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C19 20-393 – HSR&D Study

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C19 20-393
Expanding VA Peer Support Workforce Capacity to Facilitate Increased Access to VHA Mental Health Services and Continuity of Care for Veterans with Mental Illness During The COVID-19 Pandemic
Johanne Eliacin PhD
Indianapolis, IN
Funding Period: August 2020 - April 2021

Emerging data indicate that the COVID-19 pandemic and its associated effects, such as mass unemployment and social isolation, are contributing to emotional distress in the general population and exacerbating mental health conditions for those with existing mental health and substance use disorders. Veterans are particularly at high risk of negative mental health sequelae associated with the COVID-19 pandemic due to existing high rates of mental illnesses, social isolation, and other social risk factors.
With a potential influx of new and existing Veterans presenting with emotional distress due to COVID-19, the VHA mental health care system will face additional pressure to increase access to mental health services. These increased demands will potentially make access to VHA mental health services, which is already difficult, even more limited, particularly for racial and gender minority Veterans (i.e., African-American, women, and LGBTQ Veterans) who often struggle with engagement in VHA services. Alternative strategies are urgently needed to expand services and increase access during the COVID-19 outbreak and thereafter.
Peer support is a promising, but largely untapped resource that could increase VA mental health care systems' capacity to attend to Veterans' mental health care needs. In VHA mental health care settings, peers are Veterans with a history of mental illness or substance use disorder who receive specialized training to use their recovery experiences to instill hope, engage patients, and support their recovery. Several studies have shown that, in mental health care settings, peers are effective at engaging Veterans, reducing inpatient admissions, and delivering short-term mental health interventions focusing on depression, anxiety, and substance use disorders.
Despite growing evidence demonstrating the effectiveness of peer services and the increasing number of peers in VHA mental health care settings, peers remain grossly underutilized, and are not given opportunities to perform higher-level duties that are within their scope of practice. The ramifications of underutilization and inadequate utilization of peer support services are far reaching. Most importantly, underutilization negatively affects Veterans who would otherwise benefit from peer services. Moreover, peers may become disengaged employees, adding to potential loss of financial revenue for the VHA due to reduced billable hours. The unique circumstances of COVID-19 also could dilute the peer role even further if administrators, desperate for staff coverage, are tempted to reassign peers to menial tasks as opposed to carrying out their specialty role.
Given the healthcare changes and related challenges created by COVID-19, we seek to develop better understanding of how peer programs have reconfigured or shifted peer support services to maintain and potentially expand delivery of peer support services such as Veterans' outreach and engagement that traditionally require in-person contact, and to respond to new and potentially increasing mental health needs of Veterans.

This study seeks to explore how to maximize existing peer support services to provide mental health support to Veterans seeking mental health treatment during and after the COVID-19 outbreak. The study's specific aims are:

Aim 1: Describe changes in peer programs' structures, peers' roles and activities in mental health settings during the COVID-19 pandemic, and characterize programmatic adaptations made to maintain and/or enhance mental health care services delivery to Veterans.

Aim 2: Identify and describe successful strategies for enhancing peer support capacity in mental health care during the COVID-19 pandemic.

The setting for this study was VHA medical centers and community-based clinics (CBOCs) from Indiana, Ohio, and Michigan. Study Participants were 19 peers and 10 peer supervisors from 13 VHA facilities. Participants were recruited using direct outreach by email, through presentation at regional peer support meetings, and snow-ball methods, asking enrolled participants to refer other potential participants.

We conducted semi-structured interviews with participants over the phone or through VA Microsoft Teams. Interviews lasted 30-60 minutes and focused on peer support services utilization before and during the COVID-19 pandemic, as well as challenges experienced, and adaptations made to peer programs to maintain service delivery and/or to meet new Veterans' mental health care needs. The interviews were guided by the Consolidated Framework for Implementation Research (CFIR). In addition, we collected demographic data (e.g., age, gender, education, length of work tenure). We inquired about their experiences of burnout using the three items from the VA All Employee Survey (AES): a) I feel burnout from my work; b) I worry that this job is hardening me emotionally; and c) I have accomplished many worthwhile things in this job. We also administered self-report measures that assessed the impact of COVID-19 on participants using a modified version of the Pain Management Collaboratory Coronavirus Pandemic Measures (PMC), the PROMIS Global health Scale, and the Fear of Illness and Virus Evaluation (FIVE) - Adult Report Form.

