting all inmates with suspected or confirmed TB disease, so that the public health staff can ensure timely performance of case management, contact investigations, and entry of information into the TB registry. Correctional facilities should contact their local or state health departments to identify their designated TB control staff. Likewise, public health departments should make efforts to contact the infection or TB control staff of local correctional facilities. To facilitate effective collaboration, correctional facilities and public health departments should designate liaisons and have regularly scheduled meetings to discuss correctional TB control issues (Lobato et al.).

Community-based partners, including clinical and social service providers and community correction staff (e.g., probation and parole officers), are vital to the success of discharge planning efforts. Recently released inmates have a multitude of health- and nonhealth-related needs and it is imperative to link them with organizations that are interested and experienced in working with these populations; correctional facilities and public health agencies should make efforts to identify and partner with such organizations. Soon-to-be-released inmates often express a need for help in accessing healthcare services after release and have high expectations of the role that community correction staff will play in helping them gain lawful employment, find substance use treatment programs, stay crime free, or otherwise transition into the community (LaVigne, Visher, & Castro, 2004). Parolees meet with their assigned parole officer on a monthly or bimonthly basis; as such, including community correction staff in prerelease TB-discharge planning, with inmate consent, may facilitate continuity of care (Nelson & Trone, 2000). By participating in discharge planning for soon-to-be-released inmates with LTBI or TB, community correction staff become more knowledgeable about TB and can assess TB management-related compliance issues with their parolees; as such, they are better able to protect themselves, their clients, and their communities (Hammett et al., 2001; Wilcock, Hammett, & Parent, 1995). Community correction can also assist public health departments in locating TB cases that are lost to follow-up in the community and are on probation or parole.

Successful TB discharge planning requires correctional facilities to provide timely and thorough TB diagnostic and treatment information to public health agencies (via mandatory TB case-reporting), as well as to community partners involved in postrelease provision of services. Likewise, feedback of postrelease TB follow-up data from public health departments and community partners back to correctional facilities is helpful in maintaining continuity of care, particularly for persons with TB who are reincarcerated. However, there are patient-confidentiality-related restrictions on sharing information across agencies, and local, state, and federal regulations should be followed. Correction, public health, and community partners should inform and reassure inmates of their confidentiality rights. In addition, inmates should be explained the importance and benefits of signing a limited release or consent so that their TB-related information can be shared among appropriate agencies (Hammett et al., 2001). Caution should be taken to share only the information necessary to provide continuity of care.

Components of Discharge Planning

Incarcerated populations have a complexity of discharge planning needs. Following release from correctional facilities, reentrants face urgent housing, employment, financial, and other subsistence needs that often take priority over their healthcare (Hammett et al., 2001). While incarcerated, inmates may lose their employment, housing, eligibility for food stamps, or Medicaid and Social Security benefits. As such, postrelease, reentrants with TB may not have the ability or resources to make or keep follow-up appointments or obtain necessary medications. They may have language, literacy, or cultural barriers, which further complicate their ability to seek care. In addition, reentrants often have mental health or substance use issues that can hinder their ability to access healthcare services. Thus, to be effective, TB discharge planning efforts must be holistic and tailored to the needs of the reentrant. As such, correctional facility discharge planning programs should (1) initiate discharge planning early; (2) provide case management; (3) obtain detailed postrelease contact information; (4) assess and plan for substance abuse, mental health, and social service needs; (5) make arrangements for postrelease follow-up; (6) make provisions for unplanned release and transfers; and (7) provide education and counseling (CDC, 2006a).

