Veterans’ views of PARTNER-MH, a peer-led patient navigation intervention, to improve patient engagement in care and patient-clinician communication: A qualitative study

Abstract

Objective:

In this study, we report on participants’ experiences of PARTNER-MH, a peer-led, patient-navigation intervention for racially and ethnically minoritized patients in Veterans Health Administration mental health services aimed at improving patient engagement in care and patient-clinician communication. Participants described their views of PARTNER-MH, barriers and facilitators to the intervention’s implementation, and their application of varied intervention concepts to improve engagement in care and communication with their mental health clinicians.

Methods:

This is a qualitative analysis of the PARTNER-MH pilot randomized controlled trial. Participants participated in semi-structured interviews guided by the Consolidated Framework for Implementation Research (CFIR). Rapid data analysis approach was used to analyze the data.

Results:

Participants (n = 13) perceived PARTNER-MH as an acceptable intervention, and viewed use of peers as interventionists, long-term outreach and engagement efforts, and navigation services favorably. Barriers to implementation included limited flexibility in peers’ schedules and lack of peer/participant gender concordance, as well as limited options for program delivery modality. Three main themes summarized participants’ views and perceived benefits of PARTNER-MH that contributed to improved patient-clinician communication: 1) increased patient engagement, 2) improved patient-clinician relationship, and 3) enhanced communication self-efficacy.

Conclusions:

Participants viewed PARTNER-MH as beneficial and identified several intervention components that contributed to improved engagement in care, communication self-efficacy, and patient-clinician communication.

Practice implication:

Some patients, especially minoritized patients and those who have been disenfranchised from healthcare systems may benefit from peer-led interventions that facilitate engagement in care and communication self-efficacy to improve patient-clinician communication and healthcare outcomes.

Trial registration:

ClinicalTrials.gov NCT04515771.

1. Introduction

Communication self-efficacy, defined as the ability and confidence to communicate effectively with clinicians [1,2], and engagement in treatment shared decision- making (SDM) are foundational and modifiable components of effective patient-clinician communication. Communication self-efficacy plays a critical role in facilitating patients’ active participation in clinical encounters and their ability to manage their healthcare, which in turn contribute to positive health outcomes [3]. SDM is a patient-centered care delivery model that involves patients working collaboratively with clinicians to reach evidence-based and value-congruent medical decisions [38,39]. It is associated with increased patient satisfaction with healthcare services [40-42], enhanced self-care management including medication adherence [43,44], and improved health outcomes [45-47].

The absence of communication self-efficacy or SDM often leads to ineffective patient-clinician communication, which is often characterized as lacking mutual exchange of information, irresponsive to patients’ preferences and values, unsupportive of patients’ emotional needs, and even unethical [21-25]. Ineffective patient-clinician communication contributes to negative healthcare experiences [4-6] and poor health outcomes [7-9], disproportionally affecting socially and economically disadvantaged patients, such as individuals of racially and ethnically minoritized backgrounds [10-13]. Several studies have documented that compared to non-minoritized groups, minoritized groups, especially Black individuals, have shorter clinical encounters, less positive engagement and rapport (i.e., displayed emotion) from clinicians, are less likely to be offered participation in treatment decisions, and are more likely to experience disrespectful or biased treatment [4,14-17]. These disparities in quality of care and patient-clinician communication are further exacerbated in mental health care settings where patients with mental illness often struggle with communication barriers and interpersonal challenges that include difficulties processing information, stigmatized views of mental illness, and lack of motivation to be involved in treatment [18]. In addition, many clinicians lack communication training and self-efficacy to engage patients in critical conversations about mental health symptoms disclosure, goals for recovery, and treatment decisions, which may lead to dissatisfaction with and disengagement from services and deterioration in mental health [19]. Yet, efforts to improve patient-clinician communication, especially in mental health settings, remain limited [20-22]. Given the central role of communication in mental health services [19,23-25], improving clinical communication for minoritized groups may lead to positive mental health outcomes and improved health equity.

