Barriers and Enablers to Implementing Peer Specialists in Veterans Health Administration Primary Care: a Qualitative Study

Abstract

Background

Peer specialists (PSs) are increasingly deployed in a variety of settings to provide patient-centered care. In the Veterans Health Administration (VHA), efforts are underway to integrate PSs into primary care settings. Little is known about the barriers and enablers to implementing PS services in primary care.

Objective

To characterize barriers and enablers to implementing PSs in primary care.

Design

Qualitative study using semi-structured interviews.

Participants

PSs and their supervisors from 25 VHA primary care settings.

Approach

PSs and supervisors were interviewed about their experiences integrating PSs in primary care. Rapid analysis was conducted to identify barriers and enablers to PS integration, as well as to examine the role of external facilitation in implementation experiences.

Key Results

Fifty-two interviews were completed (25 PSs from 19 sites and 27 supervisors from 24 sites). Barriers and enablers to PS integration in VHA primary care settings included PS role clarity and constraints, provider buy-in, supervision, leadership support, and primary care culture. The barriers and enablers were consistent across both external facilitation and control sites.

Conclusions

Results describe how the characteristics of the innovation, the recipients, and the context impact successful implementation of PSs in primary care settings. The identification of barriers and enablers holds promise for improving future efforts to embed PSs in primary care.

Trial Registration

This project is registered at ClinicalTrials.gov with number NCT02732600 (URL: https://clinicaltrials.gov/ct2/show/NCT02732600).

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-022-07782-0.

INTRODUCTION

Peer specialists (PSs) play an increasing role in supporting the health and wellness of Veterans. PSs are Veterans with lived mental health experience who are trained and certified to provide support to other Veterans.^1,2 The United States Veterans Health Administration (VHA) employs over 1100 PSs, typically in behavioral health services. PSs serve as role models, group facilitators, community connectors, and healthcare navigators. They use empathetic listening and self-disclosure to build rapport,³ and their services have been associated with wide-ranging benefits including functioning and patient activation.⁴

In 2014, the White House issued an unfunded Executive Action mandating the assignment of two PSs to primary care Patient Aligned Care Teams (PACTs) in 25 VHA facilities nationally.⁵ Participating sites reallocated existing PS time from their typical behavioral health settings to PACT, comprehensive medical homes that utilize a multidisciplinary team-based approach^6,7 to effectively manage chronic conditions.^8–11 Primary care settings, with their physical health focus and shorter and less frequent appointments, differ from behavioral health settings, but PSs’ skills in helping Veterans manage chronic conditions and offering a patient-centered approach may transfer well to primary care. The White House mandate presented an opportunity to evaluate potential implementation challenges as VHA set out to deploy PSs in PACT.

Historically, the implementation of PSs has been challenging in VHA and other health care settings. Barriers include a lack of understanding of the PS role, lack of experienced supervision, and stigma related to behavioral health.^12–21 In VHA, PSs receive clinical supervision by licensed providers (e.g., psychologists),²² and have been widely deployed in behavioral health since 2013.²³ However, PSs are newcomers to VHA primary care, and little is known about what barriers and enablers may exist in implementing PS services in this new setting. The current study fills this gap, examining the perspectives of supervisors and PSs embedded in VHA PACTs.

In a mixed-methods randomized program evaluation of PSs in PACT, we compared 12 sites that received external facilitation and 13 sites receiving standard support.²⁴ External facilitation, an evidence-based implementation strategy,^25–29 improves implementation of a wide range of evidence-based innovations by connecting outside consultants with teams working to integrate innovative practices (e.g., deploying PSs in primary care).^13,30–34 Facilitation is the active ingredient in the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, which posits that successful implementation of evidence-based practices is a function of facilitation of an innovation (i.e., PSs) with recipients (i.e., Veterans in PACT), considering the context of the organization (i.e., VHA). We selected the i-PARIHS framework because it presents logically linked elements that are commonly used to organize data collection and analysis in implementation science.²⁹

