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

Process mapping with failure mode and effects analysis to identify determinants of implementation in healthcare settings: a guide

BACKGROUND

Generating and analyzing process maps can help identify and prioritize barriers to the implementation of evidence-based practices in healthcare settings. Guidance on how to systematically apply and report these methods in implementation research is scant. We describe a method combining a qualitative approach to developing process maps with a quantitative evaluation of maps drawn from the quality improvement literature called failure mode and effects analysis (FMEA).

METHODS

We provide an outline and guidance for how investigators can use process mapping with FMEA to identify and prioritize barriers when implementing evidence-based clinical interventions. Suggestions for methods and reporting were generated based on established procedures for process mapping with FMEA and through review of original research papers which apply both methods in healthcare settings. We provide case examples to illustrate how this approach can be operationalized in implementation research.

RESULTS

The methodology of process mapping with FMEA can be divided into four broad phases: 1) formulating a plan, 2) generating process maps to identify and organize barriers over time, 3) prioritizing barriers through FMEA, and 4) devising an implementation strategy to address priority barriers. We identified 14 steps across the four phases. Two illustrative examples are provided. Case 1 describes the implementation of referrals to chiropractic care for adults with low back pain in primary care clinics. Case 2 describes the implementation of a family navigation intervention for children with autism spectrum disorder seeking care in pediatric clinics. For provisional guidance for reporting, we propose the REporting Process mapping and Analysis for Implementation Research (REPAIR) checklist.

CONCLUSIONS

Process mapping with FMEA can elucidate barriers and facilitators to successful implementation of evidence-based clinical interventions. This paper provides initial guidance for more systematic applications of this methodology in implementation research. Future research should use a consensus-building approach, such as a multidisciplinary Delphi panel, to further delineate the reporting standards for studies that use process mapping with FMEA.

Health Conditions and Treatment Utilization Among Older Male Veterans Incarcerated in Prisons

BACKGROUND

More than 50,000 older male veterans incarcerated in prisons are expected to return to their communities and utilize the Veterans Health Administration (VHA) and community healthcare systems. To support the continuity of healthcare and overall successful community reentry of older incarcerated veterans, an understanding of their health profiles and treatment utilization while in correctional care is needed.

OBJECTIVE

To assess the health status of older male veterans incarcerated in state prisons and explore demographic, military, and VHA-related factors associated with medical conditions, disabilities, behavioral conditions, and medical and behavioral treatment utilization.

DESIGN/PARTICIPANTS

Cross-sectional observational study of 880 male veterans aged 50 + incarcerated in state prisons using data from the 2016 Bureau of Justice Statistics Survey of Prison Inmates.

MAIN MEASURES

Veteran status, self-report health status, and treatment utilization since prison admission. Prevalence rates for conditions and treatment utilization were calculated. Logistic regression models were used to examine the association of characteristics with conditions and treatment utilization.

KEY RESULTS

Among the 880 older male veterans in state prisons, the majority reported having a current medical condition (79.3%) or disability (61.6%), almost half had history of a mental health condition (44.5%), and more than a quarter (29%) had a substance use disorder. Compared to White veterans, Black veterans were less likely to report a disability or mental health condition. Few demographic, military, and VA-related characteristics were associated with medical or behavioral conditions or treatment utilization.

CONCLUSION

Our results suggest that the VHA and community healthcare systems need to be prepared to address medical and disability conditions among the majority of older male veterans who will be leaving prison and returning to their communities. Integrated medical and behavioral healthcare delivery models may be especially important for these veterans as many did not receive behavioral health treatment while in prison.

Scoping review of military veterans involved in the criminal legal system and their health and healthcare: 5-year update and map to the Veterans-Sequential Intercept Model

BACKGROUND

A previous scoping review of legal-involved veterans' health and healthcare (1947-2017) identified studies and their limitations. Given the influx of literature published recently, this study aimed to update the previous review and map articles to the Veterans-Sequential Intercept Model (V-SIM) - a conceptual model used by key partners, including Veterans Health Administration, veteran advocates, criminal justice practitioners, and local governments to identify intercept points in the criminal legal system where resources and programming can be provided. Developing an updated resource of literature is essential to inform current research, discover gaps, and highlight areas for future research.

