Homeless Veterans and Peer Whole Health Coaching (PWHC)

February 9, 2026 updated by: VA Office of Research and Development

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

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.

Study Overview

Status

Active, not recruiting

Conditions

Intervention / Treatment

Detailed Description

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.

Study Type

Interventional

Enrollment (Actual)

177

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Arkansas
      • North Little Rock, Arkansas, United States, 72114-1706
        • Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR
    • California
      • Palo Alto, California, United States, 94304-1207
        • VA Palo Alto Health Care System, Palo Alto, CA
    • Massachusetts
      • Bedford, Massachusetts, United States, 01730-1114
        • VA Bedford HealthCare System, Bedford, MA

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

  • Child
  • Adult
  • Older Adult

Accepts Healthy Volunteers

No

Description

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

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: 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.
Behavioral: 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.
Other Names:
  • PS-WHC
No Intervention: 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).

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
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.
9 months (post-baseline)

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
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.
9 months (post-baseline)
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.
9 months (post-baseline)
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.
9 months (post-baseline)
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.
9 months (post-baseline)
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.
9 months (post-baseline)
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.
9 months (post-baseline)
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.
9 months (post-baseline)
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
9 months (post-baseline)
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.
9 months (post-baseline)
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 months (post-baseline)
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.
9 months (post-baseline)
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.
9 months (post-baseline)
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.
9 months (post-baseline)

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

VA Office of Research and Development

Investigators

  • Principal Investigator: Daniel M. Blonigen, PhD MA, VA Palo Alto Health Care System, Palo Alto, CA
  • Principal Investigator: David A. Smelson, PsyD, VA Bedford HealthCare System, Bedford, MA

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

February 1, 2022

Primary Completion (Actual)

October 22, 2025

Study Completion (Estimated)

June 30, 2026

Study Registration Dates

First Submitted

December 16, 2021

First Submitted That Met QC Criteria

December 16, 2021

First Posted (Actual)

January 4, 2022

Study Record Updates

Last Update Posted (Actual)

February 10, 2026

Last Update Submitted That Met QC Criteria

February 9, 2026

Last Verified

February 1, 2026

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • IIR 19-187

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

product manufactured in and exported from the U.S.

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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