In this study, external facilitation included meetings with PSs, their supervisors, and other stakeholders to promote planning, information-sharing, and problem-solving. Standard support involved allowing sites to ask questions of VHA leaders overseeing the initiative to place PSs in PACT. Across the 25 sites, PSs varied in the amount of time they were dedicated to PACT (1–40 hours per week) and in the types of services delivered (e.g., health coaching, connecting Veterans to services, facilitating groups on health topics). Providers referred Veterans to PSs via the electronic health record or warm hand-offs. External facilitation was associated with significantly shorter time to PS service delivery and more PS services delivered.³⁵ The present study builds on these findings through in-depth qualitative analysis of barriers and enablers of PS integration in PACTs across all 25 sites included in the program evaluation.

METHODS

Participants and Procedures

Semi-structured, qualitative interviews were conducted with PSs and their supervisors. A PhD-level researcher (AP) designed the interview guide with open-ended questions using the i-PARIHS framework to guide question development. The guide was then reviewed and approved by all members of the research team. Interview questions explored PSs’ and supervisors’ experiences of the integration of PSs into PACT, including what PSs were doing in PACT, their supervision and training, and barriers and enablers to their success. The VHA determined this program evaluation to be quality improvement; therefore, formal informed consent was not sought from PSs or their supervisors.²⁴ PSs and supervisors were given the option to decline participation in the interviews.

Participants were interviewed approximately 1 year after the start of the PS work in PACT at each site, between December 2016 and February 2019. Interview requests were emailed to all supervisors (n = 45) and PSs (n = 43) participating in the larger evaluation. Our final sample included at least one PS or supervisor at each site, and multiple PSs or supervisors at some sites, for a total of 52 interviews (25 PSs from 19 sites and 27 PACT supervisors from 24 sites). Interviews were conducted via telephone by PhD-level researchers with qualitative experience (AP and AM) and lasted an average of 1 hour. Interviews were audio-recorded then transcribed verbatim. Demographic information of interviewees is presented in Table 1.

Table 1.

Demographics by Interviewee Type

	Peers (n = 25)	Supervisors (n = 27)
Race/ethnicity*, No. (%)
White	14 (56)	15 (56)
Black	7(28)	2 (7)
Asian	0 (0)	1 (4)
Hispanic	1 (4)	0 (0)
More than one	2 (8)	2 (7)
Gender, No. (%)
Male	21 (84)	6 (22)
Female	4 (16)	21 (78)
Years at VA*, No. (%)
<1–2	12 (48)	0 (0)
3–5	9 (36)	2 (7)
6–9	2 (8)	12 (44)
10+	1 (4)	6 (22)
Age, mean (SD)	50.8 (10.9)	--†
Min	32	--
Max	73	--

*Some data missing; †supervisor age not collected

Data Analysis

We utilized a rapid analysis approach to analyze and interpret our data.³⁶ Following transcription and proofreading, a templated summary of key domains for each PS and supervisor interview was completed by five members of the analysis team. Summary templates allow for the condensing of qualitative data without losing key information.³⁷ The template was finalized after testing with the first five interviews. Remaining interviews were assigned to two analysis team members in rotating dyads. For each interview, one member was the primary summarizer, and their partner would review the summary to add missing information or clarification. If the dyad was unable to agree on the summary, a third team member was consulted. All summarization and subsequent analyses were completed using standard word processing software.

For the present analysis, we focused on the domains of barriers (what made integrating PSs into primary care difficult) and enablers (what made integrating PSs easier). Data from facilitation and control sites were first examined separately. We compared thematic lists of barriers and enablers from both conditions and found the lists were strikingly similar, so we consolidated lists. We then compared our lists of barriers and enablers, identifying when a theme could be either a barrier or an enabler, depending on whether it was present or absent at a site (e.g., PS role clarity is an enabler when present, a barrier when absent), and matched themes and sub-themes accordingly, using i-PARIHS, the framework guiding the larger evaluation, to organize our work. Finally, to ensure that our findings were firmly grounded in the data, we reviewed over 450 transcript quotes that were referenced in the summary data; quotes presented here and in the online supplement (Table 3) were drawn from this step.

