# Using Data Analytics and Targeted Whole Health Coaching to Reduce Frequent Utilization of Acute Care among Homeless Veterans

> **NIH VA I01** · VETERANS ADMIN PALO ALTO HEALTH CARE SYS · 2022 · —

## Abstract

Background: Ten percent of patients account for up to 70% of acute care costs. Among these “super-utilizer”
patients, homelessness is a robust social determinant of acute care utilization. Through a field-based
dashboard and clinical aids, the Hot Spotter Analytic program assists Patient Aligned Care Teams (PACT) with
targeting and tailoring care for the highest-need homeless Veterans. However, many Veterans identified by the
Analytics do not engage in supportive services that reduce risk for acute care utilization. Peer Specialists (PS)
are a high-value workforce that can facilitate Veterans’ engagement in care. Yet, there is a need to enhance
the PS role with a structured approach that can capitalize on known facilitators of care engagement among
homeless Veterans. Whole Health Coaching (WHC) is one such approach. By focusing on patients’ values and
goals rather than treatment of specific conditions, WHC reduces patients’ stigma regarding their care needs
and increases patient activation and well-being, which can increase engagement in supportive services.
Significance: By training a high-value workforce in a patient-centered approach to care that facilitates
engagement in supportive services, our proposed research can reduce homeless Veterans’ reliance on acute
care services, thereby minimizing the financial burden these patients exert on the care system. This proposal
responds to several VA HSR&D Research Priorities including Mental Health, Healthcare Value, Primary Care
Practice, Healthcare Informatics, and Whole Health, as well as VA-related Legislative Priorities (MISSION Act).
Innovation and Impact: A critical innovation of this research is use of data-driven processes (Hot Spotter
Analytics) to better target and tailor care for high-need, homeless Veterans in VHA. Our proposed research is
also innovative in that it seeks to integrate the Analytics with a workforce (PS) and approach to care (WHC)
that are rapidly expanding in primary care services VA-wide. These features of our target intervention are
consistent with the National Academy of Medicine’s recommendations for high-quality care for high-need
patients. Finally, by focusing on the development of personal health goals that are aligned with patients’
priorities and values, WHC is a key innovation to be added to existing VHA services for homeless Veterans.
Specific Aims: The goal of this project is to integrate use of Hot Spotter Analytics with Peer Specialists trained
in Whole Health Coaching (PS-WHC) and evaluate whether this approach reduces homeless Veterans’
frequent use of acute care. Aim 1: Conduct an RCT to test whether receipt of PS-WHC (vs. Enhanced Usual
Care; EUC) predicts (1a) lower acute care utilization, (1b) better health-related outcomes, and whether (1c) the
effects of PS-WHC on 1a and 1b are mediated by increased (i) patient activation and well-being, and (ii)
access to supportive services. Aim 2: Conduct a process evaluation to inform VA's potential widespread
im...

## Key facts

- **NIH application ID:** 10312596
- **Project number:** 1I01HX003151-01A2
- **Recipient organization:** VETERANS ADMIN PALO ALTO HEALTH CARE SYS
- **Principal Investigator:** Daniel Michael Blonigen
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2022
- **Award amount:** —
- **Award type:** 1
- **Project period:** 2022-01-01 → 2025-12-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10312596

## Citation

> US National Institutes of Health, RePORTER application 10312596, Using Data Analytics and Targeted Whole Health Coaching to Reduce Frequent Utilization of Acute Care among Homeless Veterans (1I01HX003151-01A2). Retrieved via AI Analytics 2026-05-21 from https://api.ai-analytics.org/grant/nih/10312596. Licensed CC0.

---

*[NIH grants dataset](/datasets/nih-grants) · CC0 1.0*