Veterans Justice Reentry (Post-Incarceration) (QUE 15-284)
Phase: NA
Conditions: Linkage to Care, Homelessness, Substance Use Disorder, Mental Health
Sponsor: VA Office of Research and Development

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Protocol 
 
Official Title: Veterans Justice Reentry (Post-Incarceration) (QUE 15-284) 
 
Brief Title: Improving Linkage to Health and Other Services for Veterans Leaving 
Incarceration (PIE) 
 
ClinicalTrials.gov ID: NCT02964897 
 
Unique Protocol ID: QUX 16-012 
 
Date Bedford R&D determined to be non-research: 1/14/2016 
 
Study Principal Investigator: D. Keith McInnes, ScD MS BA 
 
Document date: September 7, 2021

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Veterans Justice Reentry, Post-Incarceration Engagement Project, Massachusetts 
 
 
1.  SPECIFIC AIMS 
 
Veterans leaving incarceration (henceforth, “reentry Veterans”) are among the most underserved by the VA 
and thus are an increasingly high priority population. The Bureau of Justice Statistics estimates that 140,000 
Veterans are incarcerated in the U.S. at a given time, approximately 80% of whom are eligible for VA benefits 
(Noonan 2007).  Among Veterans incarcerated in state prisons nationally, 75% reported using drugs prior to 
incarceration, and roughly 25% of those reported injection drug use history (Noonan 2007).  Also, about 50% 
of incarcerated Veterans report having recently experienced symptoms of mental health disorders (Noonan 
2007). Veterans are more likely to report a recent history of mental health (MH) service use (30%) than non-
Veterans (24%) (Noonan 2007). The VA’s national Health Care for Reentry Veterans (HCRV) program 
identifies 10,000-15,000 incarcerated Veterans annually preparing to transition back to the community (2014).  
Despite many health needs, it is difficult to link reentry Veterans to Veterans Health Administration (VHA) 
primary care (the gateway to all VHA health care services).  Lack of linkage to health care can lead to a 
downward spiral in health and mental health from worsening substance use disorders (SUDs) or MH, or from 
complications from hypertension and diabetes. This worsening health can lead to inefficient use of emergency 
and hospital services, and can derail progress in vocational training, education, work, and housing, which may 
lead to re-offending and re-incarceration (Visher 2003; Travis 2005; Mallik-Kane 2008; Baillargeon, Giordano 
et al. 2009; Meyer, Chen et al. 2011; Swan 2015).  
The HCRV program was started to combat these issues.  A designated outreach specialist works with 
incarcerated VHA-eligible Veterans to establish a post-release plan for linkage to VHA services (2014).  This 
program, with 1-2 outreach specialists per state, has improved the connection between reentry Veterans and 
the VHA.  However, our analyses of homeless program data linked to CDW indicate that 43% of eligible HCRV 
Veterans do not have a VHA outpatient contact in the first 4 months post incarceration. Reducing this number 
is critical given the elevated rates of chronic health conditions, as well as MH or SUDs in this population 
(Noonan 2007; Taxman 2010; Maruschak 2012). To address this gap, we will work with the national HCRV 
office to implement an evidence-based peer support intervention to extend the reach and effectiveness of the 
HCRV program in linking Veterans to VHA.  Peers with incarceration experience are likely to better understand 
and connect with Veterans on a personal level than the outreach specialist, and thus are more likely to 
maintain contact and link to VHA during the first months post-release (Blodgett 2013; Chinman, George et al. 
2014; Bagnall, South et al. 2015). Peers are gaining popularity in forensic settings (called “forensic peer 
specialists”) with civilian populations and would likely be beneficial for a Veteran population (Miller and 
Massaro 2008) .  The aims of this project are,  
1. Conduct contextual analysis to identify VA and community reentry resources, and to describe how reentry 
Veterans use them.  
2. Implement peer-support to link reentry veterans to VHA primary, mental health, and SUD services. We will 
use external and internal facilitation as the implementation strategy.   
3. At the end of this project, we will develop a proposal for a multi-VISN expansion study, which will use a 
hybrid type III, stepped-wedge design, to demonstrate effectiveness in multiple geographic and contextual 
settings. 
 
