Care Coordination and Passive Mobile Data Monitoring to Engage Veterans and Improve Mental Health Care

Significance to VA: Providing care to individuals with serious mental illness (SMI) is challenging, requiring ongoing monitoring, treatment adjustments, and coordination of various medical and social services. Rates of emergency service and hospital use are high due to unexpected social, medical, and mental health crises. A variety of stressors and poor adherence with treatment are common and can lead to rapid worsening in symptoms, job loss, homelessness, incarceration, or suicide. Clinician visits can be infrequent. Patient- clinician contact between visits is challenging and often nonexistent. As such, illness exacerbations usually occur with no clinician awareness in real time, leaving limited opportunity to provide services. This project studies, in Veterans with SMI and high risk for acute care, the effectiveness of an enhanced care coordination mobile intervention (CCM) that uses passive mobile data and support from peer coaches. We hypothesize that CCM will reduce the need for acute care services in comparison to usual care. For the large population of Veterans with SMI, we need efficient interventions that are capable of monitoring and quickly detecting worsening behaviors and illness, to inform care coordination, outreach, treatment, and services. This project responds to the VA Health Systems Research priority topics of Data Science and Systems Science, and to Mental and Behavioral Health. Innovation & Impact: The outcomes of this study inform whether and how to improve care with CCM. The use of passive mobile data to support improvements in behavior and care coordination in mental health is highly innovative, as is peer coaching for this purpose. If CCM is effective, it has the potential to improve routine practice and outcomes. Specific Aims: Among Veterans with SMI: 1. Engage Veterans and clinicians in co-design activities that adapt previously tested protocols and tools to guide implementation of enhanced care coordination with mobile (CCM intervention) that includes passive mobile monitoring of Veterans’ mental health status, technology and behavioral supports from peer coaches, and care coordination within a Behavioral Health Interdisciplinary Program (BHIP). 2. Determine the effectiveness of CCM on acute care use. Implement CCM using protocols and tools from Aim 1 and randomize high-risk patients with SMI to CCM or usual care for 9 months. 3. Evaluate implementation of CCM. 4. Conduct a budget impact analysis of CCM. Methodology: 1. Population: patients with SMI and high risk for acute care use. Intervention: enhanced care coordination within a VA BHIP program using passive mobile monitoring and supports from peer coaches Comparison: effectiveness trial with patient-level randomization to CCM or usual care for 9 months Outcome: reduction in use of urgent care services (emergency visits, hospitalization, or death) 2. Qualitative and quantitative methods Path to Translation/Implementation: The Office of Mental Health, and the Office of Connected Care are partners on this study and oversee issues addressed here for VA: mental health and virtual care. Both offices have provided their strong support and plan to use results from this study to inform delivery of services. Project Number: 1I01RD000613-01A2 | Fiscal Year: 2026 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Alexander Young | Institution: VA GREATER LOS ANGELES HEALTHCARE SYSTEM, LOS ANGELES, CA | Activity Code: I01 | Study Section: HSR-4 Mental and Behavioral Health[HSR4] View on NIH RePORTER: https://reporter.nih.gov/project-details/11243249