RESULTS

We identified 10 themes and 12 sub-themes, organized into three i-PARIHS constructs: Innovation, Recipients, and Context (see Table 2). In this analysis, successful implementation refers to interviewees’ perceptions of both the program implementation (i.e., delivery of PS services in PACT) and the integration of the PS role into PACT. All themes were identified as both barriers and enablers, and all were present in both facilitation and control sites.

Table 2.

i-PARIHS Constructs, Themes, and Sub-themes

i-PARIHS construct	Themes	Sub-themes
Innovation	Peer Specialist Role Clarity	--
	Peer Specialist Role Constraints	Co-Location in Primary Care
		Workload & Competing Demands
		Autonomy
	(Mis)match of Services Needed & Offered	--
Recipients	Providers	Buy-In
		Burden
	Peer Specialists	Individual Qualities
		Skills & Professionalism
	Supervisors	Burden
		Relationship with Peer Specialist(s)
	Veterans	Veteran Engagement
	Champions	--
Context	Support & Advocates	Leadership
		Funding & Staffing
	Primary Care Structure & Culture	--

Innovation

The i-PARIHS Innovation construct includes the characteristics of and evidence for the change being implemented (i.e., the implementation of PSs in PACT). Within this construct, we found three themes focusing on successful implementation of the PS role in PACT: peer specialist role clarity, peer specialist role constraints, and (mis)match of services needed and offered.

Peer Specialist Role Clarity

The understanding (or lack thereof) of the PS role was an important factor across sites. When responsibilities were clearly defined, it was much easier for the PS to integrate into the PACT. Provider uncertainty about the PS role often led to inappropriate or too few referrals.

Mostly the other staff members didn’t know what a PS could or couldn’t do, and the PSs themselves were learning their roles and responsibilities…. And it also takes time for programs... to figure out how to best utilize the PSs. – Supervisor, facilitation

Role clarity was often achieved through presentations to PACT providers, at the beginning and on an ongoing basis to train new PACT providers. PSs and their supervisors provided examples of appropriate referrals and information sheets about the PS role, and identified specific target conditions for which Veterans would be referred to the PS. While educating PACT providers about the PS role was important, it was time-consuming and did not always improve integration or referrals.

Peer Specialist Role Constraints

Three characteristics of the PS role were identified as constraints: co-location in primary care, workload and competing demands, and autonomy.

Where PSs were co-located in primary care, especially when they had a dedicated workspace, they were better integrated into PACT. PSs and supervisors found that co-location helped make PSs more visible to PACT providers, which in turn led to more referrals. Conversely, when PSs were not co-located, this presented a significant barrier: “out of sight out of mind” (Supervisor, facilitation).

Workload and competing demands influenced integration of the PSs into PACT. When PSs were able to work full-time in primary care, it enabled integration because the PS was more visible in primary care and available for walk-ins and warm hand-offs (increasing provider buy-in, recognition, and Veteran engagement).

I’m full-time in PACT [and] I think that was a big help as far as building rapport with the teams, because I think that’s the hardest part of if you’re only there one day they don’t get to know you so you don’t get that rapport to be able to get as many referrals. – Peer, facilitation

Most PSs, however, split their time between primary care and other assignments, which was a significant barrier to integration as PSs needed to juggle duties across clinics. Some PSs’ non-PACT supervisors were resistant to allowing PSs time to work in PACT, making it challenging for PSs to secure time for training and activities in PACT. Further, some PSs had their time split across multiple clinics or campuses, meaning time was lost to travel between locations.

Autonomy of the PSs to perform their duties was important, including being allowed to work independently, making decisions about what types of Veterans to work with, and not being micromanaged by supervisors. PSs appreciated having flexibility to determine the balance of time between primary care and other duties, which allowed them to accommodate Veteran appointments, walk-ins, and warm hand-offs from PACT providers. At the same time, PSs appreciated support from other providers.

