Telehealth-delivered Peer Support to Improve Quality of Life Among Veterans With Multimorbidity

Eligibility Criteria

• * Veteran patient receiving primary care from VA Puget Sound
• * Complex multimorbidity (\>=3 chronic conditions in \>=3 body systems based on AHRQ Chronic Condition Index)
• * Meets \>=2 criterion from NICE multimorbidity guidelines: 1) have a chronic physical and mental health condition (via ICD-10 codes in CDW and the CCI); 2) frailty (determined by the JEN Frailty Index available in VA data, confirmed via self-reported PRISMA-7 during the eligibility screening; 3) frequent emergency care (\>=1 VA emergency department visit in past year via CDW); 4) polypharmacy (\>=10 prescribed medications via CDW), or 5) significant treatment burden (score \>22 on the self-reported Multimorbidity Treatment Burden Questionnaire at study screening).
• * Inclusion criteria assessed via the phone screen includes frailty; treatment burden; and willingness to use a either a phone or an Internet-connected device with a web camera and an email address and/or ability to receive text messages to ensure receipt of VVC visit links.
• * Agree to participate in the health coaching sessions and surveys if assigned to intervention group
• * Not fluent in English
• * Severe hearing loss
• * No phone access and/or missing phone number
• * Missing address
• * Diagnosis of dementia or severe cognitive impairment within last year
• * Diagnosis of end stage renal disease or on dialysis within last year
• * Receipt of palliative or hospice care in the past year
• * Receipt of nursing home care in past year (Stop codes: 650, 651,119,121)
• * Currently living in a nursing home, skilled nursing facility, rehabilitation facility, or long-term care facility
• * Behavior flags in EHR
• * Active treatment for non-melanoma skin cancer diagnosis
• * Diagnosis of substance use dependence/abuse disorder in last year (excluding tobacco)
• * Diagnosis of psychotic disorder in last year
• * Pregnant or planning to become pregnant in next 6 months
• * Score of \>8 (severe risk) on self-reported AUDIT-C questions on eligibility screen