Reentry into the community, of individuals who have been incarcerated, is a complex process. It is comprised of multiple interdependent steps, which involve a collection of resources, services, and organizations that interact with individuals leaving incarceration and undergoing reentry. A shared understanding of this process, among all involved individuals and teams, is thus critical in implementing an intervention to change and improve the process. We describe here an experimental use of process mapping to better enable such shared understanding of the process, for efficient and collaborative implementation work to enhance support for veterans who are leaving incarceration and reentering the community.

Process mapping is a visualization technique widely used in manufacturing and business, and more recently applied to health care and social services (Gimbel et al. 2014; Zelenitsky et al. 2014). It contributes to precise descriptions of complex processes and illustrates where steps in a process may diverge, occur in parallel, or exhibit gaps and uncertainties. The health care domain in which process maps are most often used is quality improvement, where it is deemed essential to first assess the shortcomings of the current process then design a new one to specifically target those very shortcomings. The common steps included in process mapping, as outlined within the Institute for Healthcare Improvement’s QI Essentials Toolkit (QI Essentials, 2017), are to (i) gather information about the process from those who know it the best, (ii) define clearly the first and last step in the process, (iii) articulate each step in the process (as it actually is, not as it should be), and (iv) represent using visual shapes (e.g., circles, rectangles, arrows; Fig. 1’s legend provides more detail on each shape) the articulated process.

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 Full size image

What is yet to be explored is whether process mapping can be used with formative assessment (Stetler et al. 2006) data (e.g., qualitative stakeholder interview data), prior to any interventions being developed. It will be valuable to determine if process mapping helps to understand the spatiotemporal connections between the steps of a given process, which can in turn be used to identify enhancements or modifications to programs, services, and other interventions that often involve multiple interrelated stakeholders (i.e., individuals impacting and/or impacted by the process) and organizations. The reentry support process that we focus on here exemplifies one such complex process, which involves multiple steps, institutions (federal, state, city, and private), and contingencies (e.g., the type of criminal offense often dictates available paths and resources), and it may unfold over days or weeks. Thus, using process mapping, our aims were (i) to understand the current process through which veterans are supported by organizations that work to connect them to health care and other services after leaving incarceration (“reentry support organizations”) and (ii) to identify where in the current reentry support process there are challenges that can potentially be addressed through the addition of peer support specialists.

This work was a formative step in a larger Post-Incarceration Engagement (PIE) project to implement a peer-based intervention to enhance reentry support for veterans (Simmons et al. 2017). Between 12,000 and 16,000 veterans leave incarceration every year (Homeless Services Cube 2014). Based on studies not limited to the veteran population, individuals leaving incarceration are known to often face discrimination or exclusion upon reentering their communities (Dennis et al. 2015), and homelessness, relapse in substance use behaviors, and increased mental health problems are a few of many issues related to such vulnerable populations facing discrimination and exclusion (Campbell et al. 2015; Mays et al. 2017). About 50% of veterans incarcerated in state prisons report having experienced symptoms of mental health disorders, and about 75% report using drugs prior to incarceration (Noonan and Mumola 2007). The period of transition out of incarceration is a particularly vulnerable time for these veterans, as they are likely to experience a disruption in their established mental health and substance use treatment and associated medications (Baillargeon et al. 2009; Meyer et al. 2011; Massoglia and Schnittker 2009; Hartwell et al. 2013).

The Department of Veterans Affairs (VA)’s Health Care for Reentry Veterans program links them to VA and community health care services (VHA Health Care for Reentry Veterans 2014). However, resources are limited and many veterans may not receive sufficient post-release emotional and instrumental support (Wortzel et al. 2012). Homelessness and criminal justice recidivism may result when such follow-up and support are lacking (Baillargeon et al. 2009; Meyer et al. 2011; Swan 2015). The main aims for the larger PIE project are therefore to (i) conduct contextual analysis to identify VA and community reentry resources, and describe how reentry veterans use them (this paper falls under this first aim of the larger project) and (ii) implement peer-support, in one state, to link reentry veterans to VA primary care, mental health, and substance use disorder services, then (iii) port the peer-support intervention to another, geographically and contextually different state (Simmons et al. 2017).

Peer programs have been found to decrease risk behaviors and improve health among justice-involved populations (Bagnall et al. 2015; Nyamathi et al. 2015). Benefits of using peers over non-peer professionals include how peers have had more similar experiences as support recipients, and are thus able to offer relevant advice and hope (Solomon et al. 1998; Blodgett et al. 2013). Especially for individuals with mental health and substance use disorders, peer programs have demonstrated effectiveness in improving their linkage and engagement with services (Bagnall et al. 2015; Nyamathi et al. 2015; Blodgett et al. 2013). Although there is some evidence that peer programs may improve a variety of outcomes for the reentry population (Rowe et al. 2007; Goldstein et al. 2009; Marlow et al. 2015), there are few published interventions focusing on veterans. To address this evidence gap, this paper describes how process mapping contributed to the design of a locally relevant peer-support intervention to assist veterans as they return to community settings after incarceration. Process mapping was used to extract and analyze process-related information that is available within formative qualitative interview data. This work can be understood in the context of the Sequential Intercept Model (SIM), which outlines the criminal justice continuum from arrest, to court appearances, and to community reintegration (Munetz and Griffin 2006). But whereas SIM is a generalized outline of the entire criminal justice system indicating points for potentially diverting individuals out of the system, our examination takes a micro view of the last two steps in SIM – release from incarceration and support in the community.

We demonstrate how we first gathered information from qualitative interviews with representatives of reentry support organizations. We share how we systematically generated process maps based on the information gathered, and we provide examples of the maps themselves to help illustrate their utility. Some data are provided in this paper (process details from the interviews), but our focus is on how process mapping can inform intervention planning when interventions are to be implemented within contexts that involve multiple stakeholders and organizations. Details of the larger project that are less directly related to this process mapping work (e.g., procedure for implementing and evaluating the peer support intervention, grounded thematic analysis using interview data on topics beyond the reentry support process) are provided within the larger study’s protocol paper (Simmons et al. 2017).

Through this work, we portray several reasons why other researchers should consider process mapping to guide intervention planning and implementation for studies of justice-involved populations. First, we show that process mapping can be conducted based on formative assessment data from stakeholder interviews, a data collection approach often included in studies of justice-involved populations (Taxman et al. 2013; Shafer et al. 2014; Belenko et al. 2013). Second, the reentry support process that we are targeting is one that involves multiple interrelated stakeholders and organizations (for which process mapping is well suited), which is a common situation faced by many studies of justice-involved populations being carried out (Becan et al. 2018; Fisher et al. 2018; Friedmann et al. 2013). Third, our project will later involve tailoring our peer-support intervention and implementation (first developed for Massachusetts) to other states’ contexts (for which process mapping helps to visualize key process differences across contexts that need to be accounted for), which is similar to expansion efforts of many studies on justice-involved populations that target multiple sites (Ducharme et al. 2013).