Background: 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. Significance: By training a high-value workforce in a patient-centered approach to care that facilitates engagement in supportive services, our proposed research can reduce homeless Veterans’ reliance on acute care services, thereby minimizing the financial burden these patients exert on the care system. This proposal responds to several VA HSR&D Research Priorities including Mental Health, Healthcare Value, Primary Care Practice, Healthcare Informatics, and Whole Health, as well as VA-related Legislative Priorities (MISSION Act). Innovation and Impact: A critical innovation of this research is use of data-driven processes (Hot Spotter Analytics) to better target and tailor care for high-need, homeless Veterans in VHA. Our proposed research is also innovative in that it seeks to integrate the Analytics with a workforce (PS) and approach to care (WHC) that are rapidly expanding in primary care services VA-wide. These features of our target intervention are consistent with the National Academy of Medicine’s recommendations for high-quality care for high-need patients. Finally, by focusing on the development of personal health goals that are aligned with patients’ priorities and values, WHC is a key innovation to be added to existing VHA services for homeless Veterans. Specific Aims: 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. Aim 1: Conduct an RCT to 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 (BIA) to determine the impact on total costs of VA care due to implementing PS-WHC. Methodology: Using a Hybrid Type 1 design at the Palo Alto and Bedford VAs, 220 Veterans on PACT panels who are (i) on the VA Homeless Registry, and (ii) persistent super-utilizers of acute care will complete a baseline interview, be randomized to either EUC (usual PACT care + Hot Spotter Analytics and text reminders of appointments) or EUC plus 12 sessions of PS-WHC over 12 weeks, and be re-interviewed at 3, 6, and 9 months. For Aim 2, the CFIR framework will guide key informant interviews with 7 PACT staff/leaders and 12 patients from each site. For the BIA, we will include only VA costs from VA, Fee Basis care, and Choice care. Costs will be estimated per patient for all treatment beginning with randomization and continuing for 9 months. Next Steps/Implementation: Depending on the results, we will work with our VACO partners in the National Center for Homelessness Among Veterans, the Office of Patient Centered Care & Cultural Transformation, and the Office of Mental Health & Suicide Prevention to conduct a large multisite implementation trial.

Acute care utilization contributes substantially to the cost of healthcare for Veterans. Homelessness is a robust social determinant of super utilization of acute care. Data analytics offer a means of targeting and tailoring care for the highest-need homeless Veterans; however, analytics alone are insufficient for facilitating these Veterans’ engagement in supportive services that can reduce acute care utilization. Peer Specialists trained in Whole Health Coaching (PS-WHC) is a high-value, patient-centered approach to care that can enhance homeless Veterans’ engagement in supportive services and, in turn, reduce their frequent use of acute care. By integrating data analytics with PS-WHC, our proposed research will test whether this innovative model of care reduces homeless Veterans’ reliance on acute care services. If successful, these efforts can better target and tailor care to the homeless Veterans at highest risk of poor health outcomes and premature mortality, as well as minimize the financial burden these patients exert on the care system.