Supporting Older Adults Remotely

Supporting Older Adults Remotely (SOAR) is a Type 1 Hybrid Effectiveness-Implementation randomized controlled trial designed to evaluate the effectiveness of a structured, telephonic, peer-delivered intervention to support aging in place among older adults with serious mental illness (SMI) residing in supportive housing.

Older adults with SMI experience high rates of medical comorbidity, earlier onset of disease, and premature mortality. Existing integrated medical and psychiatric self-management interventions may be difficult to implement because of their operating costs, long intervention duration, and workforce requirements. SOAR was developed in partnership with Certified Older Adult Peer Specialists to address these barriers through a structured intervention delivered remotely by telephone.

The study will evaluate whether SOAR improves independent living skills compared with Peer Support as Usual. The study will also examine medication adherence, medical self-management, and psychiatric self-management as potential mechanisms of change. Implementation research will identify barriers and facilitators to implementation and sustainability of SOAR in supportive housing, including factors related to peer-delivered telephonic care and reimbursement.

The randomized trial uses two levels of randomization. First, Peer Specialists will be randomized to receive SOAR training or no additional training beyond their foundational peer certification. Second, study participants will be individually randomized to an interventionist delivering either SOAR or Peer Support as Usual using a computerized permuted block design to ensure equal allocation. Interventionists will deliver only one model of care, and supervisors will provide arm-specific supervision to reduce contamination between conditions.

SOAR is a manualized 12-week intervention delivered one-on-one by Certified Older Adult Peer Specialists by telephone. The intervention incorporates evidence-based strategies and peer lived experience and focuses on areas including medication management, medical and psychiatric self-management, coping, goal setting, values clarification, healthcare navigation, social relationships, self-advocacy, and connection to community resources. Participants may participate using a landline, flip phone, or smartphone; an app-based interface is not required.

Peer Support as Usual consists of routine peer support delivered by Peer Specialists who do not receive SOAR training. Peer support includes listening, sharing lived experience, role modeling, goal support, discussion of progress, and referral consistent with usual peer services.

Quantitative assessments will be conducted longitudinally. Analyses will compare the two randomized conditions using mixed-effects models appropriate to the outcome distribution and repeated assessments and will account for clustering of participants within interventionists and site variation. Covariates will include psychiatric symptom severity, cognitive functioning, poverty level, psychiatric diagnosis, medical comorbidity, and frequency of health service utilization.

Mechanism analyses will evaluate whether changes in medication adherence, medical self-management, and psychiatric self-management are associated with subsequent independent living skills. Longitudinal mediation models will account for clustering of participants within interventionists. Clinically meaningful change in independent living skills will also be examined using the prespecified range described in the protocol.

The implementation component will use the Consolidated Framework for Implementation Research to examine barriers and facilitators to implementation and sustainability. Qualitative interviews will include Peer Specialists, trial participants, administrators, and policymakers. Stratified purposive sampling will support representation across stakeholder groups and characteristics relevant to implementation, including race/ethnicity, cognitive functioning, and language preference. Interviews will be audio-recorded, transcribed, and analyzed using the Consolidated Framework for Implementation Research together with emergent themes.

Intervention fidelity will be monitored throughout the study. The fidelity team will review the first three weekly SOAR meetings for each Peer Specialist and subsequently review a randomly selected sample of SOAR meetings. Peer Support as Usual will also be assessed for the presence of SOAR strategies as an additional contamination check. Booster training will be provided as specified in the protocol to minimize interventionist drift.