To improve engagement in care and communication in mental health settings for minoritized patients, we developed and pilot-tested the Pro-Active, Recovery-oriented Treatment Navigation to Engage Racially Diverse Veterans in Mental Healthcare (PARTNER-MH) intervention, which is a peer-led, patient navigation program designed for ethnically and racially minoritized patients in the Veterans Health Administration (VA) mental health services. PARTNER-MH aims to support veterans to engage in mental health services by addressing social determinants of health and personal barriers to care. It also equips them with the knowledge, confidence, and tools to become active partners with their mental health clinicians and facilitate their participation in mental health treatment decision-making [26,27].

The PARTNER-MH pilot randomized controlled trial tested the feasibility of the study design, and the feasibility and acceptability of the intervention. It also evaluated the intervention’s preliminary effects on patient engagement, patient activation, SDM, and health-related outcomes (NCT04515771) [26]. In this qualitative analysis, we: 1) examine participants’ experiences with the intervention, including satisfaction with different aspects of the program and areas of improvement and 2) evaluate participants’ views of intervention components that influenced their experiences of patient-clinician communication, which included discussions about SDM.

2. Methods

2.1. PARTNER-MH intervention

Details of the PARTNER-MH intervention have been described previously [26-28]. Briefly, PARTNER-MH was a 6-month patient navigation intervention for racially minoritized VA patients in mental health services designed to be delivered by peer support specialists (peers). In the VA, peers are veterans with lived experiences of recovery from a mental health condition, substance abuse, or military trauma, who support patients in their health journeys [29-31]. VA peer support specialist positions commonly require state certification in peer support services, a Bachelor of Arts degree, annual continued education units (CEUs), and regular peer supervision. Peers are paid employees and function as interprofessional team members, supporting clinicians and non-clinicians in delivering a wide range of health services. For example, they serve as role models, help patients learn and practice new skills, address stigma associated with mental illness, and provide support [31]. In outpatient mental health clinics, peers provide services that vary in frequency, ranging from one-time consultation to multiple visits over several months based on patients’ needs.

PARTNER-MH’s two peers are African American men, who are certified as peer specialists and embedded in a VA outpatient mental health clinic. Twenty percent of their effort was dedicated to delivering PARNTER-MH. Participants were assigned to work with one of the two peers based on availability. In addition to standard VA peer specialist training, peers completed the PARTNER-MH training program, which consisted of over 40 hours of didactic sessions covering topics such as patient engagement, diversity and racial discrimination in healthcare, effective communication, and professional development. Peers also received weekly supervision to discuss their PARTNER-MH work.

In addition to traditional peer support activities, PARTNER-MH peers provided study-specific services to participants, which included long-term outreach and engagement over 6-months. They systematically screened for unmet social needs and assisted patients with accessing VA and non-VA resources. Discussions about unmet social needs also created opportunities for peers to build rapport with patients, identify what matters to them, and engage them in VA services. They navigated patients to VA mental health services and addressed barriers to care. Moreover, peers used the PARTNER-MH workbook to guide their sessions with patients, which covered study-related topics: setting SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) goals for treatment and recovery, mental health visit preparation, effective patient-clinician communication, and SDM. Peers’ discussions with participants also focused on improving patient-clinician communication. They provided role modeling and coaching to facilitate patients’ participation in effective communication and SDM. Due to COVID-19 physical distancing constraints, PARTNER-MH sessions were delivered primarily via telephone through individual sessions, lasting on average an hour. Peer support sessions were delivered weekly for the first month, bi-weekly for two months, then monthly for the remaining three months. However, peers and patients had some flexibility to meet more frequently as needed.

2.2. Settings and contexts

The parent study was conducted with racially and ethnically minoritized patients at a Midwestern VA Medical Center outpatient mental health clinic. The VA is the largest integrated healthcare system in the U.S. and the primary mental health services provider for veterans. Study data were collected from August 2020 to April 2021.

