Evaluating the Implementation of a Prisoner Re-Entry Initiative for Individuals with Opioid Use and Mental Health Disorders: Application of the Consolidated Framework for Implementation Research in a Cross-System Initiative

Background

Given the relationship of opioid use, criminal justice interaction, and mental health, the current opioid crisis has created an urgent need for treatment among justice-involved populations. Implementation research plays a critical role in improving systems of care and integration of evidence-based practices. This study is a formative evaluation of the implementation of a prisoner re-entry initiative for individuals with co-occurring mental health and opioid use disorders. The initiative utilizes the evidence-based MISSION-CJ (Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking – Criminal Justice) model to provide case management and peer support services. The purpose of this study is to assess the fit of the Consolidated Framework for Implementation Research (CFIR) in a cross-system (corrections and community-based treatment) initiative, and to identify key barriers and facilitators to implementation of the intervention.

Methods

As part of the ongoing formative evaluation, the evaluation team collected observational field notes; documented findings from 28 structured meetings and discussions with stakeholders; conducted four focus groups with provider staff, facility staff, and policymakers; and conducted two focus groups with current participants and ten individual interviews with program graduates. The team used a mixed inductive-deductive approach to first identify themes that emerged from the qualitative analysis and then determine their fit within the CFIR framework. Themes were identified using constant comparison analysis. After common themes were identified across all data sources, members of the evaluation team independently coded the themes within the CFIR framework and then discussed to come to consensus. Based on this approach, at least one element from each of the five CFIR domains is included in the evaluation.

Results

The process evaluation found that adaptability of the clinical model and staff flexibility were critical to implementation. Cultural and procedural differences across correctional facilities and community-based treatment programs required frequent forums for communication among multiple levels within and across systems. Challenges related to recruitment and enrollment, staffing, medication assisted treatment (MAT), and data collection were addressed through the collaborative development and continuous review of policies and procedures. Despite some implementation challenges, the initiative has seen positive outcomes related to enrollment, MAT uptake, and client satisfaction. This is largely attributed to allocation of time and resources at all levels of all involved systems to improve care delivery.

Conclusion

This study found CFIR to be a useful framework for understanding implementation uptake and barriers in a complex, cross-system initiative for justice-involved individuals. Because those involved in the justice system are disproportionately represented by racially and economically marginalized individuals, examining mechanisms for implementing successful programs is critical to supporting Social Work Grand Challenges to promote smart decarceration, reduce economic inequality, and achieve equal opportunity and justice. The framework was particularly valuable in reinforcing the use of implementation research for continuous process improvement. This helps to frame evaluation as a means of improving the initiative overall, providing the best possible services to participants, and keeping the focus on processes rather than on individual performance. Overall, CFIR is a comprehensive and flexible framework that may be adopted in future cross-system process evaluations.