Qualitative Data Analysis: A team of 6 analysts analyzed the data, which included two of the study investigators and 4 research assistants trained in qualitative data analysis. We used an inductive/deductive thematic analysis approach, which involves identifying and comparing common emergent themes across transcripts. The qualitative team met early in the project to read the transcripts, gain a general understanding of the data and variations across participants, and develop a working set of codes. Once we had a defined set of codes, we coded the documents independently (focused coding), including the initial coded transcripts, with approximately 20% of the documents coded in common to maintain consistency and consensus in our coding practice. We compared our codes periodically to avoid coding drift and resolved discrepancies through consensus discussions. Throughout this process, we refined the coding scheme as new or inconsistent data emerged. Then, we conducted axial coding, analyzing excerpts from coded sections, identifying themes, and making connections in the data, and summarizing our findings.

Demographics: As shown in Table 1, peer participants had an average of 5.26 years of tenure in their position at the VHA. Most were male (61%), White (54%), aged 50 and older, and had some college education (43%).

Note: 1 participant completed the interview but declined to provide demographic data and complete the survey.

Disruption to peer support services
COVID-19 contributed to major disruption to peer services. During the early months of the pandemic, many programs suspended their programs or significantly reduced their offerings to adhere to local, state, and VA policies. At the time of the interviews, most peer support services were provided primarily virtually. Some programs still offered some in-person services, but these were limited to walk-in visits.

Below, we describe the challenges that VA peer programs faced during the pandemic, which impacted service delivery. They also provide some context for understanding how these programs adapted to continue to provide peer services delivery to Veterans.

Technology: Significant technological barriers impacted peer service delivery, especially during the early stage of the pandemic. First, many peers had limited access to needed technology, such as zoom accounts, to engage with Veterans. Some of the virtual platforms were not conductive to delivery of peer-led groups that require active group interaction, which led to reduce services and frustration for both peers and Veterans. There was also confusion with the frequent policy changes to what VA communication platforms are permissible for peers to use. Peers also struggled with the transition to telehealth services because of limited experience with technology and lack of computer skills.

"Our skills are being put to test because we're went from Skype to Teams. Knowing how to use a computer. Some people are not as savvy as others .We may get on a call and nobody knows where the mute button is.." -Peer, 113

Moreover, many Veterans did not have telecommunication devices, lacked internet connectivity, preferred not to engage in virtual visits and/or did not know how operate the devices (smart phone, tablet, phone) adequately. Some Veterans, particularly those struggling with homelessness, did not have cell phones or enough minutes on their phone to access services. Others repeatedly had their VA-issued phone stolen, lost, or broken. Peers then became their primary support, helping them to navigate VA technology and apps.

"It's not easy for somebody who hasn't used a phone, or a computer, or an iPad.. And for someone who doesn't even hardly access the internet or we're telling them to click on links. They don't really understand that because they don't do that type of thing." -Peer

"They [Veterans] know which pantries to go to.But what they weren't ready for is, I can't get to the social security. I can't talk to them. I can't file unemployment. I don't have access to a phone with enough minutes to allow me to call them. So that became a barrier."- Peer

Inter-agencies collaborations/community outreach activities: Many peer services are contingent on collaboration with community agencies. The closure of many community-based organizations and public agencies hindered peer services delivery. For example, the department of licensing at one site closed temporarily, which impacted peers' ability to assist Veterans with applying for identification card, employment, housing, and other services. Many community organizations also lost staff members, and some reconfigured their own priorities to focus on immediate COVID-19 -based needs. Some community residential programs also reduced their capacity or were no longer accepting new Veteran residents, which impacted Veterans' placement for treatment in community settings and related peer work. Indeed, one supervisor noted that the impact of COVID-19 on peer outreach activities will be long-lasting.

"It's very difficult. [Community outreach] was a big part of my job. I was going out and saying this is what we do. I was really good at recruiting... I talked about the mental health clinic and all the services we provide." -Peer

"I used to do a lot of community outreach in my role. [COVID-19] really harmed my ability to network like I used to... they're [community agencies] not even thinking about me anymore. It hurts our partnerships." -Supervisor

Communication: Participants also discussed the negative impact of COVID-19 on communication with team members and with Veterans. They reported that COVID-19 response communication as well as peer programmatic changes were communicated inconsistently, if at all, to peers. Some peers shared that they were often left out of the decision-making processes or were not informed of program and facility decisions, which affected their work performance since many Veterans rely on them as a source of VA information. Participants also noted that existing communication difficulties and organizational culture affecting peer services were exacerbated by COVID-19. For example, some peers described experiencing more scrutiny and micro-management by supervisors during COVID, which fueled feelings of mistrust.