Initiate Discharge Planning Early

Discharge planning efforts for inmates diagnosed with TB infection or disease should begin as early as possible during incarceration and continue postrelease to facilitate continuity of care and avoid delays in initiating or resuming TB treatment. Designated discharge planning staff in the correctional facilities should promptly notify the public health department of all inmates with suspected or confirmed TB disease or inmates receiving TB treatment, even if the inmates have been transferred or released from the facility. Inmates diagnosed with TB disease are of the highest priority for discharge planning and should be interviewed by public health (preferred) or correctional discharge planning staff as soon as possible after diagnosis so that the discharge plan can be developed (CDC, 2006a). Whenever possible, correctional facilities should provide the discharge planning staff with advance notice about the inmates' projected release dates; this will enable development of a more individualized and thorough discharge plan. Even in short-term detention facilities, where a significant number of inmates may be released within one to three days of admission, many critical community TB linkages can be made if the discharge planners are promptly notified about an inmate with TB.

Early involvement of the inmate in the planning process is integral to the success of the discharge plan. Inmates may perceive the discharge plan and community linkages as an extension of their punishment in jail or prison and be reluctant or fearful to participate. Discharge planning staff should work to build a rapport and trusting relationship and to educate the inmates on the benefits of discharge planning to their health and well-being. Staff should assess the inmates' perceptions of their postrelease needs and priorities and tailor the discharge plan accordingly; inmates may have received discharge planning before and know what worked or did not work for them in the past. In addition, staff should assess the inmates' expectations of postrelease support from their families, particularly as it relates to their healthcare. Often soon-to-be-released inmates expect that their families will assist them with accessing healthcare, finding housing or employment, and finances in the community; however, postrelease, inmates may find that the expected support is not always available (La Vigne, 1994; Visher, Kachnowski, La Vigne, & Travis, 2004). Whenever possible, staff should attempt to include inmate families early in the discharge planning process and link inmates with additional and varied sources of support (e.g., peer counselors, support groups) (Nelson & Trone, 2000).

Provide Case Management

Comprehensive case management is an essential component of discharge planning and involves identifying, planning, and facilitating the postrelease services required to meet reentrants' health and social service needs. Case management has been demonstrated to support reentrants in utilizing community healthcare services (Rich et al., 2001), modifying risk behaviors (Rhodes & Gross, 1997), and reducing recidivism (Flanigan et al., 1996). In addition, case management for persons with TB has been shown to improve adherence to TB treatment regimens (Marco et al., 1998) and reduce loss to follow-up in the community (Salomon et al., 1997).

Designated discharge planning staff should provide case management for inmates with TB infection or disease and work with public health and community partners to ensure continuity of care postrelease (Klopf, 1998). Prerelease case management should include a thorough assessment of the inmate's TB exposure, diagnosis, and therapy history by interviewing the inmate directly and reviewing pertinent medical records. Case managers should review the TB exposure history to identify potential TB contacts either in the correctional facility or community and should inform facility infection control and local public health partners so that contact investigations can be initiated as needed. Case managers should also review the results of all TB diagnostic testing conducted during incarceration, such as TST or IGRA, chest radiograph, sputum smears and cultures, and drug susceptibilities. In addition, TB treatment and medication compliance history during incarceration should be reviewed. Case managers should request the local or state public health department to review their TB registry data for additional information that might be useful in discharge planning. Co-morbid conditions, such as HIV or viral hepatitis, can complicate the treatment regimen and should be addressed in the overall discharge plan by ensuring linkages with appropriate community clinical providers.

Case managers should work with public health and community partners to determine where soon-to-be-released inmates will receive TB follow-up care and obtain necessary medications. Newly released inmates sometimes choose not to return to the neighborhood they lived in before incarceration either to avoid previous influences which led to their incarceration or because their family moved to another location (La Vigne, Visher, & Castro, 2004). Additionally, released inmates may wish not to receive medical care in the same neighborhood where they live due to a perceived stigma. Case managers should determine where soon-to-be-released inmates would be able and willing to continue their TB follow-up appointments. Case managers should discuss the importance of the follow-up, and identify and address any potential barriers to inmates being able to keep the appointments.

