Table 1 Summary of stakeholder feedback within each CFIR construct assessed

Inner Setting: Networks and Communications (the nature and quality of social networks and communication in an organization)

Overall, both peers and supervisors reported strong working relationships. Some communication challenges included:

 • Other team members lacked understanding of peers’ role

 • Generating sufficient referrals

 • Staying connected when peers cover very large teams or numerous teams or are doing remote work

 • Finding time for conversation with busy providers

Effective communication strategies included:

 • Peers marketing their services to providers and providing education

 • Building individual working relationships through being present virtually and in person

 • Attending team meetings

 • Peers demonstrating value and reducing provider burden through assisting with cases

 • Peers direct marketing to Veterans by spending time in waiting rooms and approaching Veterans

 • Open, flexible, multimodal communication (e.g., in person, MS Teams, phone)

 • Having established team members as champions

“At the very beginning, nobody knew who I was or what I could do, nobody was really interested, now to build those relationships, I just pretty much just showed the value of peer support.” (Peer)

“Communication wise it can be a little bit unclear sometimes, what their role is, what they should do, what they shouldn’t do. (Supervisor/Administrator)

Implementation Climate: Tension for Change (stakeholders’ perceptions of whether their current situation needs to change)

There was high variability in tension for change. Necessary changes/concerns with the current situation included:

 • Role confusion (e.g., between peers and Whole Health Coaches, peers and Primary Care Mental Health Integration providers, etc.)

 • Duplication in programming and confusion about appropriate referrals to/use of programs

 • Separation between programs both in terms of staff perceptions (e.g., considering tasks another person’s job) and administrative organization (e.g., separate staffing, different position descriptions for similar levels of staffing, different billing requirements)

 • Incomplete implementation of programs (e.g., not having all program elements available)

Reasons to maintain the status quo rather than adopt new programming:

 • Competing priorities and time constraints for both providers and Veterans

 • Resistance to change among staff

Strategies to address concerns driving desire to change the current situation:

 • Communication, marketing, and training for staff about programs including individual feedback about referrals and concrete guidance

 • Increasing peer presence to increase familiarity

 • Coordination between national and local staff about program scopes and how to integrate/coordinate programs

 • Ensure adequate provider-level and supervisory staffing for programs

“Integrating Whole Health into all levels of care has had some challenges. There’s some inherent rub, specifically, with HPDP and what their healthy living messages are and their modality of how they treat folks and then WH comes in with somewhat similar but somewhat different kind of ways of approaching that and how they integrate. So there’s some conflicting missions and goals within the programs we have here… I think there’s some turf wars around that, whose job is it, and what they are doing so I think Whole Health has struggled a little bit to integrate into different programs.” (Supervisor/Administrator)

“I think people will tell you yes that whole health is great. But the other thing folks are going to tell you is they are incredibly overworked and understaffed. They are just trying to stay afloat. Anything new-one more thing- even minute little thing is incredibly overwhelming-Anything we can do to support staff but not create more work for them. That is the greatest barrier.” (Supervisor/Administrator)

Intervention Characteristics: Relative Advantage (comparative advantage of WH-STEPS vs. the status quo)

Overall, participants perceived Whole Health STEPS as similar in value to existing programs, but some staff perceived Whole Health STEPS as better or worse. Actual and potential disadvantages to Whole Health STEPS included:

 • Some of the steps and step-transitions were perceived as more complicated and less efficient

 • Potential inconsistencies with how peers perceive their role, what they prefer to do, and strengths of peers as providers (e.g., recovery model)

 • Duplication of services and role confusion could occur with Whole Health Coaching

 • Might reduce peer availability to support mental health needs vs. Whole Health needs

 • Rigid structure

Actual and potential advantages to Whole Health STEPS included:

 • Brief telephone contact as a level (step) of care

 • Having peers work at the top of their scope and take tasks currently being performed by licensed independent providers

 • Having a peer provider can increase Veteran buy-in

 • Patient-determined goals

 • The structure is beneficial to monitor outcomes and increase comfort for Veterans and peers

“Just based off my normal interactions with Veterans, it’s similar, but having it formalized, regimented, makes it easier to dictate the outcomes a little bit better just because there’s levels and checkpoints that fall into the STEPS program that would be beneficial.” (Peer)

“I think what we miss is some of the other work the peers are doing right now. We are missing review of the recovery model with our patients [and] … I like that it’s structured but I wish that it offered more flexibility for patients to build rapport with their peers as well, I think that’s really important in the first session.” (Supervisor/Administrator)

Outer Setting: Patient Needs & Resources (how WH-STEPS meets the needs of Veterans and barriers/facilitators to Veterans participating in WH-STEPS)

Overall, Whole Health STEPS was perceived as a good fit to Veterans’ needs:

 • Structure enabling Veterans to know expectations

 • Tool will ensure more comprehensive assessment

 • Veterans have increased trust with peers compared to other staff

 • Encourage setting and following-up on self-identified goals

 • More support than comparable interventions

 • Making basic changes to lifestyle may be sufficient to address some Veterans’ needs without referral to a higher level of care or prepare them for a high level, if needed

 • Addresses loneliness/isolation

 • Virtual care options increase flexibility in scheduling

Potential barriers to Veteran engagement were noted:

