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Ongoing research

Probing the value of peer mentors for homeless Veterans

March 16, 2017

By Mike Richman
VA Research Communications

Nearly a decade ago, the White House and VA announced an ambitious plan to end Veteran homelessness. VA, in collaboration with state and local officials, has since led a series of initiatives that have helped fuel a precipitous decline in the number of former U.S. service members who are homeless.

Still, about 40,000 Veterans experience homelessness on a given night. They need as much support and guidance as possible to understand what's available through the VA health care system and to learn about job, educational, and housing opportunities.

Now, a new VA study explores whether a peer mentor—in this case a Vet who was once homeless—can play an important role in a homeless Veteran's life. The study, published online in February 2017 in Psychiatric Services, suggests that many homeless Vets will "engage with peer mentors, who may provide psychosocial support that can complement traditional health care encounters. Peer mentors may serve a key role in building trust between patients and providers to foster engagement with the health care system."

"The idea was that formerly homeless Veterans had to deal with similar problems and have successfully navigated the VA system, so they would be good resources for new Veteran patients," says lead author Dr. Jean Yoon, a health economist at the VA Palo Alto Health Care System in California. "If homeless Veterans can engage with their providers and receive the care they need, they ultimately can have improved health outcomes."

According to Yoon, the study's main goal was to help homeless Veterans better engage with their VA providers, since mutual trust can be lacking, and to increase primary care and other kinds of outpatient visits. But in that respect she and her team failed to detect a notable difference between the two cohorts, homeless Vets who met with a peer mentor and those who didn't, partly because of a relatively small sample size, she says.

Larger study needed to further assess peer mentors

Patients in the peer mentor group averaged 5.1 primary care visits in the six-month study period, compared with 4.4 for the non-peer cohort. Also, health care costs that included doctor visits and prescriptions were similar: $18,919 for the peer mentor group and $17,483 for the other cohort. "If the peer mentor was able to reduce acute care [emergency department visits and hospital stays] in that group, we would expect those patients to have lower costs overall," Yoon says. "We didn't find that in our study, but that's one thing we wanted to look at."

She adds: "We were trying to examine what the effect of the peer mentors would be. We weren't able to find a significant effect on increasing outpatient visits or decreasing acute care, although the slight difference suggests there could be a potential benefit in terms of engaging with providers. It could be worthwhile to test the effect of peer mentors with a larger sample of patients and longer follow-up periods, to determine whether the mentors can increase use of outpatient care and reduce use of acute care to improve care overall."

The study was part of a larger ongoing project that is looking at homeless Vets as a population in relation to medical home development, a model designed around patient needs that is aimed at improving access to care. The four-part umbrella study is led by Dr. Thomas O'Toole, director of VA's National Center on Homelessness among Veterans (the Center) and a co-author of Yoon's sub-study. His research team is interested in finding feasible, innovative solutions to the poor health outcomes of homeless Vets by bridging gaps that sometimes exist between them and their VA providers.

"VA offers many programs and services that can benefit homeless Veterans, who may not be aware of these services or may not be sure how they can access them," Yoon says. "A peer intervention within primary care appeared to be a novel approach to helping these Vets."

The value of peers has been tested in other VA clinical settings, specifically mental health and addiction care. But this is the first time, Yoon says, a peer mentor program was tested with VA homeless patients in primary care.

Her study included homeless patients at four VA clinics. Homeless meant someone was unsheltered, stayed in an emergency shelter or in time-limited transitional housing, or lived in an unstable setting with family or friends. Nearly all of the patients were men, and more than 80 percent had at least one mental health condition, such as depression or anxiety. "Since having a mental health condition can make managing chronic physical health conditions more challenging, these Veterans often have poor health status," Yoon says. Plus, 95 percent were not married, highlighting the lack of social support many homeless people experience, she says.

Of the patients, 195 were randomly assigned to two different VA medical home models that included a peer mentor, and 180 to the same models without a peer mentor. Two of the VA sites used a model called the Patient Aligned Care Team (PACT), and the other two used the Homeless Patient Aligned Care Team (H-PACT) model. PACTs are intended, in part, to provide superb access to primary care for Veterans and regularly integrate general medical and behavioral staff members. In addition to such integration, H-PACT sites provide services for homeless Veterans such as aid with housing, food, and chronic disease management needs, and connections to social services and community resources.

"Homeless patients may do better in H-PACT sites since we found that they have lower overall health care costs, including some types of emergency care, compared with homeless patients in PACTs," Yoon says. "However, the peer mentor intervention did not seem to be more effective in one setting versus the other."

Peer mentors brighten outlook for homeless Vets

Patients in the peer mentor group were assigned a mentor over a six-month period, in addition to usual primary care from their PACT and H-PACT clinical teams. The mentors, former homeless Vets with extensive experience in VA health care services, served as role models, assisted Veterans in articulating goals and needs, taught problem-solving techniques, and helped in understanding VA's health care system and VA benefits. They also reminded patients about medical appointments. "These discussions may have helped improve patients' relationships with their VA providers," Yoon says.

The plan called for the Vets to meet with their mentors twice a week for the first month, once a week during months two to four, and once every two weeks in the last two months. Many of the Veterans held true to the plan, but some had minimal contact with their peers, Yoon says.

The study failed to detect any major impacts of peer mentors on health care patterns or costs. But in another subset of the umbrella study, 83 percent of homeless Veterans said they benefited from visits with a peer mentor. African-American Veterans were more likely to benefit, and Veterans with PTSD were less likely to benefit. Some patients in that subset were quoted as saying:

• "I come in with [the peer], and we talk, and he's telling me how to do things: 'This is what you need to do, leave the other stuff alone, don't worry about it.' We would talk like brothers and stuff."
• "I saw [the peer] as a facilitator and a person that had information that I needed to help me get back to being a positive member of society again."
• "I think [the peer] gave me a better outlook because I was negative when I came here. [The peer] was resourceful. He helped me out with clothing, bus tokens. When I was trying to get a job, he would take me. He would drive me to the places I needed to go. He would help me out with the paperwork. He helped me a lot."

As Yoon and her colleagues see it, all of this research appears critical to the fate of homeless Veterans, who were once overrepresented in the homeless population. The number of homeless Veterans stood at 400,000 nearly two decades ago, but has plummeted since former VA Secretary Eric Shinseki unveiled in 2009 a comprehensive plan to end Veteran homelessness by 2015. That plan led to innovations such as H-PACTs.

"While the root causes of homelessness remain, and some Veterans will continue to be at risk for and possibly become homeless, we hope that with the continued support of these initiatives and rigorous evaluation of what works and why, we will see more communities and states able to end Veteran homelessness," O'Toole says.

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