Obtain Detailed Contact Information

Case managers should emphasize the importance of continuity of care in TB treatment and encourage inmates with LTBI or TB disease to provide accurate postrelease contact information. Case managers should request detailed information from soon-to-be-released inmates, such as (1) their expected residence, including shelters; (2) names and contact information for friends or relatives; and (3) community locations usually frequented, in order to enable location of the released inmate in the community (White et al., 2002). In addition, case managers should obtain a signed consent from inmates authorizing the case manager and public health department to contact and share TB-related information with worksites, community clinical or social service providers, or community correction staff if necessary (CDC, 2006a).

Inmates may provide contact information based on their expectations of where they will reside postrelease; however, for many reasons, they may need to change their residence after they return to the community. Alternatively, inmates may intentionally give correctional staff aliases or incorrect contact information because of mistrust or fear of incrimination or deportation (CDC, 2006a). The inability to locate and provide continuity of care for released inmates with LTBI or TB disease can result in incomplete treatment regimens (Nolan, Roll, Goldberg, & Elarth, 1997) and the risk of transmission or drug resistance (Glaser & Greifinger, 1993). In addition, the use of an alias by an inmate with LTBI or TB disease can hinder continuity of care upon reincar-ceration and potentially place other inmates and correctional staff at risk. Case managers should confirm contact information, including true identity and any aliases, with inmates on a periodic basis throughout incarceration and immediately before release if possible. Correctional facilities should also develop strategies to confirm an inmate's true identity as quickly as possible after admission to the facility (e.g., using fingerprint-based unique identification number).

Assessment and Plan for Substance Abuse, Mental Health, and Social Service Needs

TB case management efforts must include an assessment of substance abuse, mental health, or social service needs that may adversely influence the inmate's ability to adhere to the TB discharge plan. Substance abuse and mental health issues are significant barriers to continuity of care postrelease and should be addressed by discharge planning staff in correctional facilities (Hammett et al., 2001). After release from jail or prison, many reentrants return to their old neighborhoods and are challenged to avoid the same influences or circumstances that led to their recent incarceration, which places them at risk for defaulting on their TB care. Relapse to substance abuse postincarceration often occurs and can impact all aspects of a reentrant's life including his or her health, housing, relationships, employment, parole conditions, and likelihood of reincarceration (Rich et al., 2001). Inmates with mental illness have similar postrelease issues as those with substance abuse problems. Without sufficient postrelease support in the community, reentrants with mental illness may have difficulty in coping or with treatment adherence and may experience acute decompensation of their mental status, thus greatly increasing the chances of nonadherence to TB follow-up or treatment. Reentrants with prior drug offenses or mental illness often have difficulty in obtaining permanent housing and risk becoming homeless (Lindblom, 1991), which is a major barrier to completion of TB therapy (LoBue, Cass, Lobo, Moser, & Catanzaro, 1999). For inmates with a substance abuse history, case managers should provide referrals to or information about convenient substance abuse treatment programs and peer support group meetings (e.g., Alcoholics or Narcotics Anonymous). In addition, inmates with substance abuse histories are at risk for HIV and viral hepatitis, both of which can affect TB management, and would benefit from referrals to community clinical providers experienced in working with these issues. Inmates with TB who have mental illness require community linkages to mental health treatment programs that are integrated with primary care, substance abuse, and social service providers to best facilitate continuity of care.

Incarceration creates several other barriers for released inmates, which can hinder continuity of TB care. During incarceration, inmates may lose their employment or other sources of income. In addition, inmates often lose health insurance or other government benefits, such as Medicaid, Temporary Assistance for Needy Families, Food Stamps, Supplemental Security Income, or Social Security Disability Insurance, while incarcerated and may have to wait several months postrelease to become eligible again (Bazelon Center for Mental Health Law, 2000). This loss of income and services can adversely impact the inmate's ability to adhere to TB follow-up and treatment in the community. Although federal laws require the suspension of certain benefits during the period of incarceration, many states will terminate the benefits and require inmates to reapply for benefits upon release (Human Rights Watch, 2003). The requirement to reapply for benefits postrelease can present difficulties for inmates as they must provide documentation that may have been lost or destroyed (e.g., birth certificates, social security card, passport, driver's license, or other photo identification). Many states will allow inmates to apply for reinstatement of benefits in anticipation of release from jail or prison; case managers should assist inmates in obtaining the necessary documentation and completing the required application forms.