2. RATIONALE 
 
Reentry from incarceration is a precarious time.  Individuals (including Veterans) leaving incarceration often 
have complicated biopsychosocial needs (Mallik-Kane 2008).  They face many barriers to accessing needed 
services for co-occurring substance use and MH disorders, infectious diseases, other chronic medical 
conditions. Homelessness, unemployment, and financial instability are prevalent (Visher 2003; Travis 2005; 
Baillargeon, Giordano et al. 2009; Meyer, Chen et al. 2011; Swan 2015).  Literally overnight they experience 
sudden responsibilities, and competing needs, and yet they have rusty social and self-management skills, and 
may mistrust service providers and health care systems (Visher 2003; Meyer, Chen et al. 2011; Anaya 2012).  

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A 2012 study examined Veterans leaving Los Angeles jails and found that, commonly, Veterans held negative 
views of the VA and were resistant to link to VHA services upon their release (Anaya 2012). Peers may help 
bridge this mistrust. 
Reentry represents a major break in continuity of care (Palepu 2004; Springer and Altice 2005; Harzke 
2006; Baillargeon, Giordano et al. 2009; Massoglia 2009; Meyer, Chen et al. 2011).  Compared to the other 
pressing needs, health needs are often de-prioritized by the reentering individual due to drug use relapse 
and/or untreated mental health disorders (Seaman 1198; Visher 2003; Inciardi 2007; Pettus-Davis 2009; 
Rebholz 2009; Merrall 2010; Meyer, Chen et al. 2011; Swan 2015). Without addressing a Veteran’s behavioral 
and physical health issues, the other components of reentry and reintegration (housing, employment, family, 
etc.) can be undermined, which may lead to unstable housing or homelessness, or repeat incarceration.  The 
VA established the HCRV program to: 1) identify Veterans incarcerated in state and Federal prisons, 2) 
conduct a clinical assessment of these Veterans’ needs, and 3) link them to the services that they need when 
they transition back to the community after they complete their sentence (2014; 2015; 2015). 
Preliminary research (Anaya 2012) and discussions with operational partners indicate that the HCRV 
program excels at identifying incarcerated Veterans and conducting reentry planning – a process that occurs 
inside prisons and jails. However, the HCRV outreach specialists have quite limited time, given the very small 
size of the program and the demand that they cover such large geographic areas, to ensure that Veterans link 
to and engage with VHA in the first months post-release.  Such attention to reentry success requires frequent 
contact with these Veterans and a thorough understanding of their abilities, potential pitfalls, needs and 
priorities during this vulnerable and thus critical period.  Better meeting reentry Veterans’ needs would be 
facilitated if HCRV could leverage other VA and community resources such as peers who understand the 
attitudes and experiences of reentry Veterans and who can build rapport (Chinman, Shoai et al. 2010).  
Studies have shown that in various settings, including VA, peer-mentoring facilitates health related behavior 
change (Chinman, Lucksted et al. 2008; Blodgett 2013; Chinman, George et al. 2014; Bagnall, South et al. 
2015).  Peer-support provided in prison environments, and to individuals under community corrections 
supervision (such as parole) is effective at reducing risk behaviors and improving health among justice-
involved populations (Bagnall, South et al. 2015; Nyamathi, Salem et al. 2015), and a recent structured 
evidence review has shown that peers provide critically important emotional, informational, and instrumental 
support for this justice-involved Veterans (Blodgett 2013). Moreover, in the context of Veterans treatment 
courts, peer support has been shown to facilitate linkage to VHA services and Veterans’ progress through their 
treatment programs and goals (Blodgett 2013).  It is reasonable to expect a similar facilitating effect of peer 
support with reentry Veterans in linking and engaging them in needed treatment services. 
 