 • Generating referrals and increasing visibility

 • Hour long sessions

 • This will be a difficult population to engage because supporting Veterans with low motivation for change and making health and lifestyle changes are challenging

 • Access for Veterans who are not available during normal working hours

 • Some Veteran populations may have difficulty engaging due to more immediate needs (e.g., homelessness, difficulty establishing basic healthcare)

 • Lack of access to a working phone is a barrier to telephone-based services for some Veterans

 • Some Veterans will not want virtual care options

“I just wonder about advertisement and how we can make this more accessible/visible so that we are getting the good turnout. This is like preventative medicine stuff. I think anyone can benefit from this.”(Supervisor/Administrator)

“I do think some patients aren’t sure what to talk about or how to use a mental health provider or a peer and I like that it can provide a framework for what their sessions could look like.” (Supervisor/Administrator)

Implementation Climate: Compatibility (fit with stakeholders’ values, needs, and workflow)

Overall, Whole Health STEPS was perceived as consistent with participants’ values and models of care: Structure was perceived as helpful to complement other organizational changes (e.g., transformation to high reliability organization)

 • Good fit with goals and content of existing programs including PC, PCMHI, and Whole Health

Concerns related to compatibility included:

 • Less efficient than existing processes

 • Would result in duplication of services and role confusion/conflict due to administrative separation between Whole Health Coaching and Peer programs and positions

 • Insufficient referrals to support the service

 • Potential for Whole Health STEPS to take away from other peer functions (e.g., connecting Veterans to care)

“It would allow me to still do everything else I’m doing. This would just be another sort of interaction, another tool that I would be able to interact with a particular vet, rather than an add on or another box to check, or another ball to juggle. It’s just another tool that I’d get to utilize.” (Peer)

“Blending peer specialists doing the whole health steps in their two different departments…we strive to have a great working relationship but it might confuse the role.” (Supervisor/Administrator)

Characteristics of Individuals: Knowledge and Beliefs about Whole Health STEPS (general attitudes about Whole Health STEPS)

Participants generally expressed positive beliefs and attitudes about Whole Health STEPS although enthusiasm varied. Specific attributes which contributed to their perceptions largely reflecting concerns (e.g., less efficient) and strengths (e.g., structure, peer focus, flexibility, brief telephone appointments) noted above

“Honestly, I think it’s just stressful…” (Peer)

“All the steps I love, I think that’s great and it certainly plays on the strengths that peer support can bring.” (Peer)

Characteristics of Individuals: Self-Efficacy (belief in own capabilities and training needs to achieve confidence)

Both supervisors and peers generally believed they could be effective at implementing Whole Health STEPS. They recommended some specific training needs and training preferences including using role-plays, case examples, on-going consultation. Respondents also wanted a detailed manual describing the steps and providing tips and guidance on delivery, especially tailoring, personalizing, and building/maintaining rapport. A listing of available services was also requested

“I would feel perfectly confident. This is how I base my whole interaction with them [Veterans].” (Peer)

“One thing I would love to see is more examples. My 2 guys [peers] are very concrete. If it’s left in ambiguity, I tend to lose them a little. It’s just their own learning style, which we all learn a little bit differently and that’s just fine.” (Supervisor/Administrator)

Other Feedback about Whole Health STEPS and Implementation

Several participants noted the current format doesn’t fully capitalize on peer qualities or explain why peers are essential to delivering Whole Health STEPS (e.g., peer credibility, stigma-busting) which may impact peer satisfaction, Veteran experience, and contribute to role confusion

Participants provided feedback on how to approach the decision-making process for step-changes for Whole Health STEPS and described current practices for peers making level-of-care decisions with Veterans including:

 • Decision criteria need to be clear and concrete but allow for flexibility for individual Veteran needs and peer judgement

 • Referral is an important element but it should not be a part of the stepped care process; it is a core peer service that should be immediate

 • Both objective indicators (e.g., the Whole Health goal assessment) and subjective experience (e.g., not making progress) are useful to inform step and navigation decisions

Participants also provided feedback and thoughts about important considerations in delivery of Whole Health STEPS including:

 • Telehealth formats including telephone and video telehealth will need to follow established guidelines and require specific training

 • Veteran handouts with Whole Health STEPS information would be helpful

 • An intermediate step between 15-min telephone sessions and hour-long sessions was recommended

 • Tracking caseload and managing multiple contacts was identified as a potential challenge particularly for a stepped-care approach with Veterans at different steps and stages of care

 • Some participants wanted to integrate groups into Whole Health STEPS

 • Peers may have low satisfaction with the Whole Health goal assessment if it feels like “grunt work”

 • Peers need to be aware of safety and other issues outside of their scope and if self-management is insufficient

“Peer specialists are very unusual employees and the advantage that they bring is tied directly to their personal experience, the credibility they have, and the knowledge they have as someone who has personally navigated the system. When I look through this, I don’t see any reason why this is tied to a peer.” (Supervisor/Administrator)

“I think in general, yes, we should have someone else involved in that [step decisions] because you know peers don’t refer.” (Peer)

“I was a medic in the military, so you never discontinue care until someone else is there to be able to continue. We still track their care so once they’re done, we’re still part of a team and then once they are stabilized they come back to us for peer support services.” (Supervisor/Administrator)