2.3. Participants

To be included in the parent study, patients had to identify as a member of a minoritized group and have initiated treatment in the mental health clinic within 6 months prior to study enrollment. Participants’ racial and ethnic identities were obtained from their electronic health record and confirmed by patients through self-report when they were screened for eligibility. For this qualitative analysis, we focused on program completers from the intervention arm who participated in a qualitative interview at the end of the study. The PARTNER-MH study was approved by the Indiana University Institutional Review Board.

2.4. Interviews

We used selected components of the Consolidated Framework for Implementation Research (CFIR) to guide the study’s qualitative data collection and analysis [32]. CFIR offers an opportunity to evaluate intervention characteristics and contextual factors that could influence its implementation, such as quality of the clinic providing the service (inner setting) and skills of the interventionists (characteristic of the individual) [32]. We also asked participants to describe their experiences and rate their satisfaction with different aspects of the intervention. Examples of questions included: Overall, how satisfied are you with the PARTNER-MH program? How satisfied are you with your assigned peer? The questions were ranked on a 5-point Likert Scale, ranging from very satisfied (1) to very dissatisfied (5). Participants were also asked to describe aspects of the program that they like the most and the least. Interviews lasted from 20 to 45 min and were conducted by a research assistant trained in qualitative methods. Interviews were audio recorded and transcribed.

2.5. Qualitative data analysis

Interviews were analyzed by a team of 4 analysts that included the first author (JE), who is a health services researcher with a background in clinical psychology and anthropology, and three trained research assistants. The 4 analysts are female and three of them identified as racially minoritized individuals. We used rapid content analysis, a multi-step process that involves a hybrid of inductive and deductive qualitative data analysis methods [33-35]. Rapid data analysis is a rigorous, applied qualitative research method that facilitates the analysis of targeted qualitative data on shorter timeline [36]. First, we used selected CFIR domains as a priori codes (e.g., participants’ views of intervention characteristics, interventionists’ characteristics) to structure the coding process and create a templated summary table, which the analytical team populated with summaries of interview transcripts and illustrative quotes. We also created memos to capture questions and key takeaway points that emerged from the data. The team independently tested the templated table with one transcript and refined it prior to summarizing all transcripts. Each transcript was summarized independently by 2–3 analysts. To facilitate rigor, the full analytic team reviewed the templated summaries together and created a final summary of each transcript based on a consensus building process. We then incorporated an inductive approach to identify emergent themes in the data [37]. The team reviewed and synthesized the summaries under each domain to identify themes and sub-themes. Throughout the analytic process, we maintained a detailed audit trail to record team discussions and decisions [38]. In the present analysis, we discuss themes related to participants’ views of the intervention and patient-clinician communication. We report findings for this paper using the COREQ guideline, which provides standards for reporting qualitative research [39].

3. Results

Fifty participants were enrolled in the PARTNER-MH Pilot feasibility trial. Thirty were randomized to the intervention arm of the study. Of these, 18 completed the intervention and were invited to participate in the interviews; 13 (72%) agreed to be interviewed. Reasons for refusal included lack of time and interest.

3.1. Participants’ characteristics

Participants’ characteristics are presented in Table 1. Participants were mostly men (69%). Seventy-seven percent self-identified as Black. Thirty one percent of participants were in 35–44 and 55–64 age groups. Most (69%) had some college education. Participants also had a wide range of mental health diagnoses, including PTSD (46%) and 23% had a substance use disorder diagnosis.

Table 1.

PARTNER-MH participants’ characteristics (N = 13).

