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2023 HSR&D/QUERI National Conference Abstract

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4033 — Process mapping as a tool to prepare for multi-site implementation of a peer-based intervention for Veteran prisoner reentry support

Lead/Presenter: Eric Richardson
All Authors: Richardson E ((Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston)), Petrakis, BA (Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford) Hyde, J (Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford, Boston University) McInnes, DK (Center for Healthcare Organization and Implementation Research (CHOIR), VA Bedford, Boston University) Garvin, L (Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Boston University) Kim, Bo (Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston, Harvard Medical School)

Approximately 12,000 Veterans leave incarceration annually. The Post-Incarceration Engagement (PIE) intervention was designed to enhance the reach of the VA’s Health Care for Reentry Veterans program with peer specialists. A multi-site implementation trial at six VA sites is underway following a successful pilot at two sites. In preparation for the multi-site implementation, we used process mapping based on site-level stakeholder interviews to identify potential challenges and contextual variations, and to inform updates to the PIE training manual and implementation approach.

We performed process mapping, a visualization technique increasingly applied in healthcare, to identify key gaps in reentry support. Hour-long semi-structured interviews were conducted with 2-5 key stakeholders per site who help justice-involved Veterans with reentry. Interview data were used to generate process maps specifying the sequence of events, multiple parties involved, and explicit challenges in providing reentry support prior to PIE implementation. Process maps were then analyzed to revise the pilot facilitation manual and identify both site-level and across-site challenges. Stakeholders were from VA homeless programs including the HCRV specialists from the sites participating in the trial, which came from Northeastern, South Central, and Western portions of the United States.

Process maps identified three specific targets to improve implementation of PIE across the implementation sites. First, process maps identified challenges that were and were not addressable by the implementation team. For example, addressable challenges included greater communication between peer specialist and organizational leaders, whereas non-addressable challenges included not knowing the exact date of release. We also identified challenges that would require modifications to the core components of PIE. Specific examples included expectations for in-person pre-release visits, transportation on day of release, and using telephone or virtual meetings when driving distances or housing rules make it impossible to have in-person encounters with the Veteran target twice a week during the first two weeks of reentry. Second, we discovered common challenges across sites (e.g. difficulty in keeping reentry Veterans connected with VA post-release, limited transportation options, and reasons why post-incarceration veterans may not be connected to VA healthcare immediately upon release). Third, we uncovered facilitators to address challenges, such as providing access to phones upon release and using technology when in-person visits are infeasible which were included in the revised manual.

Process maps are a promising method to identify challenges in implementing interventions across multiple sites, and adaptations to the PIE interventions to meet those challenges. Our use of process maps in a reentry program identified important contextual variations that may hinder implementation. We can use this information to tailor implementation strategies and approaches, increasing the likelihood of their success.

By improving implementation of PIE across multiple sites, we can extend the reach of the PIE intervention to the thousands of Veterans that face reentry after incarceration. Our process maps were a useful visualization for refining the implementation approach to facilitate sustainability of PIE to reach the maximum reentry Veterans and provide them with effective post-incarceration support.