Employing Peer Outreach and Whole Health in Recovery for Homeless-Experienced Veterans

Official title

Employing Peer Outreach and Whole Health in Recovery (EMPOWER) for Homeless-Experienced Veterans: A Hybrid Type III Implementation Trial (QUE 25-014)

Overview

Homelessness is a national crisis in the United States, particularly in the veteran population. Due to multiple chronic conditions, homeless individuals frequently become hospitalized or are treated in emergency departments. Care engagement can mitigate this risk. Interventions grounded in evidence-based practices of peer support and whole health are effective for increasing care engagement. However, implementation of such interventions with high-acuity patients often requires strategies that are intensive and costly. This trial will evaluate the relative impacts and costs of using a high-intensity (vs. low-intensity) strategy to implement a peer-led, whole health intervention for homeless-experienced veterans in permanent supportive housing.

Detailed description

Background: Homelessness is a national crisis in the United States, particularly in the Veteran population. Due to multiple chronic conditions, homeless individuals have elevated risk for acute care service use. Engagement in primary and specialty care can mitigate this risk. Interventions grounded in evidence-based practices of peer support, patient-centered care, and whole health are effective for increasing service engagement. However, implementation of such interventions with high-acuity patients often requires multi-component strategies that are intensive and costly. This study protocol describes a hybrid type 3 effectiveness-implementation trial of Employing Peer Outreach and Whole Health in Recovery (EMPOWER) with high-need, homeless-experienced Veterans in permanent supportive housing and will evaluate the impact and cost of a high-intensity (vs. low-intensity) strategy on implementation outcomes.

Methods: (Aim 1) At 7 sites in the Veterans Health Administration (VA), a mixed methods pre-implementation evaluation will identify determinants and their potential impact on uptake of the EMPOWER and inform modifications to the intervention and implementation strategies as needed. (Aim 2) A staircase cluster randomized design will evaluate the rollout of the implementation strategies, beginning with Audit and Feedback (low-intensity) and then switching to Facilitation (high-intensity) after 6 months. Facilitation is hypothesized to have a greater impact on the reach, effectiveness, adoption, implementation (fidelity), and maintenance of EMPOWER. (Aim 3) A budget impact analysis will estimate the average cost of implementing EMPOWER at future sites and comparative costs for implementing the low- and high-intensity strategies.

Anticipated Impact: This study will provide information on the relative impacts and relative costs of strategies aimed at implementing a peer-led, patient-centered, whole health intervention for homeless-experienced Veterans in permanent supportive housing. The findings will provide guidance to VA and other healthcare systems that serve the aging population of homeless-experienced Veterans.

Interventions

• Behavioral Employing Peer Outreach and Whole Health in Recovery (EMPOWER)
  EMPOWER is a multicomponent intervention to facilitate homeless-experienced veterans' (HEVs) care engagement: (DATA ANALYTICS) HUD-VASH case managers identify high-need, HUD-VASH Veterans on the Homeless Registry Hot Spot Report. Veterans' profiles are reviewed to learn about their chronic health conditions, housing status, acute care use, and engagement in supportive care. (PEER SUPPORT): HUD-VASH peers meet with identified Veterans for up to six months, averaging once-per week sessions for the

Primary outcome measures

• Reach [Time frame: 18 months]
• Adoption [Time frame: 18 months]
• Implementation [Time frame: 18 months]
• Maintenance [Time frame: 18 months]

Secondary outcome measures (6)

• Effectiveness - Mental Health Outpatient Care [Time frame: 6 months]
• Effectiveness - Substance Use Disorder Outpatient Care [Time frame: 6 months]
• Effectiveness - Primary Care [Time frame: 6 months]
• Effectiveness - Whole Health care [Time frame: 6 months]
• Effectiveness - Hospitalizations [Time frame: 6 months]
• Effectiveness - ED visits [Time frame: 6 months]

Eligibility criteria

Inclusion criteria

• Eligible patients will be identified from VA's Homeless Registry "Hot Spot" reports, which use real-time data on acute care service utilization to identify high-need, housing-insecure patients.
• These reports identify Veterans on the VA Homeless Registry (i.e., those who had received VA housing services in the past two years) who had >1 hospital admissions and/or >2 ED visits in the past quarter of the fiscal year.
• From these reports, the investigators will identify patients at each implementation site who are

• (a) currently enrolled in HUD-VASH
• (b) have a mental health and/or SUD diagnosis

Exclusion criteria

• Not flagged on the VA's Homeless Registry Hot Spot Report
• Not currently enrolled in HUD-VASH
• Does not have a mental health and/or substance use disorder diagnosis
• Is not a patient at a participating site of the implementation trial

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Non-randomized

Model

Sequential

Masking

Open label

Primary purpose

Health services research

Study locations

United States · 1 center

• VA Palo Alto Health Care System, Palo Alto, CA — Palo Alto

Publications

• Blonigen DM, Hyde J, Smith J, TorresTower S, Podchiyska T, Taylor TJ, Raciborski RA, Roy SG, Midboe AM. Employing Peer Outreach and Whole Health in Recovery (EMPOWER) for homeless-experienced veterans: protocol for a hybrid type 3 implementation trial. Implement Sci. 2026 Apr 8;21(1):35. doi: 10.1186/s13012-026-01499-y. PMID 41952220

Identifiers

NCT: NCT07309224 · QUX 26-002

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