METHODS

A systematic search of 5 databases identified articles related to legal-involved veterans' health and healthcare published between December 2017 through December 2022. The first and senior authors conducted abstract reviews, full-text reviews, and data extraction of study characteristics. Finally, each article was sorted by the various intercept points from the V-SIM.

RESULTS

Of 903 potentially relevant articles, 107 peer-reviewed publications were included in this review, most related to mental health (66/107, 62%) and used an observational quantitative study design (95/107, 89%). Although most articles did not explicitly use the V-SIM to guide data collection, analyses, or interpretation, all could be mapped to this conceptual model. Half of the articles (54/107, 50%) collected data from intercept 5 (Community Corrections and Support Intercept) of the V-SIM. No articles gathered data from intercepts 0 (Community and Emergency Services Intercept), 1 (Law Enforcement Intercept), or 2 (Initial Detention and Court Hearings Intercept).

CONCLUSIONS

There were 107 articles published in the last five years compared to 190 articles published in 70 years covered in the last review, illustrating the growing interest in legal-involved veterans. The V-SIM is widely used by front-line providers and clinical leadership, but not by researchers to guide their work. By clearly tying their research to the V-SIM, researchers could generate results to help guide policy and practice at specific intercept points. Despite the large number of publications, research on prevention and early intervention for legal-involved veterans is lacking, indicating areas of great need for future studies.

Exploring Reasons for Non-Engagement From a Peer-Led Diversionary Intervention for Veterans in Police Custody

UK veterans with complex needs arrested in police custody can access support through pre-charge diversion into treatment and ancillary services. We consider why veterans in police custody disengaged from a peer-led criminal justice diversionary support service in one UK region that adopted a continuous case management approach. Seven hundred and fifty-seven veterans were assessed to have high levels of comorbid health needs and socio-economic harms, with one-quarter (26.7%, n = 202) subsequently disengaging from the service. A logistic regression model using Multivariate Imputation by Chained Equations identified that veterans of a younger age, no-fixed-abode, a history of incarceration, and those from a Royal Navy background were likelier to disengage from the intervention. We conclude that this peer-based diversionary model has some efficacy in maintaining the engagement of a highly complex, comorbid segment of criminally-justice-exposed UK military veterans. The perceived benefits of an integrated peer-based model predicated on continuous case-management techniques are discussed.

Dialectical behavior therapy for justice-involved veterans: Changes in treatment targets in a small, pre-post design clinical trial

[Correction Notice: An Erratum for this article was reported online in Psychological Services on Jul 13 2023 (see record 2023-89801-001). In the article, the title was incorrect and should have been "Dialectical Behavior Therapy for Justice-Involved Veterans: Changes in Treatment Targets in a Small, Pre-Post Design Clinical Trial." This error did not impact the results or conclusions. All versions of this article have been corrected.] Dialectical Behavior Therapy for Justice-Involved Veterans (DBT-J; Edwards, Dichiara, Epshteyn, et al., 2022) was recently developed as an integrative psychotherapy + case management intervention to address the range of complex criminogenic, mental health, substance use, and case management needs commonly faced by justice-involved veterans. Research to date suggests delivery of DBT-J to be both acceptable and feasible (Edwards, Dichiara, Epshteyn, et al., 2022). However, data on therapeutic change experienced by DBT-J participants has been limited. The present study represents an initial investigation into longitudinal changes in criminogenic risk, psychological distress, substance use, case management needs, and quality of life experienced by 20 justice-involved veterans across their course of DBT-J participation. Results reflected notable improvements across treatment targets from pre- to posttreatment; these gains were largely maintained at 1-month follow-up. Such findings attest to the potential utility of DBT-J and to the need for continued research into the efficacy of this intervention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Contexts shaping misdemeanor system interventions among people with mental illnesses: qualitative findings from a multi-site system mapping exercise

BACKGROUND

People with mental illnesses are disproportionately entangled in the criminal legal system. Historically, this involvement has resulted from minor offending, often accompanied by misdemeanor charges. In recent years, policymakers have worked to reduce the footprint of the criminal legal system. This paper seeks to better understand how misdemeanor systems intervene in the lives of people with mental illnesses.

