Acute Care Service UtilizationPWHCNCT05176977
Homeless Veterans and Peer Whole Health Coaching
A study testing Peer Support-Whole Health Coaching in people with Acute Care Service Utilization and Mental Health Status, run by VA Office of Research and Development at 3 sites in United States.
Trial summary
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. Read more about this study
- Who is it for?
- Any age
- Conditions the study is for
- Acute Care Service Utilization, Mental Health Status, Physical Health Status
- What is being tested?
- Peer Support-Whole Health Coaching
- Type of treatment
- Lifestyle or therapy programme
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 177 participants
- Where
- 3 sitesUnited States
- Study dates
- 1 Feb 2022to 30 Jun 2026
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages Any age
- All sexes
- No healthy volunteers
- Child, Adult, Older adult
Who may be able to join
- 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
Who cannot join
- 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
Trial locations and contacts
3 sites in 1 country.
United States3 sites
VA Bedford HealthCare System, Bedford, MA
Bedford, Massachusetts, 01730-1114
Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR
No. Little Rock, Arkansas, 72114-1706
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, California, 94304-1207
About this study
Official title: 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.
Read the 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.
- Being tested
- Peer Support-Whole Health Coaching
- Keywords
- Homeless Persons, Costs and Cost Analysis, Mental Health, Peer Support
- Medical subject headings
- Psychological Well-Being
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Peer Support-Whole Health CoachingBehavioural
Also called PS-WHC
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.
| Study group | Role | What they receive |
|---|---|---|
| Peer Specialist - Whole Health Coaching (PS-WHC) | Experimental | 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. Receives: Behavioral: Peer Support-Whole Health Coaching |
| Enhanced Usual Care (EUC) | No intervention | 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 being measured
The primary outcome is the main question the study is designed to answer.
Days of all-cause hospitalization
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.
Measured: 9 months (post-baseline)
Secondary outcomes (13)
ED visits
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.
Measured: 9 months (post-baseline)
Substance Use
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.
Measured: 9 months (post-baseline)
Alcohol Use Problems (AUDIT)
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.
Measured: 9 months (post-baseline)
Depression (PHQ-9)
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.
Measured: 9 months (post-baseline)
PTSD (PCL-5)
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.
Measured: 9 months (post-baseline)
Days of Ambulatory Care Sensitive Condition (ACSC) hospitalizations
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.
Measured: 9 months (post-baseline)
Percent Days Homeless
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.
Measured: 9 months (post-baseline)
Days of mental health hospitalizations
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.
Measured: 9 months (post-baseline)
Patient Engagement (ACE)
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.
Measured: 9 months (post-baseline)
Days of medical hospitalizations
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.
Measured: 9 months (post-baseline)
Perceptions of Health (PROMIS-10)
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
Measured: 9 months (post-baseline)
Peer service engagement
Data on peer services (number of encounters) will be obtained from the CDW Inpatient and Outpatient files.
Measured: 9 months (post-baseline)
Whole Health service engagement
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.
Measured: 9 months (post-baseline)
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted4 Jan 2022
- Study start1 Feb 2022
- Primary completion19 Jan 2026
- Study completion30 Jun 2026
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (1)Papers the sponsor has linked to this study.
- Other trials for Acute Care Service UtilizationStudies of the same condition, open and under way.
- More trials run by VA Office of Research and DevelopmentThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Single blind
- Who is masked
- Outcomes assessor
- Enrolment
- 177 participants (actual)
Sponsor and investigators
- Lead sponsor
- VA Office of Research and Development
- Sponsor type
- US federal agency
- Responsible party
- Sponsor
- Investigators
- Daniel M. Blonigen, PhD MA, Principal investigator, VA Palo Alto Health Care System, Palo Alto, CADavid A. Smelson, PsyD, Principal investigator, VA Bedford HealthCare System, Bedford, MA
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT05176977
- Sponsor's protocol ID
- IIR 19-187
- Acronym
- PWHC
- Status last verified
- Oct 2026
- First submitted
- 16 Dec 2021
- Last updated
- 7 Oct 2026
- Results posted
- No
- Data monitoring committee
- Yes
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Publications
Blonigen D, Hyde J, McInnes DK, Yoon J, Byrne T, Ngo T, Smelson D. Integrating data analytics, peer support, and whole health coaching to improve the health outcomes of homeless veterans: Study protocol for an effectiveness-implementation trial. Contemp Clin Trials. 2023 Feb;125:107065. doi: 10.1016/j.cct.2022.107065. Epub 2022 Dec 23.