Correctional facilities should assist this process by making the inmates' driver's licenses, Medicaid cards, or other forms of photo identification available to the case managers during incarceration, as needed, and to the inmates with their personal property postrelease. In addition, correctional facilities should create agreements with agency partners to facilitate prompt reactivation of these benefits (e.g., with state Department of Motor Vehicles to provide nondriver's license photo identification cards, with local Social Security Administration offices to expedite processing of applications) (Hammett et al., 2001). Case managers should ensure that inmates requiring TB care in the community have access to free TB follow-up appointments and medications immediately postrelease and for as long as they are needed.

Make Arrangements for Postrelease Follow-Up

One of the most critical components of discharge planning for inmates with LTBI or TB disease is the arrangement of postincarceration follow-up appointments and access to medications. Inmates on LTBI therapy who are released from jail or prison before treatment is completed have low community clinical follow-up and treatment completion rates (Nolan et al., 1997; Tulsky et al., 1998). Inmates with TB are at high risk for not completing their TB treatment regimen (MacNeil et al., 2005). Factors such as homelessness, substance abuse, lack of social support or stability, unemployment, and lower education levels contribute to nonadherence postrelease (Cummings et al., 1998; White et al., 2002). Whenever possible, efforts should be made to have inmates complete their LTBI or TB therapy during incarceration. If this is not feasible, case managers, in collaboration with public health staff, should arrange for postrelease follow-up of inmates with appropriate community-based clinical providers so that treatment can be completed.

Case managers should first create an individualized discharge plan based on interviews with inmates about their perceived postrelease health- and nonhealth-related needs, review of the medical records, and discussions with appropriate correction, public health, and community correction staff. When deciding where to refer inmates for TB care and substance abuse, mental health, or other social services needs, case managers should attempt to find community providers that can best integrate and coordinate all of these areas. To maximize the likelihood of continuity of care, case managers should ensure that the community-based providers are interested and experienced in meeting ex-inmates' needs and provide services in locations convenient to where inmates anticipate living or working postrelease. Case managers should establish relationships and agreements with community partners to facilitate inmates' utilization of services (e.g., enabling "walk-in services," providing phone or mail appointment reminders, or providing transportation for referred inmates).

A variety of models exist in correctional facilities for linking prerelease inmates to community clinical providers (Hammett et al., 2001). Some involve community providers coming into the jail or prison to provide direct clinical services, establish a therapeutic alliance with the inmates and follow them clinically in the community postrelease (Flanigan et al., 1996). Less intensive models include (1) community providers working with inmates for only a few months prerelease; (2) inmates not meeting the provider during incarceration, but receiving a set appointment postrelease; and (3) inmates receiving a prerelease list of clinical providers to contact (Hammett et al.). Correctional facilities that enable community providers to establish a direct therapeutic relationship with inmates during incarceration optimize the likelihood of continuity of care postrelease. Correctional staff should encourage public health and community partners to establish a prerelease relationship with inmates either by providing direct services to inmates during incarceration, or by working closely with the discharge planning staff to assist in prerelease planning. For some correctional facilities, however, the distance between them and likely community providers presents difficulties to meeting with the inmates prerelease (Hammett et al.). Even in such cases, providing the inmate with a set appointment date can improve compliance with community follow-up (Rich et al., 2001). At minimum, soon-to-be-released inmates should be given a list of community clinical and social service providers and resources.