METHODS

System mapping exercises were conducted with misdemeanor system stakeholders from the jurisdictions of Atlanta, Chicago, Manhattan, and Philadelphia. Narrative detail on decision-making and case processing, both generally and in relation to specific types of behavior, including trespassing, retail theft/shoplifting, and simple assault, were coded and analyzed for thematic patterns. Based on the qualitative analysis, this paper offers a conceptual diagram of contexts shaping misdemeanor system interventions among people with mental illnesses.

RESULTS

All four sites have been engaged in efforts to reduce the use of misdemeanor charges both generally and in relation to people with mental illnesses. Decision-makers across all sites experience contexts that shape how, when, and where they intervene, which are: (1) law and policy environments; (2) location of the behavior; (3) expectations of stakeholders; (4) knowledge of mental illnesses; and (5) access to community resources. Law and policy environments expand or constrain opportunities for diversion. The location of offending is relevant to who has a stake in the behavior, and what demands they have. Clinical, experiential, and system-level knowledge of mental illnesses inform a chain of decisions about what to do. The capacity to address mental health needs is contingent on access to social services, including housing.

CONCLUSION

People making decisions along the criminal legal continuum are critical to illuminating the dynamic, inter-related contexts that facilitate and frustrate attempts to address defendants' mental health needs while balancing considerations of public safety. Multi-sector, scenario-based or case study exercises could help identify concrete ways of improving each of the contexts that surround whole-of-system decisions.

Parent-identified barriers to accessing exposure therapy: A qualitative study using process mapping

Background

Youth with anxiety and obsessive-compulsive disorder (OCD) rarely access exposure therapy, an evidence-based treatment. Known barriers include transportation, waitlists, and provider availability. Efforts to improve access to exposure require an understanding of the process that families take to find therapists, yet no prior studies have examined parents' perspectives of the steps involved.

Methods

Parents of children who have received exposure therapy for anxiety and/or OCD (N = 23) were recruited from a hospital-based specialty anxiety clinic where the majority of their children previously received exposure. Recruitment was ongoing until thematic saturation was reached. Parents completed questionnaires and attended an online focus group during which they were asked to describe each step they took-from recognizing their child needed treatment to beginning exposure. A process map was created and shown in real-time, edited for clarity, and emailed to parents for member checking. Authors analyzed process maps to identify common themes.

Results

Several themes emerged, as visually represented in a final process map. Participants identified a "search-outreach" loop, in which they repeated the cycle of looking for therapists, contacting them, and being unable to schedule an appointment due to factors such as cost, waitlists, and travel time. Parents often did not know about exposure and reported feeling guilty about their lack of knowledge and inability to find a suitable provider. Parents reported frustration that medical providers did not often know about exposure and sometimes dismissed parents' concerns. Participants emphasized the difficulty of navigating the mental health system; many reported that it took years to find an exposure therapist, and that the search was sometimes stalled due to fluctuating symptoms.

Conclusion

A common thread among identified barriers was the amount of burden placed on parents to find treatment with limited support, and the resultant feelings of isolation and guilt. Findings point to several directions for future research, such as the development of parent support groups for navigating the mental health system; enhancing coordination of care between medical and mental health providers; and streamlining referral processes.

Enhancing community integration after incarceration: findings from a prospective study of an intensive peer support intervention for veterans with an historical comparison group

BACKGROUND

The transition to the community after incarceration presents challenges for returning citizens, including the immediate need to secure housing, employment, and income. Additionally, health care is essential for this population due to high rates of chronic physical health and mental health problems and substance use disorders. There is growing recognition of the need for interventions that support returning citizens as they navigate community reintegration while simultaneously tending to physical and behavioral health needs. We developed and pilot tested a peer support intervention designed to provide social, emotional, and logistic support and promote linkage and engagement in healthcare for returning citizens. We tested the intervention with US military veterans in Massachusetts who were being released from prison and jail. Outcomes related to linkage to and engagement in healthcare were evaluated using an historical comparison group. Engagement in peer support, housing status, and reincarceration rates were monitored for the intervention group.