We have a lot of freedom to make our own decisions and… what attributes to that freedom is I am not alone…. I can always talk to several doctors on the PACT teams about anything that comes up. – Peer, facilitation

In addition, PSs involved with decisions about how to best implement their services in PACT cited this as important to successful implementation.

(Mis)match of Services Needed and Offered

The PS role hinges on their “peerness” — that is, the lived experiences they have in common with the patients they serve. Within VHA, that lived experience is with mental health or substance abuse, and their Veteran status. In PACT, PSs also drew on their experiences with physical health conditions and using VHA services to make connections with Veterans. In some cases, however, the lived experience of the PS did not fit the needs of the PACT patient population.

[We] haven’t selected peers who have lived experience with diabetes or weight management problems or a history of cancer or chronic pain or any other kinds of things that might be really relevant and prominent in primary care. – Supervisor, control

Interviewees noted the unique qualities of the PS role as an enabler. PSs offer a non-judgmental, patient-centered approach, and can spend more time with Veteran patients than other PACT providers. Sometimes the PSs were offering unique services at their site, such as educational groups or health coaching, filling an otherwise unmet need. At other sites, however, another provider was already offering such services, diluting the need for PS services.

Recipients

This i-PARIHS construct concerns the characteristics of an innovation’s Recipients, which included five groups in PACT: providers, PSs, supervisors, Veterans, and champions.

Providers

We identified two related sub-themes for providers: buy-in and burden. Interviewees said that it takes time and persistence to build buy-in from PACT providers. In some cases, PSs faced provider stigma (e.g., against a PS’s capabilities due to their lived experience with mental health) which inhibited buy-in. When PSs demonstrated success, provider buy-in improved.

There is a tendency to compartmentalize [peers] as in recovery or ill or injured and they’re not really part of that team. Once you’re working with [providers] and they know you and then they come to accept and trust you based upon your demonstrating capabilities and commitment and the acceptance by the patients that they’re also working with, that say “hey, this guy’s part of the team,” but until you establish that demonstrated level of competence, they—it’s almost like [peers are] on the fringe. – Peer, facilitation

Burden was a barrier to provider buy-in. If the referral process was complicated, other new programs or initiatives were being undertaken at the same time, or providers were understaffed, they were unlikely to send referrals to the PS.

A big part of the problem was we had a lot of people that kind of looked at it as [peers are] just one more referral that I have to do. – Peer, facilitation

However, when PSs were able to relieve burden from providers, for example by offering to help with pre-appointment paperwork or by generating their own caseloads, it was easier to get provider buy-in.

Peer Specialists

Examination of PSs as recipients yielded two sub-themes: individual qualities and PSs’ skills. Interviewees cited several individual qualities of PSs as enablers, including enthusiasm, motivation, flexibility, and empathy. PSs’ skills, including prior PS VHA experience and training, were cited as key to success. Conversely, lack of prior training and experience in the PS role presented a significant challenge.

[The peer] went into [PACT] as an experienced PS which is a good way to do it. I think bringing somebody in fresh is hard for a PACT team sometimes. – Supervisor, control

A lack of medical knowledge was an additional barrier to PS work in PACT. PSs’ more general professional skills, such as time management, documentation, and organization, were also important, especially as a barrier when these were lacking.

Supervisors

One sub-theme expressed by supervisors was the added burden of supervising PSs in PACT. This was especially true when the PS was new to the role.

[Peer] doesn’t have that experience and he needs a lot more support and more than I can give him. It is just taking longer. Not that he is inept or anything, he just needs somebody to be with him through this little bit. – Supervisor, facilitation

Further supervisory burden came from the need to coordinate with the PSs’ supervisors in other departments, particularly when other supervisors were not supportive of the PSs’ work in PACT. In some cases, PSs expressed that they were receiving inadequate supervision due to having no on-site supervisor or no designated PACT supervisor at all.