As part of the discharge plan, case managers should ensure that all inmates who have been diagnosed with LTBI or TB disease receive community referrals for initiation or continuation of TB treatment. In particular, inmates started on DOT for TB disease or LTBI while incarcerated should continue to be closely monitored by local public health staff who will arrange for the continuation of DOT postrelease until the treatment regimen is completed. Inmates with LTBI who do not require DOT should have uninterrupted access to TB medications postrelease for the duration of their treatment regimen. At minimum, they should be given a sufficient supply of their TB medications until their next TB follow-up appointment in the community (CDC, 2006a). If the anticipated inmate release date and community follow-up appointment date are known, then the case manager can determine the exact amount of medication to provide. If either of these dates is unknown, case managers should work with correction or public health staff to arrange for at least a 2-week to 1-month supply of the TB medications to be available at discharge (Hammett et al., 2001). Providing soon-to-be-released inmates with the actual medication is preferable to giving them a prescription; suspension of health insurance or benefit programs due to incarceration may prevent inmates from being able to fill the prescription soon enough to avoid missing doses. However, if legal, policy, or financial reasons prohibit correctional facilities from providing sufficient amounts of medication for discharge, inmates should be given a prescription to cover the time period from release to the first TB appointment in the community (Hammett et al.). Case managers should also inform inmates about public hospitals and clinics affiliated with state or local health departments that may provide free or low-cost TB care and medications. Regardless of whether medications or prescriptions are given, case managers should ensure that the inmates understand the proper dosing and administration of the TB medications and provide written instructions in the inmates' preferred languages.

Make Provisions for Unplanned Release and Transfers

Correctional facilities should have policies and procedures in place to address unplanned transfers or releases of inmates with LTBI or TB disease (CDC, 2006a). Correctional clinical or discharge planning staff should create and routinely update a summary health record for all inmates (Re-Entry Policy Council, 2003), particularly those with LTBI or TB disease. The summary health record can be initiated based on the initial health screening and added to as needed. The summary should contain all pertinent medical history; physical examination, radiology, and laboratory results; prescribed medications; scheduled consults or clinical appointments; and postrelease management plans. For inmates with LTBI or TB, the summary health record should contain detailed information on TB exposure history, diagnostic testing results including TST or IGRA, chest radiograph, sputum smear and cultures, TB therapy, drug susceptibility patterns, and planned postrelease follow-up.

The summary record should be updated throughout the case management and discharge planning process, based on collaboration with public health and community partners. It should be part of the inmate's medical record and be easily accessible. In addition, staff should ensure that the summary is as complete and up-to-date as possible prior to inmate transfer or release. All inmates being released or transferred from jail or prison should receive a copy of their summary health record, so that they have documentation of the tests or services provided and can share this information with clinical providers upon release (CDC, 2006a).

Correctional discharge planning staff should promptly notify the public health department of all releases into the community of inmates with TB disease or those on treatment for LTBI, to ensure continuity of care postrelease. Inmates with LTBI or TB disease who are being released into the community and did not yet have a discharge plan, should, at minimum, be given their summary health record and a list of community TB providers where they can follow-up postrelease. If the summary record cannot be provided before release, inmates should be informed on how to obtain a copy postrelease. Inmates with LTBI or TB disease who are being transferred to another correctional facility should have all of their TB diagnosis and management information sent to the receiving facility, to avoid duplication of tests or delays in treatment initiation or continuation. Inmates with TB disease who are infectious but are eligible for release or transfer to another medical or correctional facility should remain in AII precautions until they become noninfectious (CDC, 2006a). If AII precautions cannot be maintained during and after the transfer process, facility administrators can consider using a brief "medical hold," so that a follow-up plan can be initiated.

Provide Education and Counseling

Ongoing education and counseling about TB is an important component of discharge planning and TB control efforts in correctional facilities. Inmates, as well as correctional facility staff, may not fully understand TB transmission, the difference between LTBI and TB disease, and methods of TB prevention and treatment (Woods, Harris, & Solomon, 1997). In addition, some inmates and staff may still perceive a stigma associated with TB, which may be a barrier to seeking or providing proper TB care (Woods et al., 1997).