"I didn't even know we were having groups until my supervisor brought it to my attention because I was off that email chain. He said they're starting groups next week. No one told me... I haven't gotten an email in two months about what we're doing." -Peer

"I've been told that I have to do video on demand in the office underneath a supervisor to supervise what happens. Prior to COVID, you're out in the community all day without supervision. And so, it's almost like a slap in the face. You're okay when you're out in public, but you're not okay if you have to do a video on demand. You have to be supervised." -Peer

"Here's what's happened since the pandemic that I noticed that says a lot. When we switched over to virtual, some supervisors went to this thing about like, "I got to make sure they're productive." So, they had each staff member gets with them at the end of the day. Who did you see? How many phone calls did you make? It's like there was a complete lack of trust. So, it's like the peers have to defend themselves. It sets up this kind of difficult interaction, where it's not productive." -Supervisor

Peers also described feeling disconnected from Veterans using virtual communication modalities. They discussed that it is increasingly more challenging to have difficult conversations with Veterans over the phone. They also noted that it takes longer to initiate contact with Veterans because of missed calls, long response delays, and ongoing back and forth with voicemails. Participants also shared that communicating with Veterans who have severe mental illness is particularly difficult virtually due to Veterans' concern about privacy and paranoid symptoms. They also noted that many Veterans do not have a private space at home for telehealth visits.

Telework: Discussions about telework involved two main themes. First, participants discussed perceived unfairness related telework policies and implementation. Second, they identified the impact of telework on peer services. Several peers in the study shared that they were the last group to be given telework privileges in their team. Some reported that their application for telework privileges were repeatedly denied despite having multiple high-risk factors for COVID-19, while other non-peer staff were given permission to telework. Many interpreted the denial of peers' requests for telework as additional evidence of under-appreciation and mistrust of peers. The transition to telework was also a stressful experience for some peers. Several reported difficulties with transitioning to the virtual modality and expressed frustration with all the technical barriers they experienced as well as learning new technologies. Also, some found the change from in-person interactions with Veterans to remote and virtual interactions challenging. They also shared mistakes made with group sessions, such as not allowing themselves enough time to sign up for the group and difficulties managing group interactions virtually. Both peers and supervisors emphasized the need for additional training and supervision to facilitate adoption of virtual modality and telework services for peers.

Burnout and COVID-19 Stress
Participants also discussed the impact of COVID-19 on their physical and emotional well-being. Overall, more supervisors reported feelings of burnout. However, all participants shared that they feel engaged in their work and that they have accomplished many worthwhile things in their jobs a few times a week. Participants also shared that they have some concerns about the negative impact of COVID-19 stress on peers' recovery, and most participants noted that peers and supervisors have engaged in some discussions about self-care. These findings corroborated our qualitative data results.

Participants also reported experiences of emotional distress related to COVId-19. As shown in Figures 1 and 2, 28% of peers and 20% of supervisors shared that being afraid of the virus causes them to experience strong emotions. Relatedly, 22% of peers and 50% of supervisors reported that fear of the virus has interfered with their lives, made them feel isolated or hopeless about the future. More White participants (33%) compared to Blacks (17%) reported emotional distress associated with fear of having an illness or virus. Yet, similar percentage of both Black and White participants (33% respectively) reported that fear of the illness has interfered with their way of enjoying their lives.

1.Technological Adaptations
Peer programs rapidly adapted to new technology to deliver peer telehealth services to Veterans. Many programs began to offer individual and group peer programming to Veterans over the phone and via videoconferencing for the first time during the COVID-19 health crisis. Participants reported that adoption of telehealth services allowed peers to deliver new programs and interact with Veteran populations they could not reach prior to the pandemic. By providing telehealth services, they removed many transportation barriers to care for rural Veterans, including frustration with onsite parking and crowds at the medical centers. Some programs also adopted new technology beyond VA communication platforms, such as Facebook, to reach out to Veterans who may not be already connected to VA services. Moreover, they increased collaborations with peers and peer supervisors from other VA medical centers and increased referrals to VA services within and outside their networks.