The quality of the supervisor-PS relationship was also important. Poor relationships hampered PS success. A few PSs expressed that their relationship with their PACT supervisor was tense, and at least one PS noted that they were hesitant to come to their supervisor with problems. Where the supervisor-PS relationship was strong, however, PSs found their supervisor to be an advocate for their work in PACT and felt supported to fulfill their role.

If something comes up that comes down the line, [supervisor] will talk to us about it and ask our opinion about it, and we respond accordingly with him. He is our supervisor, but he looks at us as the experts at what we do. – Peer, control

Veterans

Veteran engagement with PSs was a challenge for many sites, including Veterans’ lack of understanding or interest in PSs’ services and Veterans missing PS appointments. The setting in which PSs delivered services also impacted engagement. Transportation to PS meetings was challenging in rural settings. When PSs delivered services by phone, Veteran engagement was hampered by lack of supplemental materials used in in-person visits. The burden and time associated with Veterans’ other VHA appointments may have also impacted engagement, with Veterans being perceived as reluctant to make additional appointments for PS services.

If they’re already there an hour, waiting on their labs… a lot of [Veterans] do not wanna stay just for one more extra thing that’s not really required. – Supervisor, control

In addition, one PS noted that as Veterans’ health improves (often with support from PS services), they tend to become less engaged with PSs because they no longer feel they need that level of support.

Champions

The presence of a champion for PS services in PACT was an enabler. Champions are “individuals who dedicate themselves to supporting, marketing, and driving through an implementation, overcoming indifference or resistance that the intervention may provoke in an organization” (p9).³⁸ One supervisor summarized the importance of having a champion, especially one in a position of power or influence:

We need a champion on each team. And the team that we had difficulties with, we didn’t have a champion. But the teams that [were] more successful [had] somebody who really believes in the model and who is a good point of contact, and who had clout and could direct within the program, and who could also directly supervise the peer – that's been so much more helpful. – Supervisor, facilitation

The champion role was filled by different types of stakeholders. Sometimes the PS themself was the champion, due to their individual qualities (e.g., enthusiasm, motivation, initiative) and prior work experiences. Some PSs viewed their supervisor as their biggest champion; in other sites a nurse, social worker, or other clinician was the main champion.

Context

The i-PARIHS Context construct focuses on the setting in which an innovation (i.e., PS services) is delivered. This included two main themes: support and advocates and primary care structure and culture.

Support and Advocates

Buy-in from leadership, both at the clinic and hospital level, was key to PSs and their supervisors feeling supported. Conversely, a lack of support or changing priorities from leadership presented a significant barrier.

One thing that’s made a huge difference is that we got a great deal of support from our executive leadership team as well as the primary care leadership. – Supervisor, facilitation

Funding and staffing were also barriers to implementation. Several sites reported challenges securing ongoing funding for the PS PACT position, as well as in funding training for the PSs. The sub-themes of funding and staffing and leadership support often interacted — i.e., when funding and staffing were a challenge, support from leadership was perceived as low.

Primary Care Structure and Culture

Supervisors noted that there was a sharp learning curve for PSs in transitioning to the medical-model culture of primary care.

Working with doctors is the biggest difference…. sometimes you’ll have physicians who really are still kind of the old medical model that don’t have much of a recovery approach. – Supervisor, control

In sites where there was no truly team-based PACT model in place, and/or where the primary care staff did not hold regular meetings, the PSs had a difficult time integrating.

We did not have the infrastructure ready to accept the pilot…. So, how were the [PSs] supposed to integrate into primary care when primary care doesn’t use PACT and there’s no good primary care mental health integration. So, right there, the infrastructure was just miserable. – Supervisor, facilitation

Conversely, primary care settings with a strong, collaborative PACT model were seen as enabling easier integration of PSs. This was true both for smaller settings where PSs were able to be well known by all staff, as well as larger settings with many PACT teams and large caseloads.

