JMIR Publications

ABSTRACT

Background:

High-risk Veterans often have poor ability to maintain health due to complicated unmet health and social needs. The use of Peers is a promising approach to improving patient engagement and addressing unmet needs.

Objective:

High-risk Veterans often have poor ability to maintain health due to complicated unmet health and social needs. The use of Peers is a promising approach to improving patient engagement and addressing unmet needs.

Methods:

The P2P intervention is a clinical demonstration pilot of older HNHR Veterans in one Department of Veterans Health Affairs (VA) hospital. Participants receive i. a peer-led home visit to identify unmet needs and home safety risks aligned with Age-Friendly Health Systems, ii. care coordination, healthcare system navigation and linking to needed services and resources in collaboration with their Patient Aligned Care Team (PACT), and iii. patient empowerment and coaching using VA Whole Health principles. Peers work with Veterans through in-person visits, telephone calls, or via videoconferencing, depending on patient preferences. The primary outcome is change in mean healthcare engagement 6-months pre- to 6-months post- P2P in the intervention group, and compared to a matched control group, as measured by outpatient healthcare utilization and use of home services. Secondary descriptive measures include number and type of unmet needs identified during the home visit, and barriers and facilitators to P2P intervention implementation.

Results:

Study enrollment began in July 2020 and was completed in fall 2022. Pilot study findings are expected to be published in 2023.

Conclusions:

P2P is the first intervention to examine the effectiveness and feasibility of Peers integrated into PACT conducting a peer-led home-visit for unmet needs identification among older HNHR Veterans, to improve health care engagement and link Veterans to needed services. We also examine factors that could impact P2P’s future implementation in VA settings.