"I've been able to connect with people further away. I just got a request from a peer in [CITY/STATE 2] which is many miles away from me, to help him do an introduction to whole health with people that he has through VVC. And we would have never thought of that pre Corona, that we could help each other out, one clinic could help another clinic out, if you want to think about it that way, much more easily now than, so that's another change." - Peer

Peers in homeless programs also adapted to COVID-19 in-person restrictions to develop new means to provide housing services to Veterans. An example is their use of virtual apartment tours for Veterans. In so doing, they eliminated the need to travel and in-person showing. In addition, this new adaptation created hands-on learning opportunities for the Veterans. Peers can model a virtual house search for Veterans by sharing their screen. They can also watch Veterans go through the same process and provide feedback to facilitate their learning.

2.Group Adaptations
Due to COVID-19, many peer programs made significant adaptations to their group programming. First, several programs cancelled their peer-led groups and others transitioned to providing primarily individual-based peer support services. Second, others transitioned to offering virtual peer-led groups, but made changes to their group selections and reduced group sizes. For example, they stopped offering some of their groups due to perceived safety and feasibility concerns. These included groups such as anger-management and social skill groups. Some programs also discussed technological barriers to offering interactive groups because some VA virtual platforms such as VVC are not viewed as conductive to teaching and online group interactions. This was a significant concern for peer providers of some Whole Health classes that rely heavily on in-person group interactions.

Programs also developed new groups and changed group structures to meet Veterans' needs. Some groups changed their meeting location to large conference rooms or outdoors so that staff and Veterans can practice social distance. Moreover, some peers joined forces to offer their programs to new Veteran populations. For example, a peer was no longer allowed to offer his money management group to Veterans at the inpatient psychiatric unit at his facility, so he collaborated with another peer to offer the group to Veterans in residential substance use programs. Consequently, more Veterans had access to this group. They also increased the number of group offerings at residential programs because of reduction in group sizes to ensure that Veterans continued to have access to needed services.

The transition to peer telehealth services also led to the development of several new virtual groups and an increase in group participation. Many peer programs responded to the new need of social support and developed virtual walk-in/call-in social support groups. Peer programs also adapted their group programming by loosening their restrictions for different groups and increased cross-department/services collaboration. For example, they created a peer-led group to help Veterans cope with the stress of COVID-19 and the group was open to all Veterans across various services and departments. As a result, some peers experienced increased productivity and saw rapid expansion of their services.

Another notable adaptation is the development and adaptation of "VA University," which provides multiple virtual groups to Veterans. This program also offers rapid training to peers to lead virtual groups. The supervisor explained the rationale and success for these groups below. He emphasized that prior to COVID, many peers and even peer supervisors were not very receptive to the idea of virtual groups. However, out of the need to maintain their productivity, they were encouraged to adapt to this new group format. He also connected how multiple implementation factors, such as external and internal factors facilitated the launch of this new service.

"I had staff here who did not want to connect virtually. . And there was really no pushing on my part that could get them to move. Their supervisors weren't really trying to push them. .So, when this [COVID-19] happened, I immediately sent out an email saying, we need to create a VA virtual university that offered groups to Veterans. I was very fortunate to have a good relationship with our homeless program. And they got shutdown, they could no longer go into the community. They saw this as an opportunity to keep their numbers up.... we started out with like 12 [groups], but then like as they sort of mandated you are going to do groups, we started to fill out into 30.. And we grew to 50... the idea came from the need... I knew that our staff wasn't virtually savvy, nor did they want to become that way. But I felt... if you can figure out how to do a group virtually, individual where you're talking to just one person, that's nothing." - Supervisor

3.Peer Role and Tasks Adaptations
Many of the peers' activities shifted during the COVID-19 pandemic. They transitioned from primarily in-person interactions with Veterans to limiting their services delivery to phone or videoconference. They also transitioned from offering multiple groups a week to doing individual consultations with Veterans. Some programs, especially those with robust and well-integrated peer programs responded to Veterans' needs during the pandemic by creating new outreach and peer support services. For example, peers helped Veterans connect remotely with clinicians during walk-in crisis sessions by providing technological support and setting up a tablet in a private room for Veterans to use. Peers also innovated by responding to Veterans' increased need for food security and social support. They created new programs to deliver food and other basic supplies to Veterans where they live, thus reducing their risk for COVID exposure. Peers also identified new financial needs for Veterans that had surfaced since COVID. This led them to more community-based collaborations, to identify non-VA resources to assist the Veterans.

