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...