Peer Support Specialists' Unique Contribution to Veterans' Health

HSR&D’s new monthly publication Veterans’ Perspectives will highlight research conducted by QUERI investigators, showcasing the importance of research for Veterans, and the importance of Veterans for research. Our inaugural issue of Veterans’ Perspectives features QUERI for Team-based Behavioral Health and its evaluation of peer support specialists’ involvement in helping Veterans treated in VA primary care settings.

In the April 2018 Issue:

• Vital Role of Veterans in VA Research
• Peer Specialists in Primary Care
• Increasing and Evaluating the Role of Peer Specialists in Primary Care
• Using Peer Support in Primary Care: Perspectives of Peer Specialists

Vital Role of Veterans in VA Research

Veterans are integral to the VA research mission, ever since VA established academic affiliations. Their role is more vital than ever due to the growing need for implementation strategies to ensure that best practices get off the academic shelf and into the hands of Veterans and their providers. This issue features examples of how Veterans helped to implement patient-centered care models in the VA healthcare system, notably, through the use of peer specialists in primary care settings.

Peer specialists are important allies for Veterans in that they understand what they are going through and can offer suggestions to enhance recovery-oriented care. A central factor to recovery is the ability of an individual to work towards personal goals as a means to achieve better health; that is, rather than striving to be a “good patient,” striving to be a better parent, student, spouse, etc. VA is at the forefront in promoting effective recovery-oriented care through its collaborative care models (e.g., Patient-Aligned Care Teams, Primary Care-Mental Health Integration, telehealth collaborative care for bipolar illness, and the Whole Health Initiative).

These models provide essential tools to help providers achieve VA priority goals of suicide prevention and opioid/pain management under the Comprehensive Addiction and Recovery Act (CARA). As these models of care become disseminated it will be important to maintain fidelity to the core elements of the recovery approach, include the use of peer specialists, and promote effective implementation strategies that scale up and spread these effective practices.

Peer Specialists in Primary Care

In 2010, VA adopted the PACT (Patient-aligned Care Team) model of healthcare, which puts Veterans’ goals and needs at the center of the treatment decision-making process. PACT is a team-based model of care in which a group of healthcare professionals, led by a primary care provider, work collaboratively with the patient to provide all of the patient's healthcare, or to coordinate care with other qualified professionals as needed. The implementation of PACTs within VA primary care has already shown benefits. For example, one study by HSR&D investigators showed that primary care clinics with the most PACT components in place had greater improvements in 5 of 7 chronic disease intermediate clinical outcomes and 2 of 8 chronic disease process measures when compared to clinics with the least PACT components in place.¹

Embedding Peer Specialists in primary care PACTs encourages Veterans to play a more active role in managing their health and healthcare. A Peer Specialist is a Veteran with mental health experience – actively engaged in his or her own recovery – that has been trained and certified to help other Veterans. Peer Specialists may share their own experiences in dealing with mental health conditions, including PTSD and/or depression, and utilizing VA mental health resources. They may also assist Veterans in identifying and achieving specific life and recovery goals.

Reference

1. Rosland A, Wong E, Maciejewski M, et al. Patient-centered medical home implementation and improved chronic disease quality: A longitudinal observational study. Health Services Research. November 20, 2017;e-pub ahead of print.

Increasing and Evaluating the Role of Peer Specialists in Primary Care

In August 2014, the White House issued an Executive Action mandating that 25 VA medical centers pilot the deployment of Peer Specialists in primary care PACTs. More than 1,000 Peer Specialists have been hired in VA mental health in recent years, and this Executive Action further signaled their growing importance as service providers in the VA healthcare system. However, Peer Specialists had not been widely deployed in primary care before. In partnership with VA Central Office (VACO) leadership, QUERI for Team-based Behavioral Health investigators, along with both the VISN 4 and VISN 5 MIRECCs (Mental Illness Research, Education and Clinical Center), is completing an evaluation of the Peers in Primary Care pilot study.

This evaluation will provide critical data to guide administrators and VA policymakers on future deployment of Peer Specialists in primary care settings. In addition to characterizing the experiences of participating sites, QUERI investigators also are testing the impact of providing external facilitation, consultation, and feedback to assist with implementation. By the end of 2017, Peer Specialists participating in this pilot delivered a range of services, including whole health coaching, to an estimated 4,479 Veterans.

