A novel application of process mapping in a criminal justice setting to examine implementation of peer support for veterans leaving incarceration

Abstract

Background: Between 12,000 and 16,000 veterans leave incarceration every year, yet resources are limited for reentry support that helps veterans remain connected to VA and community health care and services after leaving incarceration. Homelessness and criminal justice recidivism may result when such follow-up and support are lacking. In order to determine where gaps exist in current reentry support efforts, we developed a novel methodological adaptation of process mapping (a visualization technique being increasingly used in health care to identify gaps in services and linkages) in the context of a larger implementation study of a peer-support intervention to link veterans to health-related services after incarceration ( https://ichgcp.net/clinical-trials-registry/NCT02964897" title="See in ClinicalTrials.gov">NCT02964897, registered November 4, 2016) to support their reentry into the community.

Methods: We employed process mapping to analyze qualitative interviews with staff from organizations providing reentry support. Interview data were used to generate process maps specifying the sequence of events and the multiple parties that connect veterans to post-incarceration services. Process maps were then analyzed for uncertainties, gaps, and bottlenecks.

Results: We found that reentry programs lack systematic means of identifying soon-to-be released veterans who may become their clients; veterans in prisons/jails, and recently released, lack information about reentry supports and how to access them; and veterans' whereabouts between their release and their health care appointments are often unknown to reentry and health care teams. These system-level shortcomings informed our intervention development and implementation planning of peer-support services for veterans' reentry.

Conclusions: Systematic information sharing that is inherent to process mapping makes more transparent the research needed, helping to engage participants and operational partners who are critical for successful implementation of interventions to improve reentry support for veterans leaving incarceration. Even beyond our immediate study, process mapping based on qualitative interview data enables visualization of data that is useful for 1) verifying the research team's interpretation of interviewee's accounts, 2) specifying the events that occur within processes that the implementation is targeting (identifying knowledge gaps and inefficiencies), and 3) articulating and tracking the pre- to post-implementation changes clearly to support dissemination of evidence-based health care practices for justice-involved populations.

Keywords: Care coordination; Community providers; Implementation methods; Incarceration; Intervention design; Peer support; Process mapping; Qualitative analysis.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Example of an interview-based process map generated for this study. The start and end points that were used to bound the discussion are indicated as circles (numbered with letter “c”) at the top left and bottom right corners of the map, respectively, and arrows between the shapes mark the sequence in which individual events (represented as rectangles on the map, numbered with letter “r”) take place within the process. A diamond (numbered with letter “d”) is used when there is a decision point in the process, where events following the point are determined by the answer to the question asked within the diamond. “Burst” shapes (numbered with letter “b”) indicate uncertainties, gaps, bottlenecks, or inefficiencies. Notice the small circle (above and to the right of the center of the figure, labeled “c2”) that demonstrates an alternative end point to the process based on the answer to a decision point question (e.g., in this case, whether veteran status can be verified). Form DD214 (in the rectangle labeled “r1”) is documentation by the United States government on individuals leaving military service, used to verify their veteran status and eligibility for receiving VA services

Fig. 2

Map of the generalized reentry support process with current challenges at identification, pre-lease, and post-release. This figure is a summarized and generalized process map synthesized from four individual process maps. While the individual maps focus on detailing the process complexities, this generalized map focuses on visualizing major issues that were emphasized repeatedly in the individual maps