Homeless Veterans and Peer Whole Health Coaching

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

ACTIVE_NOT_RECRUITING

Clinical Phase

NA

Total Enrollment

177 participants

Study Classification

INTERVENTIONAL

Study Start Date

2022-02-01

Study Completion Date

2026-06-30

Brief Summary

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Use of acute care services (e.g., hospitalizations, Emergency Department visits) contributes substantially to the cost of healthcare for Veterans. Homelessness is a robust social determinant of super utilization of acute care. The goal of this project is to test if Peer Specialists trained in Whole Health Coaching can reduce homeless Veterans' frequent use of acute care.

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Detailed Description

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Ten percent of patients account for up to 70% of acute care costs. Among these "super-utilizer" patients, homelessness is a robust social determinant of acute care utilization. Through a field-based dashboard and clinical aids, the Hot Spotter Analytic program assists Patient Aligned Care Teams (PACT) with targeting and tailoring care for the highest-need homeless Veterans. However, many Veterans identified by the Analytics do not engage in supportive services that reduce risk for acute care utilization. Peer Specialists (PS) are a high-value workforce that can facilitate Veterans' engagement in care. Yet, there is a need to enhance the PS role with a structured approach that can capitalize on known facilitators of care engagement among homeless Veterans. Whole Health Coaching (WHC) is one such approach. By focusing on patients' values and goals rather than treatment of specific conditions, WHC reduces patients' stigma regarding their care needs and increases patient activation and well-being, which can increase engagement in supportive services.

The goal of this project is to integrate use of Hot Spotter Analytics with Peer Specialists trained in Whole Health Coaching (PS-WHC) and evaluate whether this approach reduces homeless Veterans' frequent use of acute care. Using a Hybrid Type 1 design at the Palo Alto, Bedford, and North Little Rock VAs, the investigators will test whether receipt of PS-WHC (vs. Enhanced Usual Care; EUC) predicts (1a) lower acute care utilization, (1b) better health-related outcomes, and whether (1c) the effects of PS-WHC on 1a and 1b are mediated by increased (i) patient activation and well-being, and (ii) access to supportive services. Aim 2: Conduct a process evaluation to inform VA's potential widespread implementation of Hot Spotter Analytics + PS-WHC on PACTs. Aim 3: Conduct a Budget Impact Analysis to determine the impact on total costs of VA care due to implementing PS-WHC.

Conditions

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Physical Health Status Housing Acute Care Service Utilization Mental Health Status

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Primary Study Purpose

TREATMENT

Blinding Strategy

SINGLE

Outcome Assessors

Study Groups

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Peer Specialist - Whole Health Coaching (PS-WHC)

Participants will meet with a Peer Specialist for 18 sessions over 24 weeks. The essential elements of this intervention include 1) general support provided via the core functions of a Peer Specialist, and 2) a structured Whole Health Coaching curriculum.

Group Type EXPERIMENTAL

Peer Support-Whole Health Coaching

Intervention Type BEHAVIORAL

Participants will meet with a Peer Specialist for 18 sessions over a period of 24 weeks. The essential elements of this intervention include 1) general support provided via the core functions of a Peer Specialist and 2) a structured Whole Health Coaching curriculum.

Enhanced Usual Care (EUC)

Usual PACT care plus Hot Spotter Analytics (consists of access to field-based dashboard that allows PACTS to identify homeless Veterans on their panels who were super-utilizers, and the hot spotter manual).

Group Type NO_INTERVENTION

No interventions assigned to this group

Interventions

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Peer Support-Whole Health Coaching

Participants will meet with a Peer Specialist for 18 sessions over a period of 24 weeks. The essential elements of this intervention include 1) general support provided via the core functions of a Peer Specialist and 2) a structured Whole Health Coaching curriculum.

Intervention Type BEHAVIORAL

Other Intervention Names

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PS-WHC

Eligibility Criteria

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Inclusion Criteria

Veterans who:

* are on VA's Homeless Registry, which comprises those who utilized any VA homeless programs and services in the past 2 years
* are enrolled on a Patient Aligned Care Team (or "PACT") at a study site
* had a hot spotter qualifying event in two or more quarters in the past year will be eligible for participation

Exclusion Criteria

* Veterans who have a suicidal and/or behavioral flag in their medical record and those who are too cognitively impaired to understand the informed consent process and other study procedures will be excluded

Eligible Sex

ALL

Accepts Healthy Volunteers

No