3.  PROCEDURES:  
 
Peer-Support Interventions: Peers provide support that differs from professionals (Solomon, Jonikas et al. 
1998).  First, peers tend to offer practical help; second, relationships between the peer and the recipient may 
involve self-disclosure and friendship; and third, peers can offer hope as a result of having experienced similar 
issues.  In the current project a peer will be a Veteran who has been incarcerated, but has not committed a 
felony (which would prevent many reentry Veterans with associating with the peer), and who has received VHA 
services.   The peer support program will be adapted from two models: one developed by O’Toole, shown 
highly effective in an RCT with homeless Veterans, involves basic health-related instrumental support (e.g. 
accompanying to 1st clinic visit) to help link and engage vulnerable Veterans in VHA health (O'Toole, Johnson 
et al. 2015), while the other is Ellison’s VetSEd model which is a recovery oriented approach supported by 
RCTs (Ellison, Mueller et al. 2012; Smelson, Kalman et al. 2012; Smelson, Kline et al. 2013), to assist 
returning OIF/OEF/OND Veterans reintegrate into civilian life (Ellison, Mueller et al. 2012). The proposed 
HCRV peer support program will focus on a limited number of specific health-related linkage and engagement 
goals – recognizing that for several years the Veterans will have used few health navigation and management 
skills. Our guidebook, to be developed during the project by building on O’Toole and Ellison materials, will 
likely consist of modules such as these: a) understanding the goals, elements, and processes of the HCRV 
program; b) insights and experiences that peers bring; c) review of VHA services (and community services) 
that emphasize primary care, MH, and SUD; d) navigating reentry Veterans to their first and subsequent 
health-related appointments; and, e) facilitating, motivating, and advising skills.  2 peers will be hired for each 
state.  Peers will be expected to have at least twice monthly contact with each Veteran (Smelson 2010).  One 

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of the first Veteran-peer encounters will involve accompanying the Veteran to his first VHA health care 
appointment and orienting him to check-in, appointment making, laboratory, and pharmacy.  Other encounters 
may include reviewing health-related priorities and goal setting, assistance with health tasks (e.g. refilling 
prescriptions), and brief motivational interviewing related to health goals. Training of peers will be conducted by 
Drs. Smelson, Ellison, Swan and Visher, over a 4-day period, at Bedford VAMC.  Following training, the HCRV 
team (VISN coordinator(s), outreach specialists, and peers) will participate on twice monthly conference calls, 
led by the trainers and the external facilitators (McInnes and Swan), to discuss issues that arise in the use of 
peer support.   
 
Implementation Frameworks and Strategy: Guided by our QUERI’s selection of Consolidated Framework 
for Implementation Research (CFIR), we will ensure that our intervention is appropriate for the contexts in 
different states.  Context, in CFIR, is delineated by the domains of Outer Setting (e.g. external policies, patient 
needs and resources) and Inner Setting (e.g. structure of the organization, culture). As with the other 
BridgeQUERI projects, we have selected facilitation as our implementation strategy. In addition our peer-
support intervention is enhanced by the Behavioral Model for Vulnerable Populations (BMVP), (see description 
of BridgeQUERI Implementation Core), namely Predisposing characteristics (demographics, social structure, 
health beliefs), Enabling characteristics (personal/family, community, insurance, competing needs, ability to 
negotiate bureaucracy), and health-related Need based factors( perceived and evaluated health conditions). 
We propose both external and internal facilitation, because we are working in a complex setting with a highly 
complex population (Stetler, Legro et al. 2006; Jones, Auton et al. 2008; Kirchner, Kearney et al. 2014).  To our 
knowledge there has been no evaluation of facilitation as an implementation strategy for state-level 
implementation of a VA program.  Thus we have an excellent opportunity to contribute to the VA knowledge 
base on using facilitation as an implementation strategy.  Additionally, we will vary the organizational level of 
internal facilitation.  The internal facilitator will be one of the Outreach Specialists (Thomas Baker, LCSW). 
Facilitation will include use of a manualized peer-support training (using a peer-support guidebook from Aim 1), 
and ongoing problem solving and technical assistance provided to VISN HCRV leadership, outreach 
specialists, and peers over the course of the project.  Our implementation strategy was developed with our 
operational partners at HCRV program.  They have great interest in HCRV program differences from state to 
state, realizing that states vary considerably in the resources available for reentry programs, and the 
supportiveness of the culture in relation to ex-offenders. 
 