RESULTS

There were 43 veterans in the intervention group, and 36 in the historical comparison group. For linkage to primary care within 90 days of release, there were no statistically significant differences between the intervention and comparison groups (58% versus 67%). Intervention participants were significantly more likely to receive substance use treatment than the comparison group (86% versus 19%, p < .0001) and the mean monthly substance use visits was greater in the intervention group (0.96 versus 0.34, p < .007). Engagement in mental health services was greater for the intervention group than the comparison group (93% versus 64%, p < .003). There were no significant differences between groups for emergency department use and hospitalization. At the end of the study period, the majority of intervention participants who had been released for over a year were living in permanent housing (84%). Recidivism among the was low, with 7% re-arrested during the study period.

CONCLUSIONS

Augmenting reentry support through intensive peer support appears to have substantial benefits for veterans in terms of engaging them in health care and contributing to their longer-term stability, including housing and recidivism. Flexible reentry support such as this intervention may be well suited to meet the widely varying needs of returning citizens.

Protecting the Public's Health Through Successful Reentry for Sex Offender After Incarceration

This paper describes the post-incarceration reintegration experiences of military veterans convicted of sex offenses and identify potential interventions to ease reintegration for this population. Participants were a convenience sample of 14 veterans who were on sex offender (SO) registries and 21 community stakeholders involved in supporting persons during re-entry. Subjects were identified purposively and through snowball sampling, in Massachusetts. We employed semi-structured qualitative interviews of participants, followed by analysis including process mapping to identify barrier and facilitation points. We used both a grounded thematic approach and a priori codes, guided by the Behavioral Model for Vulnerable Populations. We found re-entry barriers include older age, stigma, lack of social support, inadequate information about sexual offense levels, limited housing options and access to mental health treatment to reduce sexual impulses, and re-entry information tailored to SOs. Re-entry facilitators include access to SO treatment, knowledge about services, self-efficacy, ability to self-advocate, and social support. Interventions to aid successful re-entry include pre-release counseling and classes tailored to SO needs, re-entry planning including housing resources, sexual deviance treatment, and referral to legal counseling to assist with altering assigned SO level. Specific needs and resources unique to veterans should be integrated into reentry plans. Convicted SOs often lack information and assistance to prepare for life after release, putting them at increased risk of homelessness, emotional difficulties, and financial hardship. Failure to recognize the unique needs of this population, and to leverage resources, creates a public health risk as it increases the likelihood that SOs will recidivate. Veterans who are SOs have unique resources available to them through the Veterans Administration such as SO treatment and peer-support specialists. Nevertheless there are additional steps that could be beneficial, such as timely provision of information, creating more opportunities for treatment, and providing more housing options.

Development of a workflow process mapping protocol to inform the implementation of regional patient navigation programs in breast oncology

BACKGROUND

Implementing city-wide patient navigation processes that support patients across the continuum of cancer care is impeded by a lack of standardized tools to integrate workflows and reduce gaps in care. The authors present an actionable workflow process mapping protocol for navigation process planning and improvement based on methods developed for the Translating Research Into Practice study.

METHODS

Key stakeholders at each study site were identified through existing community partnerships, and data on each site's navigation processes were collected using mixed methods through a series of team meetings. The authors used Health Quality Ontario's Quality Improvement Guide, service design principles, and key stakeholder input to map the collected data onto a template structured according to the case-management model.

RESULTS

Data collection and process mapping exercises resulted in a 10-step protocol that includes: 1) workflow mapping procedures to guide data collection on the series of activities performed by health care personnel that comprise a patient's navigation experience, 2) a site survey to assess program characteristics, 3) a semistructured interview guide to assess care coordination workflows, 4) a site-level swim lane workflow process mapping template, and 5) a regional high-level process mapping template to aggregate data from multiple site-level process maps.