TB education, to increase knowledge, and counseling, to change attitudes, have been shown to increase perception of self-efficacy (Morisky et al., 2001) and improve adherence to community TB follow-up visits and completion of treatment regimens postrelease (White et al., 2002). Frequent education sessions were shown to be more effective than a single education session at diagnosis or even financial incentives in facilitating improved adherence to clinic visits and completion of treatment postrelease (White et al., 2002). Inmates on TB treatment should receive ongoing supportive education and counseling about the importance of adhering to the treatment plan after release into the community. Education should be provided in the inmate's preferred language and be culturally sensitive with regard to ethnicity, gender, and age (Goldberg, Wallace, Jackson, Chaulk, & Nolan, 2004; Hovell et al., 2003; White et al., 2003). Individual TB counseling should be conducted in a private setting if possible (White et al., 2003), so that inmates feel comfortable discussing their questions or concerns. Case managers should ensure that inmates are active participants in the development of the TB discharge plan and provide feedback into their motivations or challenges regarding treatment and adherence.

Community-Based Case Management After Release

The first 24 h after release from a correctional facility are critical to an ex-inmate's success with reentry into the community (Mitty, Holmes, Spaulding, Flanigan, & Page, 1998). Reentrants returning to the same neighborhood where they lived prior to incarceration may be exposed to the same circumstances and influences that led to their arrest. Additionally, at the time of release from jail or prison, reentrants may not have adequate food, clothing, shelter, or financial resources; thus, healthcare becomes less of a priority than these other urgent needs. Therefore, it is imperative that the case management process begun in the correctional facility be continued after release, particularly for ex-inmates with suspected or confirmed TB disease, LTBI who are at high risk for progression to disease, or those who are on TB treatment (CDC, 2006a). Former inmates may experience a lack of social stability and support after reentry into the community; often they find that their community case manager is a much-needed source of support and encouragement (Rhodes & Gross, 1997). As such, public health and community partners should attempt to make contact with reentrants within the first week of release to assist with general transition issues and ensure continuity of TB care as prescribed in the discharge plan created in the correctional facility. Case management that is culturally sensitive and serves reentrant-defined needs, along with TB control needs, has been shown to improve completion rates for therapy (Goldberg et al., 2004). Public health and community partners should also work with community correction staff to ensure that ex-inmates adhere to their follow-up TB clinic visits and medication regimens.

DOT for active TB or LTBI, both in the correctional setting and postrelease, is a strategy for facilitating adherence to TB treatment regimens. DOT initiated in the correctional facility provides an opportunity for education and counseling and establishes the medication as routine (CDC, 2006a). The continuation of DOT postrelease may enhance compliance and reduce relapse rates and acquired drug resistance (Nolan et al., 1997). Implementation of DOT in conjunction with housing programs has been effective in improving TB therapy outcomes in homeless populations (LoBue et al., 1999).

Incentives and enablers are another strategy that case managers can use to promote adherence to TB treatment. Incentives are items or services that encourage individuals to complete TB treatment by motivating them with something they want or need (e.g., food, money, clothing). Enablers help clients overcome barriers to completing their TB treatment (e.g., transportation, stable housing, service programs). Incentives and enablers, combined with education and counseling, have been shown to improve adherence to TB follow-up appointments and treatment completion in incarcerated populations (Frieden et al., 1995; Tulsky et al., 1998, White, Tulsky, McIntosh, Hoynes, & Goldenson, 1998; White et al., 2002). Financial incentives are believed to be most effective for promoting adherence (Giuffrida & Torgerson, 1997). Recent data suggest that financial incentives may be helpful in adherence to initial follow-up clinic visits, but that ongoing education and counseling may be more effective in facilitating completion of TB treatment regimen (Pilote et al., 1996; White et al., 2002).

Comprehensive discharge planning and community linkages have been shown to reduce recidivism rates (Flanigan et al., 1996). Despite these successes, approximately two-thirds of all parolees are rearrested within three years; most are rearrested within the first 6 months after release. Thus, case management after release is critical for continuity of care in the event of reincarceration, particularly for inmates who are still taking TB treatment when rearrested.

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