Project Plan Overview:  We propose to implement the Post Incarceration Engagement intervention in 
Massachusetts using a facilitation implementation strategy.  We conduct formative and summative analyses, 
including assessment of fidelity, and a matched comparison group to evaluate the intervention’s Veteran 
outcomes of linkage and engagement in VHA health care (using health care utilization measures).  The project 
proceeds in 3 phases (see Figure 1).  First, in preparation for implementation of peer-support intervention in 
the first state, we will conduct a contextual analysis in MA of the resources available in VHA and in community 
organizations to meet the needs of Veterans released from incarceration (Aim 1), development of peer-support 
guidebook (based on findings of the contextual analysis) and hiring of 2 peers. Next the intervention will be 
implemented in MA (Aim 2).  It will last 6 months with a total of 30 Veterans receiving the peer support.  We will 
identify a matched sample of comparison reentry Veterans. Qualitative formative and summative interviews will 
be conducted with a sample of stakeholders and Veterans to assess fidelity of the intervention.  A review of 
peer worksheets documenting contacts with Veterans will also help evaluate fidelity evaluation.  Utilization of 
VHA primary care, mental health care, and SUD care will be evaluated through chart reviews, and self-report 
(self-report for intervention Veterans only).  Finally we will develop a proposal for the spread of this intervention 
through the use of a cluster-randomized multi-VISN hybrid implementation-effectiveness study (Aim 3).   
Design and Methods: Key Outcomes: Our Veteran level outcomes include # of primary care visits, MH 
visits, and SUD visits (where diagnosis indicates appropriateness); and missed opportunity rates (no-shows 
and cancellations) for primary care, MH, and SUD visits.  Secondary outcomes include # of emergency room 
(ER) visits, hospitalizations, and hospital days – these are also being assessed in the BridgeQUERI MISSION 
project, providing cross-project comparisons. Our main implementation outcome will be fidelity of the 
intervention as implemented, in comparison to core elements as contained in the peer-support guidebook. We 
use a practical approach based on the NIH’s Behavioral Change Consortium fidelity framework for 
psychosocial Treatments (Bellg, Borrelli et al. 2004). Our two primary fidelity measures are number of peer 

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contacts attempted and made with each Veteran, number of months in the 6 month-intervention period in 
which a Veteran had at least 1 peer contact, proportion of contacts in person and by phone.  This will be 
assessed through a Peer Encounter Workload form adapted from Ellison, which is completed by the peer and 
includes his weekly delivery of service, the types of contacts (in person, phone) and the content discussed 
(e.g, navigating VHA, logistics of appointments, or increasing motivation for seeking health care).(Ellison, 
Mueller et al. 2012) 
 