"People in our program, it might be in HUDVASH, they were working and doing really well until payday. And then they've either had their powers cut, or they've lost their job. And now they're finding themselves back in financial hardship where they're needing more resources and the resources are drying up. .. You can use it [resource] once and then you can't use it again for a year. Well, what are the supposed to do the other 11 months? . I've really tried recently to kind think outside of the box, in incorporating different resources that maybe I've never used before out in the community to help the Veteran." - Peer

There were also some programs that assigned peers with new tasks that may be outside of their scope of practice, such as sewing face masks, cleaning/disinfecting waiting areas, and doing data entry. Although many participants noted that they are flexible and willing to support their team and department during the pandemic, they also expressed frustration that peers were not being utilized to their full potential and that they were burdened with menial tasks.


We identified five strategies that peer programs used to enhance peer support services during the pandemic. They include: 1) identification and use of VA resources to meet Veterans' needs; 2) development of new cross-sector collaborations; 3) creation of training opportunities for peers; 4) development/maintenance of an open-door policy for supervision and effective team communication; and 5) maximizing peers' strengths to connect with Veterans and improve programming.

First, some programs were successful at using VA resources to innovate and deliver enhanced or new peer services to Veterans. For example, they collaborated with social work, VA IT, and occupational therapy to delivery technology resources, such as VA-issued iPads and phones to Veterans. Peers also used additional VA resources such as occupational therapy services to help Veterans interact with their new devices and technologies. Moreover, they shared information about VA digital resources and encouraged Veterans to use them, such as apps for PTSD, sleep, and relaxation. Homeless programs also placed Veterans in hotels during the pandemic and peers continued to maintain regular contact with them, doing wellness checks and providing emotional support. In fact, many participants emphasized how much Veterans appreciated the peers' wellness checks during periods of stay-at-home orders.

Second, some programs actively engaged in outreach activities and developed new collaborations during the pandemic to meet Veterans' emergent needs. Many programs sought out and developed cross-services collaborations in the VA and in the community to support Veterans. Peers identified new, non-VA services to help Veterans meet basic needs, such as toiletries and food. They also collaborated with peers from other VA departments to reach out to new Veteran populations and to provide new programming. Third, many programs created and offered new training opportunities to peers. During the early months of the pandemic, many programs were operating at significantly reduced capacity. To keep the peers engaged, many supervisors encouraged peers to complete TMS training modules or a new training course. Some supervisors also provided training to peers and encouraged them to take on new tasks that further expand their skillset.

A fourth strategy focused on changes made to improve mental health teams' dynamics and communication. Some supervisors adopted or strengthened their open-door communication policy to facilitate active and ongoing communication with the peers. They encouraged peers' input and creativity and emphasized a culture of transparency and rapid quality improvement. Specifically, supervisors encouraged an atmosphere of collaboration. They welcomed peers' feedback and autonomy and promoted transparency in their communication and activities. They also increased the frequency of contact with peers to maintain communication, provide support, and generate new approaches to serving Veterans. In addition, peers played a significant role in communicating VA, State, and CDC COVID-19 guidelines to Veterans. For many Veterans, peers were their first point of contact at the VA and a trusted source of information. They not only shared useful COVID-19 information with Veterans, but they also encouraged them to follow the guidelines, such as mask wearing in public, and navigated them to useful resources in the VA and the community. This was particularly valuable in the early stages of the pandemic when many Veterans needed information and support for accessing needed care and other services. Lastly, some programs capitalized on peers' strengths, such as their lived experiences and relatability to Veterans to identify Veterans' emerging needs during the pandemic. They promote peers' creativity and flexibility to develop new groups and outreach activities, and to help Veterans focus on their strengths and foster resilience during the pandemic.

Study participants discussed the negative impact of COVID-19 on the delivery of services to Veterans. For some programs, the pandemic made bare some of the underlying issues that impede peers' utilization, success, and full integration into interdisciplinary teams. However, many programs capitalized on opportunities offered during the pandemic to reconfigure their programs and innovate. We identified several strategies that helped some peer programs to maximize peer support services to meet Veterans' mental health and social needs during the pandemic. We also reinforced the value of peer support programs to support Veterans during times of crisis and highlight their potential contributions to continue to improve Veterans' health.

None at this time.

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: TRL - Applied/Translational
Keywords: Attitudes/Beliefs
MeSH Terms: None at this time.

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