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2023 HSR&D/QUERI National Conference Abstract

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1157 — The Peer-2-PACT (P2P) Program: A peer-led, home-visit needs assessment intervention for High-Need High-Risk older Veterans

Lead/Presenter: Stuti Dang
All Authors: Dang S (Miami VAMC, University of Miami Miller School of Medicine, Elizabeth Dole Center of Excellence in Veteran and Caregiver Research), Maxwell M (Veterans Affairs Medical Center (VAMC), Miami, FL) Bryant A (Veterans Affairs Medical Center (VAMC), Atlanta, GA) Garcia-Davis S (University of Miami Miller school of Medicine) Shook CB (VA Center for Integrated Health Care Peers in PACT Implementation team) Wray LO (VA Center for Integrated Health Care Peers in PACT Implementation team) Penney L (VAMC San Antonio, TX, Elizabeth Dole Center of Excellence in Veteran and Caregiver Research) Palacio A (Veterans Affairs Medical Center (VAMC), Miami, FL, University of Miami Miller School of Medicine) Bast E (Veterans Affairs Medical Center (VAMC), Miami, FL) Finley E (Greater Los Angeles VA) Kinosian B (VAMC Philadelphia) Intrator O (GECDAC (Geriatrics & Extended Care Data & Analysis Center), Canandaigua VA Medical Center, University of Rochester School of Medicine and Dentistry)

VA Geriatrics and Extended Care (GEC) proactively identifies high-need high-risk (HNHR) Veterans most likely to benefit from additional GEC services and programs. Attending to the unmet needs of older HNHR Veterans by designing targeted interventions is critical to reducing institutionalization, hospitalization, and death. The Peer-2-PACT (P2P) program implemented Veteran Peer Specialists (Peers) as home extensions of VA primary care Patient-Aligned Care Teams (PACTs). This pilot aims to evaluate the effect of the P2P intervention on identifying unmet needs and increasing access to needed services.

P2P is a multipronged intervention implemented by trained Peers which includes: i. Identifying unmet needs via via checklist-guided virtual and/or in-person home-visit and targeted data gathering, ii. Collaboration and care coordination with PACT to link Veterans to needed services based on unmet needs, and, iii. Providing Veterans education and resources. The P2P intervention research protocol was iteratively modified and bolstered for concordance with peer scope of work. We developed i) a CPRS note-template for needs-assessment and guidance for referring Veterans with specific needs (e.g., home-safety assessment for falls), ii) a Veteran- and caregiver-education/resource book, and iii) an enhanced peer-education curriculum, based on feedback from Peers, Veterans, experts, and local and national stakeholders. In this open-label, single-arm trial, eligible participants were Veterans on the HNHR list at the Miami VA or referred by PACT providers due to poor engagement in healthcare (missed appointments/no-shows). A 3-month pre-post analysis after initial contact measured differences in the number of PACT encounters using paired sample t-tests, and use of GEC services.

Intervention participants (N = 25) were mostly 75 +/-10.4 -year-old white (55%) males (92%) with a mean CAN and JFI score of 93.2 and 6.6, respectively, NHB (44%), and Hispanic (12%). The most common needs identified were managing mental or physical health (52%), medical supplies (48%), home safety devices (44%), transportation (32%), scheduling medical appointments (32%), food insecurity (28%), assistive devices (28%), ADL/IADL assistance (28%), and medication refills (24%). Mean PACT encounters increased in the 3-months after beginning the P2P intervention from 0.52 to 2.36 (p < .01) for social work, 1.76 to 3.72 (p < .01) for nursing, and 1 to 3.36 for pharmacy (p < .01). Identification of the unmet needs by peers results in HNHR Veterans initiating new services including, but not limited to, home-safety equipment (28%), transportation assistance (24%), home-health aid (24%), assistance with scheduling appointments (32%), and food drop-off (24%).

Preliminary data show that Peers may help bridge the gap between PACT and HNHR Veterans by evaluating Veterans’ outside PACT clinics, identifying and ensuring PACT is aware of unmet needs, facilitating linkage to appropriate referrals, and following up to ensure needs were addressed. The P2P is a promising and innovative model to identify unmet needs and increase Veteran use of needed services.

HNHR Veterans make up VA’s highest-cost and most complex patients. Many HNHR Veterans do not get needed care and services. P2P offers a model to integrate Peers into PACT by acting as a home-extension of PACT and enhancing health equity by increasing access to care for HNHR older Veterans.