Integrated CarePart 3: Peer-Delivered Services in Behavioral Health Care

"It is one of the beautiful compensations in this life that no one can sincerely try to help another without helping himself." ~ Ralph Waldo Emerson

This final issue in the series on integrating behavioral health into primary care will focus on working with another important potential partner on the health care team—peers support specialists. Although peer-delivered support services have been utilized for many years, formalizing, developing and documenting the impact of such services is relatively new in behavioral health. As management of chronic disease and integrative care continue to evolve, the research, lessons learned and models for implementation of peer support services continue to evolve as well. To date, the research and preliminary documentation of peer services has shown enough merit to garner endorsement from many key organizations including; SAMHSA, the Institute of Medicine and the Center for Medicaid Services, among others. The use of peers is expected to continue and expand, particularly with an increasing focus on recovery-oriented systems of care (for more on this, see the Addiction Messenger series on "Recovery Management" and "Recovery Oriented Systems of Care" at http://www.attcnetwork.org/regcenters/c1.asp?rcid=10&content=CUSTOM1).

Peer-delivered services take a variety of forms and are offered by persons with varying titles, including: peer/recovery coaches, peer/recovery mentors, peer/recovery support specialists, and peer bridgers, to name a few. William White, in an article entitled "Ethical Guidelines for the Delivery of Peer-based Recovery Support Services" offers some definitions and examples of the variety of these roles and titles: "…services may be provided by clinically-trained professionals as an adjunct to their clinical (assessment and counseling) activities, or they may be delivered by persons in recovery who are not clinically trained but who are trained and supervised to provide such support services. These services are being provided by persons working in full and part-time paid roles and by persons who provide these services as volunteers." (1)

Do peer-delivered services work and are they cost effective?

Programs considering adding a peer component may be concerned about whether they are affordable, sustainable and effective. Emergent research is showing promising outcomes and a growing body of implementation experience is developing which can help address those concerns.

For example, in Cost Effectiveness of Using Peers as Providers, Bergeson reports:

• Consumers working with certified peer specialists as compared to those who received the normal day-treatment (control group) reduced current symptoms/behaviors, increased skills/abilities, increased ability to access resources/ and meet their own needs. Certified peer specialists cost $997 vs. $6491 for day treatment, for an average costs savings of $5494 per person.
• Certified peer specialists were used to offer respite services instead of immediately sending consumers in crisis to the hospital, reducing involuntary hospitalizations by 32% leading to a savings of 1.99 million dollars in one year.
• Certified peer specialists are being used as health coaches with late life (average age 71) populations. 100% of the consumers had been hospitalized prior to having a peer coach, only 3.4% were hospitalized after getting a coach. The average length of stay went from 6 days to 2.3 days.
• Hospital-based peer support (focused on developing recovery plans and recovery-oriented discharge plans including strategies to reduce readmission).has resulted in a reduction of 36% in the use of seclusion and a 48% reduction in the use of restraint, and a 56% reduction in hospital readmission rates. (2)

Other researchers who have looked into peer-delivered services have found the following:

• Using trained peers leads to improvement in psychiatric symptoms and decreased hospitalization (Galanter, 1988; Kennedy, 1990; Kurtz, 1988);
• Persons dually diagnosed with serious mental illness and substance abuse, peer led interventions were found to significantly reduce substance abuse, mental illness symptoms, and crisis (Magura, Laudet, Mahmood, Rosenblum, & Knight, 2002);
• Consumers participating in peer programs had better adherence to medication regimens (Magura, S., Laudet, A., Mahmood, D., Rosenblum, A. & Knight, E.);
• Peer-delivered services lead to better healing outcomes, greater levels of empowerment, shorter hospital stays and less hospital admissions (Dumont, J. & Jones, K. 2002);
• Peer-delivered services result in larger social support networks; enhanced self-esteem and social functioning (Carpinello, Knight, & Janis, 1991; Rappaport, Seidman, Paul, McFadden, Reischl, Roberts, Salem, Stein, & Zimmerman, 1985; Markowtiz, DeMassi, Knight, & Solka, 1996; Kaufmann, Schulberg, & Schooler, 1994). (2)

As for funding concerns, peer-delivered services are increasingly covered by Medicaid. Pillars of Peer Support (http://www.pillarsofpeersupport.org/) is an initiative whose purpose is to further develop and foster the use of Medicaid funding to support peer support services in state mental health systems of care. For the past several years this group has brought together key players to participate in summits, information from which is posted to their website. Reviewing those materials is a good primer on the current state of peer-delivered services. Background information on Medicaid coverage for peer-delivered services is also available at: https://www.cms.gov/

The role of peers in effective services

Peers can bring a wonderful "magic" to the behavioral healthcare mix (3). A recent article in the Behavioral HealthCare journal by Ashcraft and Anthony (2012) describes the value of peers to the health care team, citing "the service improvements that they bring occur by virtue of their lived experience" and further notes their valuable experience and skills in "navigating service systems". The authors go on to note that, "well-trained" peers offer:

