Background: One in four Veterans presenting to VA primary care suffers from mental health conditions, most commonly depression. However, due to barriers such as time constraints on providers, Veterans? stigma about seeking mental health care, and costs associated with traveling to VA for care, most of these Veterans do not receive any treatment for their mental health problems. Mobile health (?mHealth?) is an innovative and low-cost means of expanding access to mental health care for Veterans. The effectiveness of mobile applications (apps) and other mHealth tools is emerging. Nevertheless, poor patient engagement and poor sustainability remain the Achilles? heel of these tools. These implementation challenges greatly limit the routine use of these otherwise promising innovations. Peer Specialists (PS) can enhance patients? engagement with apps that are intended for self-care of mental health problems by helping to orient patients to these apps and by providing technical support and accountability. Consistent with this, recent studies indicate strong support among PSs and primary care providers for using PSs to facilitate patients? engagement with mobile apps. In combination with the recent expansion of PSs into primary care, these studies suggest that PSs may be the ideal workforce and primary care the ideal setting in which to facilitate the implementation of mHealth into routine care in VA. Significance/Impact: By capitalizing on a high-value workforce shown to improve Veterans engagement in mental health care (i.e., PSs), this research stands to accelerate the implementation of mHealth in VA, and, in turn, improve access to mental health care for Veterans. Our proposed research responds to VHA and HSR&D priorities of Access to Care, Mental Health, Population and Whole Health, and Virtual Care, as well major VA- related Legislative Priorities (MISSION Act). Innovation: PSs hold substantial promise for maximizing routine implementation of mHealth in VA, but no protocols have been designed to guide this process. In this study, we will rapidly design and then conduct a proof-of-concept test of the deployment of PSs in the implementation of mHealth in VA primary care. The protocol for PS support of mHealth will be grounded in the Whole Health model being disseminated in primary care settings VA-wide. Although we expect our PS protocol design will be easily adaptable and generalizeable to multiple apps, in this study we focus on one expert-endorsed VA app ? Mood Coach.
Specific Aims : (1) Conduct a formative evaluation to identify barriers and facilitators to using PSs to support implementation of mHealth in primary care. (2) Integrate the findings from the formative evaluation to design the protocol for PS? support of mHealth in VA primary care. (3) Evaluate the feasibility, acceptability, and safety of the protocol among Veteran patients and PSs. Methodology:
For Aim 1, we will hold qualitative interviews with three PSs and three primary care providers each from five sites participating in a VA national evaluation of Peers in primary care.
For Aim 2, to guide protocol design, we will convene two meetings of a Steering Committee comprising VA and DoD stakeholders and incorporating the Veteran perspective.
For Aim 3, at each of two sites that are participating in the national evaluation of Peers in primary care (Palo Alto and Syracuse), PSs will use the protocol to introduce Mood Coach to 12 primary care patients who screen positive for depression but subsequently did not meet the VA SAIL metric for continuity of care for depression. Four weeks later, objective app usage data will be extracted and patients will be interviewed to assess satisfaction with the mHealth support received from the PS, feedback regarding barriers and facilitators to this process, and changes in depression symptoms. Next steps: By completing these pilot aims, we will be well positioned to submit a subsequent HSR&D IIR ? a Hybrid Type 1 RCT at the Palo Alto and Syracuse VAs to evaluate the effectiveness and implementation potential of using PSs to support mHealth implementation.

Public Health Relevance

In the Veteran primary care population, mental health disorders are common, costly, and cause untold suffering, including increased risk for suicide. Yet, most of these Veterans go untreated due to patient, provider, and organizational barriers. Mobile health (?mHealth?) has enormous potential to address these challenges; however, the implementation and sustainment of these tools into routine clinical practice remains unfulfilled. Using Peer Specialists to support implementation of mHealth in primary care settings can maximize the reach and engagement of these tools with patients and sustainability in VA over the long term. If successful, this program of research represents a unique opportunity to expand access to mental health care for Veterans with low staff burden and at low cost, and, in turn, help to reduce the array of adverse health outcomes that stem from untreated mental health problems.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (I21)
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HSR-4 Mental and Behavioral Health (HSR4)
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Veterans Admin Palo Alto Health Care Sys
Palo Alto
United States
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