Findings from the COACH Trial: Implications for an Expanded Role for VA Whole Health Coaches and Peer Specialists
With the introduction of VA Whole Health Coaching and Veteran Peer Specialists, more Veterans are receiving coaching and peer support for behavioral (e.g., weight) and mental health concerns. Many Whole Health Coaches and Veteran Peer Specialists (“peers”) in VA are trained in Motivational Interviewing (MI), an evidence-based, affirming, and patient-centered approach for facilitating behavior change. Whole Health Coaches and peers use MI-informed communication (or Motivational Coaching) and the VA Whole Health Model to help Veterans explore their values, develop personal health plans, and make progress toward personal health goals.
Both Whole Health Coaches and peers work to cultivate warm, supportive, non-hierarchical relationships with their Veteran patients, which may come naturally to peers who share experiences with other Veterans and who “speak the same language.” With the broad promotion and dissemination of Whole Health and peer coaching within VA, questions arise about which Veterans are best served by coaches and peers and how health coaching can bridge Veterans’ access to VA mental health services, including suicide prevention, particularly among rural Veterans.
Rural Veterans experience significantly worse mental health outcomes and are 65 percent more likely to die by suicide than their urban counterparts, yet only 20 percent of rural Veterans engage in mental health treatment. Low mental health engagement among rural Veterans has been attributed to poor access, including stigma and stoicism, with rural Veterans preferring to address mental health conditions within families, religious communities, and with their peers. Thus, among rural Veterans, non-clinician peer coaches may be effective in facilitating engagement in mental health care because they have rural Veterans’ trust as insiders rather than outside experts.
COACH [CRE 12-083; Seal, PI] was a randomized controlled trial funded by HSR&D that sought to determine the effectiveness of Veteran peer-delivered telephone motivational coaching to improve mental health treatment engagement among rural Veterans, and secondarily to assess change in rural Veterans’ mental health symptoms.1 At the start of the COACH trial, we assessed Veteran participants not engaged in mental health treatment, and enrolled those who screened positive for one or more mental health conditions (e.g., depression, post-traumatic stress disorder, anxiety, substance use disorders) in COACH. A peer coach then provided them with feedback about their mental health screen results and a referral to one or more mental health services. Thereafter, we randomized participants to receive the control condition (no further follow-up with the peer coach) or the intervention: four sessions of peer-delivered telephone motivational coaching. We found that among the 272 Veterans who screened positive for a mental health condition and received feedback and a referral, 45 percent of those receiving peer telephone motivational coaching versus 46 percent of controls initiated mental health treatment, indicating no between-group difference. However, compared to controls, Veterans receiving peer motivational coaching achieved significantly greater improvements in the study’s secondary outcomes including improvements in depression, post-traumatic stress disorder, and cannabis use symptom scores; quality of life domains; and initiation of self-care strategies.
"When she opened up that she was a Veteran...I let my guard down a lot more. It gave me more freedom to express myself and actually talk."
Although COACH demonstrated no difference in treatment engagement between the intervention and control groups, Veterans in both study arms had twice the rate of mental health treatment engagement (> 40 percent) observed in other rural Veteran populations (20 percent), pointing to the potential role of mental health assessment, feedback, and referral (in this case, by a Veteran peer) as a key contributor to improved treatment engagement. This finding replicates prior studies showing that assessment and feedback about mental health symptoms, in itself, can prompt engagement in mental health treatment. That this could be done effectively by a Veteran peer was a novel finding.
It is also notable that Veterans assigned to Veteran peer coaching had modest but significant improvements in mental health symptoms, quality of life, and initiation of a variety of self-care strategies to reduce stress (e.g., walking, gardening). In qualitative exit interviews, Veterans named several benefits of peer motivational coaching, including peers’ help with problem-solving, providing community or web-based mental health resources, and providing encouragement and accountability to meet personal goals. Participants also reported that Veteran peers asked and cared about them and seemed less judgmental than the mental health professionals they had encountered in the past.
During the COACH trial, researchers measured peer coaches’ fidelity to MI using the Motivational Interviewing Treatment Integrity scale (MITI). While overall fidelity to MI was rated as “fair,” Veteran peers scored highest on “partnership,” perhaps because of the collaborative and non-hierarchical relationship between the Veteran peers and participants. For example, one participant reported, “To me it was actually kind of therapeutic to talk to someone about it all. Just having that person available to talk to, to learn stuff, someone who is able to talk to you as real person… Just kind of, relaxing – no judgment, no biases, to me it was really calming.”
As is well known, one of the greatest drivers of mental health treatment engagement is having more severe mental health symptoms; and hence, a greater perceived need to seek treatment. Veterans who received peer motivational coaching that resulted in reductions in their mental health symptoms may have perceived the peer coaching itself to be therapeutic, thus reducing perceived need for clinician-directed mental health treatment. One COACH participant described the Veteran peer coach as helping them, “catch [the problem] quickly, without it getting so out of hand that I have to call somebody for mental health. That was – to me – the highlight of all this.”
Other recent small studies have demonstrated the effectiveness of Whole Health coaching to improve Veterans’ psychological well-being, mental health symptoms (depression, PTSD, perceived stress, and anxiety), and perceived health competency, which, in turn, has been shown to be protective for suicidality.2,3 As with the COACH trial, in these studies qualitative interviews found high levels of satisfaction with the coach-Veteran relationship and many participants thought of their coach as providing a therapeutic intervention that, in itself, improved their mental health. Participants suggested that Whole Health Coaching could be an option for Veterans who are struggling with stress and mood concerns but are not willing or ready to engage in formal treatment. Multiple participants explicitly noted that coaching focuses more on strengths than problems and does not carry the stigma of mental health treatment; thus, Whole Health or peer coaching may be a more attractive option for Veterans who are reluctant to pursue formal mental health treatment.
Currently, the Office of Patient-Centered Care and Cultural Transformation is partnering with VA Primary Care Operations and the Office of Mental Health and Suicide Prevention to explore better integrating coaches within healthcare teams in an effort to improve patient-centered care. Such integration would potentially better meet patients where they are, and strengthen referral pathways between coaching and VA's primary care and mental health services. Thus, there is a real-time, practical need for further health services and implementation research that explores the feasibility, effectiveness, and costs of an expanded therapeutic role for Whole Health Coaches and peers embedded in VA clinical services.