Phase 1: Contextual Analysis and Preparation for Implementation in Massachusetts.  We will 
conduct contextual analysis (Chambers, Mustard et al. 2013; Chambers, Glasgow et al. 2013; Lyon, Pullmann 
et al. 2015) through interviews and network mapping (Aim 1).  At the end of this phase the findings will be 
incorporated into the peer-support guidebook.  This phase will involve interviewing Veterans (thrice over 6 
months) and stakeholders (once).  Network mapping is a technique used in business and engineering, and is 
increasingly being applied in health care.  It involves documenting potential paths that individuals and groups 
follow in the process of accomplishing a task (here, linkage to primary care and other health services)(Lyalin 
and Williams 2005; Williams, Lyalin et al. 2005; Rico, Yalcin et al. 2014).  We use interview questions that seek 
temporal, spatial, and participatory information.  The timing, sequence, and duration of Veterans’ contacts with 
individuals and organizations are mapped in an activity diagram (Lyalin and Williams 2005), which are then 
combined to comprehensively map the network of reentry-related contacts that Veterans make. These maps 
may reveal unhelpful contacts, waiting between contacts, and useful but infrequently tapped resources.   
Population: There are about 200 Veterans, released from Massachusetts prisons each year.  Recruitment of 
Veterans: We will use a method currently in use VHA by a contractor, Policy Research Associates (Delmar, 
NY), to contact reentry Veterans.  During prison visits, the outreach specialists will collect contact information 
from incarcerated Veterans who indicate willingness to participate in the project after their release.  The 
outreach specialist will provide our team with the contact sheets of those Veterans and their release dates. We 
will contact these Veterans after their release, enrolling 10 Veterans.  Inclusion/Exclusion: Released from an 
MA state prison, eligible for VHA services, and no history of dementia.  
Data Sources, Collection, and Analysis: The 10 Veterans will each be interviewed 3 times (at 1-week, 1-
month, and 6-months post-release), while up to 20 stakeholders will be interviewed once.  Interview questions 
will be guided by CFIR and BMVP frameworks, address patient needs and resources (CFIR) and enabling 
characteristics and health-related need based factors(BMVP) (see Section 3, above). As indicated above, the 
interviews will also involve questions to create activity diagrams and network maps.  (See draft interview guide 
in Appendix)  Stakeholder Interviews: participants will include leaders, managers, and providers in VA (e.g. 
primary care, MH, SUD, homeless programs) and in non-VA organizations.  Community interviews will include 
stakeholders from community organizations such as health care for homeless programs, programs for persons 
with justice involvement, hospital ERs, and Vet Centers.  Discussions with community organizations indicates 
high interest in participation on this project (see letter of support from Boston Health Care for the Homeless 
Program; and from the National Health Care for the Homeless Council). Veterans will receive a $25 store gift 
card for completion of each interview. Analysis will involve verbatim transcription of interview audio recordings, 
and use of NVIVO, a qualitative data analysis software (this will be the procedure for all interviews in all 
phases).  Drs. Swan, Kim, and Drainoni will separately code transcripts using a-priori coding (based on CFIR 
and BMVP constructs) for example coding for Enabling characteristics and health Need. They will also use 
tenets of grounded theory to identify new themes that may help understand issues related to linkage and 
engagement in health care. Dr. Kim will conduct the network analysis and then the research team will combine 
interview and network map findings to create two descriptions of reentry resources: one from the perspectives 
of Veterans and reentry stakeholders, respectively. This information will guide the content of the peer-support 
intervention, and will be incorporated into the peer-support guidebook. 
 
Phase 2 -  MA Implementation of Peer Support. This phase involves implementation and evaluation of 
the peer-support intervention in MA. For Population, Recruitment of Veterans, Inclusion/Exclusion, see Phase 
1, above.  Our target is 30 Veterans receiving peer support.  We will enroll Veterans on a rolling basis as 
released from MA correctional facilities. We will use HOMES database to create a matched comparison group 
of Veterans released in the same time period in MA, matching on demographics, SUD/MH diagnoses, criminal 
offense, length of incarceration, and # of arrests.  Intervention will last for 6 months for any single Veteran, with 
peers having caseloads of 15 Veterans (Dihoff 2009).  A VISN 1 outreach specialist, Thom Baker, will serve as 

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internal facilitator, while McInnes and Swan will be external facilitators. Peer Training: see above in “Peer-
Support Intervention”.  
Data Sources, Collection and Analysis: Peers will administer a health care utilization questionnaire with 
intervention Veterans at baseline (week 1) and at 6 months to capture information about VA and non-VA health 
service use (the former for comparison with VA medical record data).  
Analysis: During implementation we will collect formative evaluation data about the intervention through 
interviews (5 stakeholders and 5 Veterans).  We will assess elements of the implementation by learning what 
meanings the participants (stakeholder, peers, Veterans) assign to the intervention and the processes that the 
intervention is designed to affect (Orlikowski and Baroudi 1991).  We will also conduct summative evaluation, 
including qualitative interviews (5 Veterans and 5 stakeholders) to evaluate, for example, whether peers were 
Enabling linkage to and engagement in health care, and whether this helped address Veteran’s health care 
Need.  With stakeholders we will explore the effectiveness of external and internal facilitation, and identify 
facilitators and barriers to implementation.  Quantitatively, we will use HOMES and CDW to compare 
intervention and comparison Veterans. Also for intervention Veterans we will have self-report diagnoses and 
utilization from baseline and 6-month follow up (including utilization of non-VA health care sources). We will 
compare rates of visits for primary care, MH, and SUD between intervention and comparison groups using t-
tests and chi-square tests.   For our secondary measures we will compare intervention to comparison Veterans 
on ER and hospital use (episodes and # of days) during the 6 month reentry period. 
 