Age	2 (15%)
25–34	4 (31%)
35–44	3 (23%)
45–54	4 (31%)
55–64
Race	2 (15%)
White	10 (77%)
Black	1 (8%)
Other
Ethnicity	2 (15%)
Hispanic Non-Hispanic	11 (85%)
Gender	9 (69%)
Male	4 (31%)
Female
Education	0 (0%)
HS/GED	9 (69%)
Some college/2 years	2 (15%)
4 years college degree	2 (15%)
> 4 years college
MH Diagnosis	7 (54%)
Mood disorders	6 (46%)
Post-Traumatic Stress Disorder	3 (23%)
Substance Use Disorders	2 (15%)
Severe Mental Illness	2 (15%)
Personality Disorders	2 (15%)
No dx listed

Note that percentages and counts for mental health diagnosis will not add up to 100% given that some participants had more one diagnosis.

3.2. Participants’ views of PARTNER-MH

Overall, most participants, (80%), reported satisfaction with PARTNER-MH during their interviews and viewed the program as beneficial. For example, participants described PARTNER-MH as a valuable service that provided a “lifeline” in time of great need, and that made them feel “seen” and cared for.

Around the time I started going, navigating through the mental health system at the VA, I was so angry. It was at the point where I wanted to hurt other people. So, in the last almost year, I’ve learned so much, I feel so much better. And I give a lot of that credit to [peer] because he was that lifeline I needed in that moment.

– 2101 Female

I was going through a very bad time. My mom gone. My two brothers are incarcerated, and I didn’t know which way to go. I needed it [PARTNER-MH] …And you guys helped.

– 1117 Male

PARTNER-MH basically showed me that there are people out there that care. I’m not just a number. I’m a person.

– 1102 Female

Participants attributed their positive experiences in PARTNER-MH to the peers’ characteristics, such as their relatability, non-judgmental attitudes, and skills at engaging patients of diverse sociocultural backgrounds. A few participants also emphasized racial concordance with the peers as an important and positive feature of the program. Indeed, 77% of participants reported being “very satisfied” with their assigned peers.

[Peer] did an excellent job. He was always available for support, and that was critical for the past 6 months for me. I appreciate that.

– 2108 Male

At the beginning, I was a lot apprehensive, kind of using avoiding techniques. … But we worked it out… [my peer] was still there. He still checked in on me. Those things I really appreciated because … all that 2020 was thrown at me and other stuff that was already on my plate, it just overwhelmed me. So, it was beneficial because I was starting to feel like I lost everyone and then I gained other people in the process, even though it was temporary.

– 1201 Female

We had the same skin color…that was a great thing. I’m not even going to hold that back. I love talking to somebody that I can relate to… from where I come from … We had like a natural chemistry just from talking.

– 2205 Male

For some participants, the navigation component of the intervention was also a valuable feature that provided person-centered outreach and support. This facilitated their engagement in mental health services by connecting them to resources to address their unmet social and mental health-related needs. Participants also noted that their relationships with their peers empowered them to discuss their unmet needs with clinicians.

Initially [I didn’t know] what all the VA offered, as far as mental health resources I have access to… We went through that a lot and the workbook. Many times, [peer] just pointed me in the right direction of what to look for, who to maybe contact, or what to ask.

– 2114 Male

[Peer] suggested the [Military Sexual Trauma] MST group, which is something I didn’t know was available, and that was a good thing. … I started to have these feelings that I never really addressed … [Peer] listened to my concern and was able to offer suggestions.

– 1102 Female

Different parts of my mental health recovery, where I needed to speak out about those things (unmet needs), and I didn’t… When I first joined the program, financially and with my food and housing completely stable. So, it didn’t feel applicable. But I know through my ups and downs, in the mental health clinic, they’ve been very relevant in the past where I’ve been almost homeless. I think it (screening) should be asked to every veteran every time. It just didn’t feel relevant to me at the time doesn’t mean it can’t be relevant in the future.

