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QUERI – Quality Enhancement Research Initiative

QUERI E-news
November 2018

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Peer Specialists in Primary Care: Improving Mental Health 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. As per the PACT model of care, 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 a mental health and/or co-occurring condition – actively engaged in his or her own recovery – that has been trained and certified to help other Veterans with these conditions. 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.

In 2008, VA systemized the use of peer specialists in its Handbook on Uniform Mental Health Services in VA Medical Centers and Clinics, which states that “all Veterans with serious mental illness must have access to Peer Support” (Chinman et al, 2012). 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), are completing an evaluation of the Peers in Primary Care pilot study.

QUERI investigators integrated a randomized implemen­tation trial into the Peers in Primary Care pilot to test the impact of expanded versus limited implementation support. Half of the sites will receive one year of support that includes training, implementation planning, ongoing external facilitation, feedback, and consultation. Other sites will receive written guidance and limited consultation by the QUERI team so that all sites get some support. Organized by RE-AIM—an evaluation model that specifies domains needed for successful implementation (i.e., Reach, Effectiveness, Adoption, Implementation, Maintenance)—data are being collected on organizational context and team functioning; peer support fidelity; patient activation, satisfaction, and functioning, as well as implementation barriers and facilitators (via interviews). The two groups will be compared on each RE-AIM domain.

This evaluation will identify specific themes and capture a detailed understanding of how well Peer Specialists were deployed - and their impact. Moreover, the 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 FY2018, Peer Specialists participating in this pilot delivered services to an estimated 5,068 Veterans.

Peer Specialists also may be of help to Veterans who will navigate both VA and private healthcare systems. As healthcare options expand due to the MISSION Act, there is concern that non-VA providers are less experienced in detecting and treating underlying conditions prevalent among Veterans. For example, a nurse practitioner in a community clinic may be less likely to explore how insomnia stems from combat-related PTSD. Veterans who get “lost” between VA and non-VA care might find their way to the care they need with the advice of peer specialists with more “navigational” experience.

For more information about Peer Specialists in Primary Care Settings, please contact Richard Goldberg, PhD, at . For information about Team-Based Behavioral Health QUERI, please contact JoAnn Kirchner, MD ( or Mark Bauer, MD ( . This QUERI national program works to improve coordination, quality, equity, and outcomes of team-based care for Veterans with behavioral health conditions.

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