Key Covariates. We will use CDW and HOMES data to evaluate whether there are substantial differences 
between the intervention and comparison Veterans at baseline.  This approach accounts for the possibility that 
observed differences in our outcomes, such as linkage rates, may be partially explained by factors such as 
duration of sentence, severity of crime, number of incarcerations, ever used VHA services, length of time since 
last used VHA services, and socio-demographics such as age and race.  
Additional Design Considerations: The focus of the Post-Incarceration project is to develop 
implementation methods, materials and training, identify appropriate level of internal facilitation, and assess 
dissemination processes across different states.  It is not designed to demonstrate a statistically significant 
effect of the intervention. With the anticipated sample size of 30 in the peer-support intervention groups and 
the 30 in the comparison group, the linkage rate, now at 57%, would need to increase by at least 20% to detect 
the intervention effect with 80% power at the 0.05 significance level. However, our measurement of these 
outcomes in the current project will allow us to estimate effect sizes and sample sizes for the next phase of this 
implementation, i.e. a cluster-randomized multi-VISN hybrid implementation-effectiveness study (this next 
phase will occur after the current project, supported by a separate funding source). 
 
4. IMPACT 
 
The implementation work described here is highly aligned with our operational partners in the national HCRV 
program (see letter of support) who recognize many HCRV Veterans are not linking to VHA, and likely are 
receiving inadequate care from a patchwork of sources.  It helps address the known challenge for HCRV of 
overcoming reentry Veterans’ mistrust of and past negative experiences with large systems – a process that 
data indicate is best done by a peer. Our project will help answer the question of whether peer-support for 
Veterans after their incarceration increases VHA linkage rates.  Also the project will provide a roadmap (with 
guidebook, training materials and implementation strategies) so that other states and VISNs can efficiently 
adapt and implement this peer-support approach in their HCRV programs. The ultimate impact will be an 
increased rate of linkage to VHA services, substantially beyond the current 57% rate.  This linkage will help 
contribute to improved health and mental health of the thousands of Veterans released from incarceration 
annually.  It has the potential to prevent the cascade of events for many former offenders, when health and 
mental health deterioration rapidly lead to negative behaviors, re-offending and more incarceration.  
 
5. PARTNERSHIPS AND PROJECT MANAGEMENT 
 
We have developed this project over more than 12 months with the national HCRV program.  In addition, the 
National Center on Homelessness Among Veterans (NCHAV) enthusiastically supports this project and 
contributed to its design (see letters and NCHAV’s MOU).  McInnes (PI) will lead all aspects.  He has led 

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multiple quantitative and qualitative VA research studies of vulnerable Veterans.  Blue-Howells, an operational 
partner, is the VA’s leader of HCRV.  She will actively engage as a Co-Investigator and will ensure the project 
activities are relevant to her program’s needs. Drainoni, Swan, and Visher have experience with prison 
reentry programs -- Visher is one of the nation’s foremost reentry experts.  Drainoni and Swan are qualitative 
experts and will lead that work with assistance from Bolton, experienced in qualitative methods. Smelson is a 
national expert on co-occurring mental illness and SUD among homeless and incarcerated persons.  He 
contributes to intervention development and peer training.  Kim is a systems engineer who will lead the context 
analysis and network mapping.  Ellison leads a VA study of the use of peer-support for individuals with serious 
mental illness, and will contribute to intervention development and training.  Byrne, highly knowledgeable of 
HOMES and related database, will do analyses. Fincke, an MD-researcher and former Director of General 
Internal Medicine at Boston VA, will guide interview content and navigation aspects of the peer-support. 
Petrakis is a highly experienced research coordinator who will assist all aspects of project management and 
communication, and facilitate weekly team meetings.   
 
 
 

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