CONCLUSIONS

This iterative, participatory approach to data collection and process mapping can be used by improvement teams to streamline care coordination, ultimately improving the design and delivery of an evidence-based navigation model that spans multiple treatment modalities and multiple health systems in a metropolitan area. This protocol is presented as an actionable toolkit so the work may be replicated to support other quality-improvement initiatives and efforts to design truly patient-centered breast cancer treatment experiences.

LAY SUMMARY

Evidence-based patient navigation in breast cancer care requires the integration of services through each phase of cancer treatment. The Translating Research Into Practice study aims to implement patient navigation for patients with breast cancer who are at risk for delays and are seeking care across 6 health systems in Boston, Massachusetts. The authors designed a 10-step protocol outlining procedures and tools that support a systematic assessment for health systems that want to implement breast cancer patient navigation services for patients who are at risk for treatment delays.

An application of agent-based modeling to explore the impact of decreasing incarceration rates and increasing drug treatment access on sero-discordant partnerships among people who inject drugs

BACKGROUND

People who inject drugs (PWID) lag behind other key populations in HIV care continuum outcomes. The impacts of criminal justice reform and increasing drug treatment access on HIV have been underexplored.

METHODS

We developed agent-based models (ABM) of sexual partnerships among PWID and non-PWID, and injection equipment-sharing partnerships among PWID in five US cities (Baltimore, Boston, Miami, New York City, San Francisco) over 3 years. The first set of ABM projected changes in partnership discordance among PWID as a function of decreasing ZIP code-level incarceration rates. The second set projected discordance as a function of increasing ZIP code-level drug treatment access. ABM were parameterized and validated overall, and by city and PWID race/ethnicity (Black, Latino, White) using National HIV Behavioral Surveillance data, administrative ZIP code-level data, surveillance reports and prior literature. Informed by research on prisoner release and community-level HIV prevalence, reductions in incarceration rates were fixed at 5% and 30% and respectively projected to increase ZIP code-level HIV prevalence by 2% and 12%. Increases in drug treatment access were fixed at 30% and 58%.

RESULTS

In each city, a 30% reduction in ZIP code-level incarceration rates and 12% increase in ZIP code-level HIV prevalence significantly increased sero-discordance among at least one racial/ethnic group of PWID by 1-3 percentage points. A 5% reduction in incarceration rates, and 30% and 58% increases in drug treatment access, led to isolated significant changes in sero-discordance among Black and White PWID that were less than 1 percentage point.

CONCLUSION

Reductions in incarceration rates may lead to short-term increases in sero-discordant partnerships among some PWID by increasing community-level HIV prevalence. Efforts to increase HIV testing, engagement in care and community reintegration post release, should be strengthened in the wake of incarceration reform. Additional research should confirm these findings and explore the lack of widespread impacts of drug treatment in this study.

Process mapping in healthcare: a systematic review

INTRODUCTION

Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare.

METHODS

We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach.

RESULTS

The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions.

CONCLUSION

The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM.

TRIAL REGISTRATION

Prospero ID: CRD42017082140.

Making change happen in criminal justice settings: leveraging implementation science to improve mental health care

BACKGROUND

It is a constitutional right to receive health care, including mental health care, while incarcerated. Yet, even basic evidence-based mental health care practices have not been routinely integrated into criminal justice (CJ) settings. Strategies from implementation science, or the study of methods for integrating evidence-based practices into routine care, can accelerate uptake of established interventions within low-resource, high-need settings such as prisons and jails. However, most studies of mental health practices in CJ settings do not use implementation frameworks to guide efforts to integrate treatments, systematically select or report implementation strategies, or evaluate the effectiveness of strategies used.

CASE PRESENTATIONS

After introducing implementation science and articulating the rationale for its application within CJ settings, we provide two illustrative case examples of efforts to integrate mental health interventions within CJ settings. Each case example demonstrates how an implementation framework either was applied or could have been applied to promote intervention adoption. The first focuses on poor implementation of a mental health screener in a county jail, retrospectively highlighting how use of a determinants framework (e.g., the Consolidated Framework for Implementation Research [CFIR]) could help staff identify factors that led to the implementation failure. The second describes an investigator-initiated research study that used a process framework (the Exploration, Preparation, Implementation, Sustainment [EPIS] framework) to systematically investigate and document the factors that led to successful implementation of a psychotherapy group for survivors of sexual violence in a women's community corrections center. Both are presented in accessible language, as our goal is that this article can be used as a primer for justice health researchers, community partners, and correctional leadership who are unfamiliar with implementation science.