– 2108 Male

3.2.1. Areas for improvement

Participants identified three key barriers to successful implementation of PARTNER-MH that relate to various domains of CFIR: 1) peers’ schedules – CFIR domain: inner setting and leadership engagement, 2) intervention delivery modality – CFIR domain: inner and outer settings and program characteristics, and 3) gender concordance – CFIR domain: interventionist characteristics. First, participants identified peers’ limited schedule as the main reason for dissatisfaction with the program: peers had only 2 h per day allocated to the PARTNER-MH program, and the rest of their time was spent on other duties in the mental health clinic. Consequently, they had limited availability to conduct outreach and to meet with patients as needed. Overall, participants recommended greater peer coverage and flexibility in scheduling to meet patients’ individual needs. The following comment exemplified the feelings of many participants: “I just didn’t get to spend enough time with [peer] … because I think the time that we talked was limited … his workload was overcrowded.” – 2202 Male.

Second, participants recommended that the program offers multiple delivery options that include both in-person and telephone or video-conference visits. As the next quote indicates, several participants thought that in-person visits would be needed, at least initially, to develop rapport with the peer and facilitate trust and program engagement.

I just don’t like everything over the phone… I would say that I’d like to be maybe more in person. … I guess for me maybe just trust issues. I like to kind of see who I’m dealing with. …get a vibe from you …. I think that’s a big one.

– 2114 Male

Lastly, participants recommended gender concordance between peers and participants. This was a salient theme among female participants, many of whom had a history of military sexual trauma and were hesitant to engage with a male peer. Although we successfully recruited female participants in the study, several female program completers noted that lack of gender concordance could be a potential barrier for future implementation of PARTNER-MH.

I don’t normally like working with men…I was apprehensive at first and it worked out in my favor to work with him…. my therapist encouraged me to use it (PARTNER-MH) to challenge myself…. But I’m not sure if everybody would be as open if they’re someone that’s coming from a background like me.

– 1201 Female

3.3. Factors that contribute to improved patient-clinician communication in PARTNER-MH

We identified three main factors in the participants’ narratives that contributed to their reports of improved communication: 1) patient engagement; 2) patient-clinician relationship, and 3) communication self-efficacy. In what follows, we describe each factor and discuss how they relate to PARTNER-MH constructs and participants’ experiences with the program.

3.3.1. Patient engagement

Patient engagement was the most frequent theme identified in discussions of the PARTNER-MH program. Several participants noted that “being engaged” in treatment was the main lesson they took away from the program. Specifically, participants discussed how PARTNER-MH helped them “take ownership” of their mental health and mental health treatment, which in turn, facilitated their active engagement in treatment, participation in treatment decisions, and improved communication with clinicians. Participants frequently described how their peer empowered them to attend mental health visits, communicate with their clinicians, and engage in activities, such as medication adherence and positive coping, to achieve their desired mental health outcomes.

You got to be engaged. I would say that’s probably the biggest thing I’ve learned. …Before I wasn’t doing nothing. I didn’t make any kind of effort at all. After speaking with (peer), just knowing, it is my mental health, and I am responsible for it as well.

– 2114 Male

The biggest takeaway is that I’ve got to be active in my treatment. It is not a wand that anyone has … and you feel better. You’ve got to work at it.

– 2101 Female

I’m a little more proactive about [shared decision-making], …a little bit more empowered to really engage in that process…at some point you have to take accountability and engage in the process.

– 1102 Female

Moreover, peers’ own success stories of navigating VHA mental health services and recovery served as a role model and instilled hope for some participants to also engage in services.

When I heard his (peer’s) story and that he had so many years of stability, it showed me that the VA services work … there’s a lot of veterans recovering. And I thought that was really positive.

– 2108 Male

3.3.2. Improved patient-clinician relationship

Peers helped participants address previously held stigmatized views about mental illness and treatment processes, which facilitated more open discussion about their mental healthcare needs with their clinicians. Due to previous negative healthcare experiences, some participants anticipated poor treatment from their clinicians and initially dismissed them as uncaring and unhelpful. Several participants discussed how PARTNER-MH changed their perspectives about the VHA, the mental health clinic, and mental health clinicians for the better. A participant explained: “[PARTNER-MH] helped me get over my barrier of they’re not going to listen to me…[PARTNER-MH] gave me that ability [to] just be open.” (1120, Male). Another noted how through the program he has become more forthcoming with his clinicians and not feel so rushed during his visits. He stated: “I try to be open with her (clinician) …just give her truthful answer and she would try to take different steps to help me to cope with what was going on, not just push me out the door.” (2202, Male).