Using Peer Support in Primary Care: Perspectives of Peer Specialists

Peer Support Specialists Tony Burnette and Mark Cowley

Now in remission for more than two years, cancer survivor Gary M. had come to believe that he was incapable of mustering the energy to walk more than a few hundred yards. The former Army mechanic and construction superintendent met with Peer Support Specialists Tony Burnette and Mark Cowley at the Chillicothe VA Medical Center in Ohio, in order to test his limits of endurance as part of the Peers in Primary Care pilot. Initially Gary sought to manage his diabetes more successfully and perhaps lose a few pounds. Setting a modest goal of walking one half mile, three times weekly, it wasn’t long before the Army veteran was walking 30-40 minutes most days, as well as modifying his diet extensively.

Peer Specialists Burnette and Cowley came to Chillicothe in an earlier pilot that sought to incorporate Veteran coaching into an emerging patient-centered culture within VA. “We just provide encouragement and someone to walk alongside…what we found is that our Veterans were much more likely to attempt and achieve the goals they expressed to us each week, knowing they’d be reporting back. Clearly, the program empowers Veterans,” said Cowley, an Air Force retiree. Tony Burnette, who served in both the Marine Corps and the Army, agrees. “Veterans respond to Veterans, and this program gives our patients something they already want…someone who listens to their goals and concerns, as well as personal follow-up that keeps them accountable. ” As VA assesses innovative ways to evaluate the effectiveness of the program, these Peer Specialists seem convinced of its value. “The strength of this program is in our commonality as Veterans,” said Cowley. “Our connection is already in place…and we know how to hold each other up.”

Peer Specialists Scott Page and Angelo Hazley

At the Cincinnati VA Medical Center, Peer Health Coaching was started in March 2014, hiring Scott Page as a full-time PS Health Coach. Services were expanded in December 2015, adding Angelo Hazley as a second full-time PS Health Coach. Scott, who retired after 21 years of service in the U.S. Army, and Angelo, a 7-year Vietnam era Army Veteran, have developed strategies for collaborating with PACT providers to identify Veterans who want to develop a personalized health plan. Along with their supervisor, they educated PACT staff about the peer role through presentations, skits, and success stories highlighting the PACT team members, the Veteran, and the Health Coach. They also share VA and community resources to assist Veterans.

Monthly follow-up calls help to keep Veterans on track with their goals and offer brainstorming when barriers arise. Scott and Angelo also have realized that they are able to reach more Veterans through groups, and often see more health improvements with this level of investment and support from other Veterans. Most recently, they collaborated with home telehealth nurses to support Veterans’ awareness of this service – and to mentor Veterans as they develop the practice of daily self-monitoring. Angelo and Scott also are leading Cincinnati VA’s Red Carpet Welcome Program that includes an in-person group visit and clinical video telehealth to help orient new Veterans. During the Welcome Program, Veterans also are invited to set goals for health improvement.

Peer Specialist Clayton McGee

The West Palm Beach VA Medical Center chose to focus its PACT Peer Program on three areas: tobacco cessation, weight management, and engagement in diabetes self-management. Initiating the pilot was not free from challenges. One of the greatest challenges was ensuring that Veterans were aware of the PACT Peer program. To overcome this obstacle, researchers empowered their Peer Specialist, Clayton McGee, to make the initial contact with Veterans without the need for a formal referral. Clayton introduces himself as a new team member and offers to assist them in discovering ways they can better care for themselves. They also created immediate access by not requiring scheduled appointments, thus Veterans could engage at a time convenient for them. After introductions, Clayton offers coaching services (smoking, diabetes, weight loss) focusing on goal setting and problem solving. While coaching, Clayton may become aware of other related concerns and can relate this back to the other team members (i.e., primary care physicians, nurses, social workers, mental health providers, and benefits counselors). Clayton helps Veterans navigate the complex system. Best of all, Veterans get answers to pressing questions they may have and do not feel alone.

Over the year, QUERI researchers and the Peer Specialist have been able to walk side-by-side with Veterans to ensure their healthcare goals were met and their immediate needs were taken care of, and they have seen a shift in the attitude of Veterans from one of Veterans being somewhat distrusting to more of an open attitude where they feel they can better partner with their healthcare team within VA. Spreading similar programs can only lead to an improvement in Veterans’ overall experience with VA healthcare.

For more information about Peer Specialists in Primary Care Settings, please contact Richard Goldberg, PhD, at Richard.Goldberg@va.gov and/or Matthew Chinman, Ph.D., at Matthew.Chinman@va.gov. For information about becoming a Peer Specialist or Peer Support Apprentice, please visit the VA Careers website.