CONCLUSIONS

Scientific research on the application of implementation science to justice settings is growing, but lags behind the work done in health systems. Given the tremendous need for mental and behavioral health intervention across the full spectrum of justice settings, information on how to successfully implement evidence-based intervention and prevention efforts is sorely needed but possible to obtain with greater integration of knowledge from implementation science.

Implementation Science to Respond to the COVID-19 Pandemic

The COVID-19 pandemic continues to expand globally, requiring massive public health responses from national and local governments. These bodies have taken heterogeneous approaches to their responses, including when and how to introduce and enforce evidence-based interventions-such as social distancing, hand-washing, personal protective equipment (PPE), and testing. In this commentary, we reflect on opportunities for implementation science to contribute meaningfully to the COVID-19 pandemic response. We reflect backwards on missed opportunities in emergency preparedness planning, using the example of PPE stockpiling and supply management; this planning could have been strengthened through process mapping with consensus-building, microplanning with simulation, and stakeholder engagement. We propose current opportunities for action, focusing on enhancing the adoption, fidelity, and sustainment of hand washing and social distancing; we can combine qualitative data, policy analysis, and dissemination science to inform agile and rapid adjustment to social marketing strategies to enhance their penetration. We look to future opportunities to enhance the integration of new evidence in decision-making, focusing on serologic and virologic testing systems; we can leverage simulation and other systems engineering modeling to identify ideal system structures. Finally, we discuss the ways in which the COVID-19 pandemic challenges implementation science to become more rapid, rigorous, and nimble in its approach, and integrate with public health practice. In summary, we articulate the ways in which implementation science can inform, and be informed by, the COVID-19 pandemic, looking backwards, proposing actions for the moment, and approaches for the future.

Coordinating across correctional, community, and VA systems: applying the Collaborative Chronic Care Model to post-incarceration healthcare and reentry support for veterans with mental health and substance use disorders

BACKGROUND

Between 12,000 and 16,000 veterans leave incarceration annually. As is known to be the case for justice-involved populations in general, mental health disorders (MHDs) and substance use disorders (SUDs) are highly prevalent among incarcerated veterans, and individuals with MHDs and SUDs reentering the community are at increased risk of deteriorating health and recidivism. We sought to identify opportunities to better coordinate care/services across correctional, community, and VA systems for reentry veterans with MHDs and SUDs.

METHODS

We interviewed 16 veterans post-incarceration and 22 stakeholders from reentry-involved federal/state/community organizations. We performed a grounded thematic analysis, and recognizing consistencies between the emergent themes and the evidence-based Collaborative Chronic Care Model (CCM), we mapped findings to the CCM's elements - work role redesign (WRR), patient self-management support (PSS), provider decision support (PDS), clinical information systems (CIS), linkages to community resources (LCR), and organizational/leadership support (OLS).

RESULTS

Emergent themes included (i) WRR - coordination challenges among organizations involved in veterans' reentry; (ii) PSS - veterans' fear of reentering society; (iii) PDS - uneven knowledge by reentry support providers regarding available services when deciding which services to connect a reentry veteran to and whether he/she is ready and/or willing to receive services; (iv) CIS - lapses in MHD/SUD medications between release and a first scheduled health care appointment, as well as challenges in transfer of medical records; (v) LCR - inconsistent awareness of existing services and resources available across a disparate reentry system; and (vi) OLS - reentry plans designed to address only immediate transitional needs upon release, which do not always prioritize MHD/SUD needs.

CONCLUSIONS

Applying the CCM to coordinating cross-system health care and reentry support may contribute to reductions in mental health crises and overdoses in the precarious first weeks of the reentry period.