Participants also discussed how PARTNER-MH contributed to their increased willingness to participate in SDM. Specifically, they shared that PARTNER-MH psychoeducation modules about mental healthcare team composition (e.g., roles of psychologist vs. psychiatrist and the patient in the team), treatment processes, and mental health visits contributed to improved communication and patient-clinician relationships.

At the beginning, taking medications was something I was completely against. But after talking with [peer]…that’s when I did talk to my talk therapist about it. … I don’t think on my own I would have pursued it…telling him [clinician] what I want more out of the therapy. …help gear him towards treatment or what I’m actually looking for.

– 2114, Male

3.3.3. Communication self-efficacy

Reflecting on their experiences in the PARTNER-MH program, participants identified skills development, especially learning to set SMART goals for treatment and to prepare for mental health visits, as essential to improvement in their communication self-efficacy. For many participants, the program’s activities, such as visit preparation worksheets, as well as role-play with and ongoing support from the peers facilitated learning and helped address barriers to communication self-efficacy.

I hadn’t really done that before [SMART goal setting]. I was just going with the flow, didn’t really have any clear-cut ideas about what I should be doing or anything to work towards as far as my mental health is concerned. So, it [PARTNER-MH] did help me organize my thoughts, and my concerns, and get a game plan.

– 1102 Female

I think that [PARTNER-MH] helps me be a better communicator because it gives me more ideas of things I should ask. It keeps me on task.

– 1110 Female

Furthermore, some participants had opportunities to practice these skills, such as visit preparation, with their providers and noted improvement in their communication with clinicians, as well as, in the quality of their healthcare visits, which they described as more productive.

Being prepared makes for a better visit rather than just going in and winging it. Now when I go to a visit, I have much more of an idea of what I want taken care of. And she [clinician] was able to help me a lot easier to where I felt I got a lot more out of it [the visit] than before.

– 2114 Male

Relatedly, participants described how they learned self-advocacy and practiced advocating for their needs with clinicians and healthcare staff. For some participants taking part in PARTNER-MH equipped them with the skills and confidence to speak up during their visits and participate in SDM.

I was having a miscommunication with my therapist and my psychiatrist. And [peer] spoke with me about …assertive communication. And as a patient, I can say “no, this is not what I want.” I didn’t really feel like I had that option before… we role played a couple times regarding talking to a clinician.

–2108 Male

Being able to stand up for myself and not just follow along blindly. [peer] and I discussed that. One call, that’s all our conversation was about was advocating for my own mental health.

– 2101 Female

3.4. Discussion

This qualitative analysis of the PARTNER-MH trial described the experiences of racially and ethnically minoritized patients who completed a peer-led, patient navigation intervention. Our results show that participants viewed the program favorably and had high satisfaction with PARTNER-MH and the peers who delivered the intervention. Participants reflected extensively upon the relationship they developed with their assigned peers, reporting appreciation for peers with similar sociocultural backgrounds, who engaged them consistently over 6 months, and who were effective educators, role models, and skillful listeners. Our findings add to a growing literature demonstrating the value of peer-led interventions in mental health services [40], especially among veterans and underrepresented groups [41-13]. They also emphasize the need for long-term investment in engagement efforts with minoritized and underrepresented groups who disproportionally experience barriers to care and mistrust of health services due to historical and personal experiences of discrimination [44,45].