DISCUSSION AND CONCLUSIONS

PSs are increasingly deployed in settings beyond traditional behavioral health within VHA, including primary care. As PS services expand into new settings, it is essential that factors influencing successful implementation are understood. Across the i-PARIHS constructs of Innovation, Recipients, and Context, our qualitative analysis identified barriers and enablers to PS integration in VHA PACT settings consistent across both external facilitation and control sites. Many of these barriers and enablers may be modifiable targets for future implementation efforts.

In the Innovation construct, consistent with research on the implementation of peer services across many contexts^39–41 and on the implementation of new roles in primary care,⁴² a lack of PS role clarity was a significant barrier. To mitigate this, education about the PS role ought to be disseminated widely and continually. PSs can use presentations in meetings, written materials, and one-to-one conversations to educate providers. Unique to this study, co-located space and protected time were identified as valuable enabling factors. When PSs had limited time and no dedicated space, there was an “out of sight, out of mind” effect with primary care providers. In future implementation efforts, PSs should be in proximity so they may regularly speak to providers, build rapport and familiarity, recruit patients, and receive warm hand-offs. Another barrier was a mismatch of services needed and offered because the PSs were primarily moved from behavioral health into primary care. While questions regarding the importance of the type and extent of “peerness” in delivering peer services have been raised in the literature,^43–46 it may be helpful to at least provide general education on the medical model and managing chronic illness to PSs delivering care in medical settings. If PSs will be working with a targeted patient population (e.g., patients with diabetes), they should receive additional training in that area.

In the Recipients construct, having a champion for PSs in primary care was helpful in overcoming barriers, consistent with literature on the role of champions in implementation.^47–49 Thus, identifying a champion early in implementation would be beneficial. Our findings align with research showing the importance of good supervision for PSs.^41,50,51 PSs’ supervisors were most helpful when they were embedded in primary care, understood the peer role, and struck a balance between oversight and autonomy. Supervisors should receive training on PS supervision and have dedicated time to build rapport with and advocate for PSs to support their integration. In addition, PS supervisors should have the flexibility and accessibility to answer PSs’ questions as they arise on a day-to-day basis. Finally, as with other research on the delivery of peer services,^52,53 gaining provider buy-in was essential to PS success.

In the Context construct, consistent with existing literature, leadership support was an important contextual factor;⁵³ ensuring such support ahead of time is critical to the success of newly deployed PSs. Our findings showed that when PACTs were not truly team-based or collaborative, this was a barrier to PS integration, in keeping with research on effective team-based care.^54,55 It is important to consider the functioning of the team when deciding where to deploy PSs — one cannot become part of a team that does not exist.

This study does have limitations. The VHA is unique; the findings may not translate to other healthcare settings. However, our study did include participants from 25 diverse VHA settings from around the USA. Our interview participants were volunteers; individuals who chose not to participate may have had different experiences. There was a large amount of variability in the implementation of PSs across sites, including number of hours PSs worked in PACT, services provided, and the nature of the PACT. While these differences were controlled for in the quantitative evaluation analysis,³¹ we did not systematically account for this in our qualitative analysis. Finally, though we collected basic demographic information about our participants, we did not examine the impact of these variables on responses.

The implementation challenges associated with deploying PSs in behavioral health are well known. The results from this pilot deployment in VHA primary care suggest similar but not fully overlapping challenges. The identification of these barriers and enablers holds promise for improving future efforts to embed PSs in primary care.

Funding Information

All the authors were funded by a grant from the Department of Veterans Affairs (QUERI): QUERI for Team-Based Behavioral Health (1IP1HX001979-01): Evaluation of Peer Specialists on VA PACTs.

Declarations

The project was deemed a Quality Improvement project on February 24, 2016. Because of this determination, individual consent was not sought from individual staff or Veterans. However, all staff and Veterans had the opportunity to decline participation without penalty after reviewing information provided to them about the study.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Disclaimer

The views expressed in this article are those of the authors and do not represent the views of the VA, the United States Government, or other affiliated institutions.