Table 3 Potential means of and currently existent mechanisms for addressing identified reentry challenges, guided by the Collaborative Chronic Care Model (CCM)
CCM element | Potential means of addressing identified reentry challenges | Currently existent mechanisms for addressing identified reentry challenges |
|---|---|---|
Work role redesign | Designate a lead case manager for the reentry veteran (among the various organizations involved with the veteran’s reentry), specifying backup procedures for when this case manager is not available | Veterans Justice Outreach specialists assess and manage cases of justice-involved veterans in local courts and correctional facilities; Health Care for Reentry Veterans (HCRV) services include outreach to incarcerated veterans and assessments prior to release |
Patient self-management support | Enable the veteran to participate in planning his/her reentry and post-release daily routines, prepare the veteran for heightened anxiety to be faced, and provide him/her with the tools to self-advocate and seek support from clinicians even outside of pre-scheduled appointments | Some correctional facilities have reentry specialists; HCRV services include short-term case management upon release, including referrals to health care and social services |
Provider decision support | Make available to all reentry support providers a regularly updated database of latest requirements, which can also be coupled with an electronic or telephone-based portal through which clarifications and questions can be posed to obtain real-time support in deciding services and programs to plan for | Some correctional facilities, interim housing facilities, and reentry support programs individually have knowledge regarding available resources for veterans leaving incarceration, and some have built regular communication with local HCRV specialists to be updated on latest changes |
Clinical information systems | Establish information systems that serve as a comprehensive registry of all reentry cases and can be programmed to generate alerts for cases that are particularly at high risk for lapses in treatment/medication, along with clear processes for regularly inputting and updating the information on each case | Some regional VA networks are utilizing databases that help HCRV specialists identify incarcerated veterans to provide outreach to |
Linkages to community resources | Hold regular forums at which reentry veterans and support providers can share their latest knowledge of resources available in the community, augmented by clear documentation of the knowledge shared at these forums that is maintained in an easily searchable format (e.g., an online log) | VA’s homelessness programs, Veterans Service Organizations, community-based organizations that have contracts to assist veterans, and states’ departments of veterans’ services provide information on available community resources |
Organizational / Leadership support | Develop processes for regularly and frequently engaging and updating organizational leaders on the current state of coordination, how changes to the current state can support the achievement of organizational goals, and what resources are needed from the leaders to accomplish the proposed changes | Support for HCRV program from national and regional VA leadership; individual VA medical centers decide on their specific level of effort dedicated to supporting veterans’ reentry, to balance available resources across multiple related (e.g., homelessness) services |