Initial Testing of Whole Health STEPS (Structured Tiered Engagement with Peer Support)

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This RR&D CDA2 will support training for Emily M. Johnson, PhD, as a RR&D research psychologist and develop and evaluate a new package of services, Whole Health STEPS (Structured Tiered Engagement with Peer Support). The training goals for this project are to develop skills in (1) designing and evaluating adaptive stepped care interventions, (2) frameworks for enhancing and evaluating implementation in patient-centered interventions, (3) qualitative methods for enhancing stakeholder engagement and evaluating Veteran engagement in healthcare, and (4) clinical trials design for brief psychosocial interventions. These trainings will support my career focused on patient centered intervention and increasing Veteran engagement in healthcare using methods prioritizing stakeholder engagement.] Whole Health STEPS is an 8-week stepped-care package of four levels of Whole Health services facilitated by a peer support specialist. The four levels include supported self-management (an individual Whole Health STEPS orientation session and use of a self-directed Whole Health tool), brief telephone coaching (weekly 15-minute telephone-based coaching using focused prompts), Whole Health Coaching (weekly hour-long sessions incorporating the full coaching framework), and referral to a higher level of care. Across all levels, Veterans will have brief weekly telephone assessments using the Whole Health Goal Attainment Scale to evaluate progress and inform step-up decisions. Veterans who are not making progress at any of the given levels will be stepped-up to a higher level of care. [The research will involve qualitative stakeholder engagement interviews with primary care peer support staff (n=12), an open trial of Whole Health STEPS (n=10), and a pilot randomized clinical trial (n=44)] with a waitlist control to evaluate the preliminary impact of Whole Health STEPS on reducing functional impairment. [The design also supports further revision of the Whole Health STEPS manual] and evaluates research and intervention feasibility. Specifically, this trial will evaluate feasibility of several aspects of Whole Health STEPS including Veteran satisfaction, peer relationship, intervention retention, fidelity, and appropriateness of the new elements (i.e., the step-up decision points). Further, the design will evaluate research feasibility for a subsequent larger trial including assessment retention and participant willingness to be randomized. The primary patient outcome will be functional impairment evaluated by the Inventory of Psychosocial Functioning. [Stakeholders participating in the interviews will be asked to complete one research interview. Veterans in the open trial will be asked to complete assessments at baseline, after each session, and at the end of Whole Health STEPS.] All Veterans in the pilot RCT will be asked to complete research assessments at baseline, 2 months, and 4 months. Veterans randomized to receive Whole Health STEPS immediately will complete Whole Health STEPS in the first two months. Veterans randomized to the waitlist control will receive Whole Health STEPS between 2 and 4 months. Veterans will be randomized using a stratified permuted block design based on baseline functional impairment. The primary outcome will be evaluated by calculating Cohen’s d effect size at the 2-month assessment point and comparing with a pre-established one-sided confidence interval using a non-central t distribution method. Other quantitative outcome measures will be evaluated with descriptive statistics including means, standard deviations, and confidence intervals. Retention rates will be evaluated using percent of Veterans who withdraw or drop out over time. Qualitative feedback will be evaluated using the Rapid Assessment Process, a qualitative approach designed to provide a rapid but comprehensive qualitative evaluation to interpret and implement changes in a short time frame using triangulation, iterative data analysis, and additional data collection.