The Justice Health and Forensic Mental Health Network (Justice Health NSW) is undertaking a clinical redesign of the Connections program, to help strengthen care provided for people transitioning from custody to the community.
Justice Health NSW established the Connections program in 2007, to support individuals with a history of drug and alcohol use as they transition from prison back into the community. The program provides pre-release planning and post-release follow-up to promote harm reduction education and continuity of care support.
Connections participants are linked with community-based health and social services, including:
- drug and alcohol treatment and support
- mental health care
- primary health
- community support services.
The program has not undergone a comprehensive review in its 18 years of operation. The lack of clearly defined eligibility and prioritisation criteria has resulted in increasing referral volumes and inconsistent support for those patients with a history of drug and alcohol related illness, who are most at risk at time of release from custody.
Ensuring equitable care for all patients
People released from custody experience some of the poorest health outcomes in Australia. Studies show that around two thirds of adults in custody have a history of illicit drug use and one third report dependence on these substances.1 The risk of drug-related death in the first weeks following release form custody is up to 10 times higher than for the general population. This highlights the importance of timely support for those people transitioning back to the community with drug and alcohol dependence.
Through our project, Getting Out and Staying Healthy, we aim to:
- enhance resource utilisation
- improve continuity of care
- align the program with contemporary, evidenced based healthcare standards.
To achieve this, we have developed a structured eligibility framework with plans to implement a triage model to improve referral assessment and ensure equitable care for our patients. The refined model will create a foundation for safe and sustainable care that reduces preventable morbidity and mortality within a holistic and recovery-oriented model of care.
Evaluating referral accuracy and patient engagement
Implementation has been delayed due to other organisational priorities, including significant system changes and infrastructure projects. We anticipate that implementation of the redesigned referral and triage processes will commence mid-2026.
We have developed a comprehensive evaluation framework, which we will implement once the new referral and eligibility criteria and prioritisation matrix is rolled out. Evaluation measures will assess:
- referral accuracy
- assessment timeliness
- patient engagement
- staff satisfaction.
We have already collected baseline data to enable comparison before and after implementation. We will gather qualitative feedback from staff and patients through surveys, interviews and focus groups to understand impact and experience. Continuous monitoring, regular feedback loops and the identification of early wins will guide improvements and support sustainability of the new model.
View this project's poster from the Centre for Healthcare Redesign graduation December 2025.
References
- Australian Institute of Health and Welfare. The Health of Australia’s Prisoners 2022. Canberra: AIHW; 2023 [cited 27 Oct 2025].
- Degenhardt L, Larney S, Gisev N, et al. Health Outcomes for People Released From Prison in NSW. Med J Aust. 2014;201(10):568-571.
- Ocloo J, Matthews R. From Tokenism to Empowerment: Progressing Patient and Public Involvement in Healthcare Improvement. BMJ Qual Saf. 2016;25(8):626-632
