The Q&A: Scott Walters

With each issue, Trib+Health brings you an interview with experts on issues related to health care. Here is this week's subject: 

Scott Walters is professor of behavioral and community health at the University of North Texas Health Science Center. His research is focused on translating effective counseling strategies, such as motivational interviewing, to nontraditional settings and technology. Walters' publications include 80 articles and book chapters and five books, including most recently Treating Substance Abuse: Theory and Technique. Walters' current project, m.chat, aims to improve the health of people moving out of chronic homelessness. The project was displayed last week at the National Healthcare for the Homeless Conference.

Editor's note: This interview has been edited for length and clarity.

Trib+Health: How does the m.chat program tackle the health issues of homelessness?

Scott Walters: M.chat is a technology-assisted health coaching program. It is targeted to people who live in permanent supportive housing. It is a category of programs that are targeted at people that were chronically homeless and disabled. If you think of most people in Section 8 — housing for people of low income — this is sort of the tier below that.

All of these folks were chronically homeless at some point and all have some sort of mental health condition. It is a complicated group.

Permanent supportive housing is a rental voucher coupled with case management services. So all these folks already have a case manager, who meets with them and works on some basic life skills. M.chat would be an add-on to their existing case management service with an explicit focus on health and wellness indicators. It would be basic things like diet, exercise, substance use, medication compliance.

Trib+Health: How does the program work in practice?

Walters: There are three components to m.chat. There is the human component of the health coach that helps people to set health goals. There is the technology component. That is the health coaching software, which we designed, that facilitates the interaction by giving people feedback about how they are doing in different areas. It helps to set goals and trigger reminders for doctor appointments or social interactions.

The final part is a system of earning points, “chat bucks.” It is sort of like a virtual currency. It is a built-in incentive. People can save up these points, then they can use them to purchase pre-approved supplies to meet their health goals.

If a person’s goal is to walk more, they might want to buy walking shoes, or a pedometer, or YMCA membership.

Trib+Health: What are the major health problems this community faces?

Walters: In a survey using data from the city of Fort Worth, we found that 73 percent of people in permanent supportive housing report some sort of chronic health condition. Two-thirds of people reported some kind of substance use. We saw 38 percent to be considered tri-morbid, so they had substance use, a chronic health condition and a chronic mental health condition.

Among those areas, we asked a little deeper to people's quality of life in different areas, about what they thought they needed. Some of the major themes people reported were really poor mental health, poor physical health, very poor social support.

When you get people off the streets and put them in this housing arrangement, it makes people’s lives better because they are not out in the elements. They are more safe and they can stay more organized.

But it can also exacerbate certain things. People can get very lonely and isolated, alone in their apartment. Some people just stay in all day. They don’t meet people. They use substances. They may have very few skills to be able to manage a normal life. It can create a lot of problems.

Trib+Health: What is the scope of the program? 

Walters: The program is funded by a Medicaid 1115 waiver. Different public agencies put forth the money to do the project, and if the project meets the milestones then they get reimbursed. There is a risk. If they don’t meet the goals then they are out that money. There is a lot of anxiety around these types of projects. 

Our goal is targeting 300 people in permanent supportive housing with current mental health conditions. We have about 160 so far. We want to hit 300 by the end of September. We have five health coaches who are assigned to the clients and they meet with people, using the software.

Trib+Health: How do the clients get access to the necessary technology for the program?

Walters: The technology of the software is for us. When we are meeting with people, we are bringing in the technology we need, laptops and print-out summaries of the visits for them. People don’t need to have access to any type of technology. It is really the health coach that uses it.

That being said, we have another part that hasn’t quite been deployed. We decided to provide cellphones to a certain percent of people. We will randomize half of people to carry a project phone, with a mobile app on it that would talk to our computer interface.

This is an extremely low-income and disadvantaged population, so even when they have cellphones from the government they come with only 300 minutes and the number is constantly changing. We are wondering if it is just cheaper to provide a person with a cellphone that contains this app to see if it is cost effective.

Half of the group will get it for six months and then we will flip it. Then the other half carries the cellphones. This allows us to reliably send reminders to people, to contact people, but they are also prompted to check in at multiple times of the day. We will have information from them everyday on their diet, exercise and their interactions. This is going to tell us a lot about whether the program is working. We can see if some are more likely to benefit from the program. That also gives the health coach more information to work with when they meet with clients.

Trib+Health: There is a lot of self-reporting on the part of the clients. What do you think will keep them checking in and on pace with the program? 

Walters: When given the opportunity, we’ve found that people are very motivated to make changes. People are sick and tired of the poverty, isolation, depression and addiction. Many of these people have never experienced an opportunity or program like this.

This is something that is widely available to people who have money. You can pay for a health coach or go to a gym. None of these service have ever been provided to such a disadvantaged population. The feedback we get is astonishing, about how beneficial it is to check in, getting reminders. And they love the health coaches. They are able to buy simple things to assist them.

People are wanting to get better, and see the value of the program.