PubMed 36572239
Study at a glance
From the registry record, last updated by the sponsor on 7 Oct 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Using Data Analytics and Targeted Whole Health Coaching to Reduce Frequent Utilization of Acute Care Among Homeless Veterans
- ClinicalTrials.gov ID
- NCT05176977
- Acronym / sponsor ID
- PWHC / IIR 19-187
- Keywords
- Homeless Persons, Costs and Cost Analysis, Mental Health, Peer Support
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 177 participants (actual)
- Lead sponsor
- VA Office of Research and DevelopmentUS federal agency
- Study start
- 1 Feb 2022 (actual)
- Primary completion
- 19 Jan 2026 (actual)
- Study completion
- 30 Jun 2026 (actual)
- First posted
- 4 Jan 2022 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
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.
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 design
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Single blind (outcomes assessor)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| Peer Specialist - Whole Health Coaching (PS-WHC) | Experimental | Behavioral: Peer Support-Whole Health CoachingParticipants 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. |
| Enhanced Usual Care (EUC) | No intervention | –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). |
Who may qualify
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Child, Adult, Older adult
Key inclusion criteria (4 listed)
- 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
Key exclusion criteria (1 listed)
- 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
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Peer Support-Whole Health CoachingAlso: PS-WHCParticipants 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. | Behavioural | Peer Specialist - Whole Health Coaching (PS-WHC) |
Primary outcome
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.
13 secondary outcomes
ED visits
Time frame: 9 months (post-baseline)
Substance Use
Time frame: 9 months (post-baseline)
Alcohol Use Problems (AUDIT)
Time frame: 9 months (post-baseline)
Depression (PHQ-9)
Time frame: 9 months (post-baseline)
PTSD (PCL-5)
Time frame: 9 months (post-baseline)
Days of Ambulatory Care Sensitive Condition (ACSC) hospitalizations
Time frame: 9 months (post-baseline)
Percent Days Homeless
Time frame: 9 months (post-baseline)
Days of mental health hospitalizations
Time frame: 9 months (post-baseline)
Patient Engagement (ACE)
Time frame: 9 months (post-baseline)
Days of medical hospitalizations
Time frame: 9 months (post-baseline)
Perceptions of Health (PROMIS-10)
Time frame: 9 months (post-baseline)
Peer service engagement
Time frame: 9 months (post-baseline)
Whole Health service engagement
Time frame: 9 months (post-baseline)
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 7 Oct 2026.
- Results publication: PubMed 36572239Blonigen D, Hyde J, McInnes DK, Yoon J, Byrne T, Ngo T, Smelson D. Integrating data analytics, peer support, and whole health coaching to improve the health outcomes of homeless veterans: Study protocol for an effectiveness-implementation trial. Contemp Clin Trials. 2023 Feb;125:107065. doi: 10.1016/j.cct.2022.107065. Epub 2022 Dec 23.
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Daniel M. Blonigen, PhD MA principal investigator
VA Palo Alto Health Care System, Palo Alto, CA
David A. Smelson, PsyD principal investigator
VA Bedford HealthCare System, Bedford, MA
3 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Peer Support-Whole Health Coaching in people with Acute Care Service Utilization and Mental Health Status, run by VA Office of Research and Development at 3 sites in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 4 inclusion and 1 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 7 Oct 2026. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 3 sites in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Days of all-cause hospitalization (time frame: 9 months (post-baseline)). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT05176977, which also lists 1 linked publication.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 7 Oct 2026.