Study findings also highlight key barriers to future implementation of PARTNER-MH that should be addressed. Results suggest that clinics’ leaders should be engaged to support policies to facilitate targeted hiring of female peers and provide flexible peer schedules to ensure greater engagement and reach of diverse study participants. Participants’ feedback on the program’s delivery modality also suggests that virtual video and in-person options should be offered. While telehealth (telephone and video conference) visit implementation significantly increased in VA settings because of the COVID-19 pandemic [46-48], our findings indicate that some patient subgroups may prefer and need in-person visits to successfully engage in VA health services. These results are consistent with emerging studies indicating varying levels of satisfaction and preference for telehealth visits among veterans [49,50]. Specifically, patients with multiple disadvantages – those with limited health and digital literacy, as well as those with restricted access to social resources – may benefit from in-person visits. For some patients, in-person visits may be more conducive to effective interpersonal or patient-clinician interactions and trusting relationships.

Screening for unmet social needs is increasingly being adopted by healthcare systems to improve patients’ health outcomes and reduce heath disparities[51,52]. While the benefits of social needs screenings are yet to be determined, the current study points to the positive impact of the PARTNER-MH screening approach, which was conducted by peer specialists. In so doing, PARTNER-MH peers facilitated a screening process that went beyond simply “screen and refer.” Peers were able to engage patients in discussions about expectations of referrals, facilitate conversations about sensitive and stigmatized topics, help prioritize needs, and follow-up on referrals.

Participants also linked PARTNER-MH’s materials and processes to improved patient-clinician communication and relationship. In their interviews, participants described how the knowledge they gained through the program was translated to specific patient engagement behaviors, such as being more forthcoming about their mental health concerns, sharing their goals for treatment, being prepared for their mental health visits and, and participating in SDM with their mental health clinicians. Indeed, participants’ discussions of how visit preparation contributed to improved visit quality indicate that this was an area of need. Though preliminary, these findings are encouraging and indicate potential value of visit preparation in facilitating improved patient-clinician communication and patient’s participation in SDM [53]. Participants also highlighted the benefit of being able to practice the different skills that they learned through role playing with their peers. The extended engagement, ongoing peer support and active learning strategies were well-received by patients and show promise in fostering communication self-efficacy and positive patient-clinician communication among minoritized VHA patients in mental healthcare services.

Moreover, our findings point to opportunities to further engage peers in interventions to support team-based communication and patient-clinician communication. Peers are well-poised to use their lived experiences and training to model effective patient-clinician communication for patients and to serve as a bridge between patients and clinical teams. Although there is a growing literature demonstrating the effectiveness of peer support in engaging patients in mental health services, peers remain underutilized, and they continue to experience persistent barriers to full integration in clinical settings that include lack of clinician buy-in and stigmatized views of peers [27,31,43,54]. Clinicians may help advance peer services by facilitating peers’ integration in their teams; elevating the peer role to address communication barriers during visits, especially by eliciting peer perspectives on clinical and patient-clinician relationships; and by increasing peer-clinician collaborations to address patients’ needs.

3.5. Conclusion

Overall, participants viewed PARTNER-MH as beneficial. They described how they applied varied concepts such as goal setting and visit preparation in their mental health treatment and engaged in the process of behavior change to positively effect patient-clinician communication and increase their engagement in care. This pilot study had several limitations that future research should address. The study was conducted at one VA Medical Center and may not generalize to other VA facilities or other healthcare systems. There was selection bias given only program completers participated in the interview. While the findings provide insights into various aspects of the intervention that are helpful and potentially conducive to improved patient-clinician communication, modifications are needed to refine the intervention and future testing of PARTNER-MH’s effectiveness in a fully-powered trial as well as detailed examination of these intervention components are warranted.

3.6. Practice implications

Findings suggest that peers who support patient engagement, navigation of mental health services, and offer opportunities to practice communication skills may contribute to improved patient communication efficacy and patient-clinician communication. While this pilot feasibility trial shows overall positive responses from participants, more research is needed to test its effectiveness in a larger trial and to explore barriers and facilitators to future adoption and implementation in diverse settings, healthcare contexts, and patient populations. Importantly, it would be helpful to examine organizational factors, such as leadership buy-in and organizational culture, needed to support these types of programs.