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

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.

Grant Number: 5I01HX003151-06
NIH Institute/Center: VA
Principal Investigator: Daniel Blonigen