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Active, Not Recruiting

NCT Number: NCT05176977

Homeless Veterans and Peer Whole Health Coaching

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.

Active, Not Recruiting

This study is active but is not currently recruiting participants.

Key information

Conditions

Acute Care Service Utilization Behavior Housing Mental Health Status Personal Satisfaction Physical Health Status Psychological Well-Being

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR, North Little Rock, Arkansas, United States

Loading trial locations.

About this study

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.

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

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

Treatment and study plan

Peer Support-Whole Health Coaching

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.

Other names: PS-WHC

Primary outcomes

  1. Days of all-cause hospitalization

    Time frame: 9 months (post-baseline)

    Data on all-cause hospitalization (medical/surgical, substance use, and mental health) (bed days of care) will be obtained from the CDW Inpatient and Outpatient files. VA-paid acute care at non-VA facilities will also be searched in the Fee Basis and Program Integrity Tool (PIT) files, including "Choice" care.

Secondary outcomes

  1. ED visits

    Time frame: 9 months (post-baseline)

    Data on ED visits will be obtained from the CDW Inpatient and Outpatient files. VA-paid acute care at non-VA facilities will also be searched in the Fee Basis and Program Integrity Tool (PIT) files, including "Choice" care.

  2. Substance Use

    Time frame: 9 months (post-baseline)

    The WHO-ASSIST measure will provide information on quantity and frequency of substance use, separately by drug type, in the past 30 days at each follow-up assessment.

  3. Alcohol Use Problems (AUDIT)

    Time frame: 9 months (post-baseline)

    The AUDIT is an alcohol screen that help identify patients who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence). Each of the 10 items on this scale has response options from 0 to 4; scores on the outcome measure can range from 0 to 40 with higher scores indicating more alcohol use problems.

  4. Depression (PHQ-9)

    Time frame: 9 months (post-baseline)

    The Patient Health Questionnaire-9 (PHQ-9) will obtain information on changes in depression symptoms over time. The scale consists of 9 items, each answered on 4-point scale (0=not at all, 4=nearly every day). Scores on this outcome measure can range from 0 to 27, with higher scores indicating more symptoms of depression.

  5. PTSD (PCL-5)

    Time frame: 9 months (post-baseline)

    The PTSD Checklist (PCL-5) will obtain information on changes in PTSD symptoms over time. The scale consists of 20 items, each answered on a 5-point scale (0=not at all, 4=extremely). Scores on the outcome measure can range from 0 to 80 with higher scores indicating more symptoms of PTSD.

  6. Days of Ambulatory Care Sensitive Condition (ACSC) hospitalizations

    Time frame: 9 months (post-baseline)

    Ambulatory Care Sensitive Conditions (ACSCs) are a set of conditions such as asthma and diabetes, where the need for emergency admissions is thought to be avoidable. We will use the Agency for Healthcare Research and Quality (AHRQ)'s definition of the Prevention Quality Indicators (PQIs) as our definition of hospitalizations for ACSC. Data on ACSC hospitalizations will be obtained from the CDW Inpatient and Outpatient files. VA-paid acute care at non-VA facilities will also be searched in the Fee Basis and Program Integrity Tool (PIT) files, including "Choice" care.

  7. Percent Days Homeless

    Time frame: 9 months (post-baseline)

    The reliable and valid Residential Timeline Followback (TLFB) interview will measure duration and frequency of homelessness (e.g., percent days homeless) in the past 90 days at baseline and each follow-up.

  8. Days of mental health hospitalizations

    Time frame: 9 months (post-baseline)

    Data on mental health hospitalizations, including for substance use, will be obtained from the CDW Inpatient and Outpatient files. VA-paid acute care at non-VA facilities will also be searched in the Fee Basis and Program Integrity Tool (PIT) files, including "Choice" care.

  9. Patient Engagement (ACE)

    Time frame: 9 months (post-baseline)

    The 21-item Altarum Consumer Engagement (ACE) Measure is a reliable and valid self-report measure of patient activation, which yields a total score. Items are answered on a 5-point scale (0=strongly disagree, 4=strongly agree). A total score is calculated ranging from 0 to 100, with higher scores indicating greater patient engagement/activation in their health care.

  10. Days of medical hospitalizations

    Time frame: 9 months (post-baseline)

    Data on medical hospitalizations will be obtained from the CDW Inpatient and Outpatient files. VA-paid acute care at non-VA facilities will also be searched in the Fee Basis and Program Integrity Tool (PIT) files, including "Choice" care.

  11. Perceptions of Health (PROMIS-10)

    Time frame: 9 months (post-baseline)

    Global health items from the Patient Reported Outcome Measurement Information System (PROMIS) will assess perceptions of health. Comprised of 10 items, this measure will assess participants' perception of their overall health and quality of life, as well as their physical, mental, and social health. Scores

  12. Peer service engagement

    Time frame: 9 months (post-baseline)

    Data on peer services (number of encounters) will be obtained from the CDW Inpatient and Outpatient files.

  13. Whole Health service engagement

    Time frame: 9 months (post-baseline)

    Data on Whole Health services, including Complementary and Integrative Health (CIH) services, (number of encounters) will be obtained from the CDW Inpatient and Outpatient files.

Sponsors and collaborators

Lead sponsor

VA Office of Research and Development

Fed

Registry information

Official study title

Using Data Analytics and Targeted Whole Health Coaching to Reduce Frequent Utilization of Acute Care Among Homeless Veterans

Acronym: PWHC

Important dates

Study start
2022
Primary completion
2025
Study completion
2026
First posted
Jan 4, 2022
Registry last updated
Feb 10, 2026

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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