• Dedication and commitment to work.
• Ability to create an immediate connection with the people they serve.
• Ability to use their stories and lived experiences to inspire hope.
• Ability to build bridges that engage other providers on the treatment team.
• Ability to guide people in accessing community resources and services.
• Ability to model healthy relationships that others can replicate in the community by being trustworthy and supportive in an intentional relationship.
  ability to demonstrate to family members and other supporters that people like their loved one can recover." (3)

Further, from an organizational development perspective, "the presence of peers:

• brings a different perspective during team staffings and meetings;
• supports the use of recovery language by reminding organizations to minimize the use of labels and diagnoses that are impersonal or demeaning to those seeking help; and
• provides living proof for primary providers and other team members that people can recover". (3)

Steps to success

Organizations that have included peers in their clinical service repertoire have some valuable lessons to share, as witnessed by the following candid comments from the Ashcraft and Anthony article (2012). "The good news is that most problems can be avoided through proper training and follow up. Here are some 'must haves' for peer training:

• Peers must understand the importance of their work or they might fail to take it seriously, leading them to be unreliable about completing work and maintaining work hours.
• Peers must be able to complete required documentation or paperwork—or get help as needed. Otherwise, they'll create problems for the treatment team.
• They must know and exercise responsibility for using wellness tools to maintain their own recovery and stability. Sometimes peers who feel great when they go to work stop doing the very things that help keep them well.
• They must be enabled and empowered to work from their strengths so that they can 'let go' of the status of 'mental patient,' shift into a 'helping role' for others, manage personal feelings and challenges that arise at work, and maintain good attendance.
• They must be able to use their own story in a healing, inspiring way that supports and guides the people they serve and contributes to the treatment team.
  They must know why and how to maintain a 'recovery environment' by reacting positively and avoiding gossip and negativity.
• They must be challenged to grow into their potential, rather than feeling they are entitled to special treatment. This compromises their effectiveness." (3)

Clearly, a significant amount of staff preparation, training and supervision is required to bring the peer support staff into the fold of ethical and effective services. More organizations are finding that the investment in peers is well worth the time and effort.

How should an organization approach the inclusion of peer-delivered services?

Again, Ashcraft and Anthony (2012) offer these words of advice: "If an organization takes the following steps when they add peers to their workforce, their outcomes will be much better and the results of the peer contribution will be stronger and more effective:

• Involve staff in the decision to employ peers. It is essential for top management to engage staff who will be supervising and coaching peers as well as the staff who will be working beside them. These individuals must 'buy in' to the concept of employing peers. If they don't have a voice, they'll have no choice but to resent and resist. Peer helpers tell us that this resistance is among the hardest challenges they face when entering the workforce.
• Recruit potential peers. Once all are 'on board' with the concept (staff don't have to love it, but most must be willing to try it), step two is to recruit peers who are interested in the possibility of contributing, making a difference, and wanting to work. There are several ways to recruit peers. Often, staff can recommend people; you can reach out to potential peer groups; or offer meetings where potential peers can stop in and learn about the possibilities or hear peers from other locations tell their stories, explain what successful peer work is like, and identify the qualities peers need to be successful.
• Provide peers with great training before they go to work. This is very important! There are a couple of training groups that do an excellent job with peer training. And, we promise if you make this investment, you will have many fewer problems as your peer employment process moves ahead.
• Ensure that trained peers have good coaching and supervision. You don't have to micromanage peers, but you must be clear about expectations and supportive in their efforts to do the best work. Some examples: Offer clear job descriptions. Give peers meaningful assignments that really use their strengths and skills—not just driving, straightening the waiting room, or ordering/delivering lunches.
• Provide ongoing peer training. Ongoing peer training need not be clinical. It can focus on sharpening skills in engagement, recovery, wellness, and resilience.
• Challenge peers to perform and enforce accountability. Build an atmosphere in which all staff members who work with peers know that peers must not be treated differently than other employees. All supervisors of peer staff—even if they are peers themselves—must understand that every employee is held to the same level of accountability. Peer staff must be held to this standard or resentment and disharmony will result." (3)

Other issues

As with any other emerging disciplines, there are developmental issues that need to be addressed with peer-delivered services; two examples follow:

Should those who deliver peer services be required to be certified, licensed or credentialed in some way? This emerging concept is discussed in detail in a recent paper entitled "Developing an Accreditation System for Organizations and Programs Providing Peer Recovery Support Services" (http://www.facesandvoicesofrecovery.org/pdf/eNews/4.2.12_accreditation_concept_
paper_FINAL.pdf) from Faces and Voices of Recovery (FAVOR). This analysis finds, among other things, that an accreditation system for organizations and programs providing peer recovery support services would help promote the development of recovery-oriented, community-based institutions and programs and help assure a commitment to quality and integrity of those services. An accreditation system would allow organizations and programs to oversee an expanding menu of peer support services and activities, providing a broader array of support to meet the needs of people seeking or in recovery. (4)

Are there promising or evidence-based curricula for training peers?
One of the best resources for this issue comes from the Oregon Health Authority's Addictions & Mental Health website (http://www.oregon.gov/OHA/amh/peers.html), which includes lists of evidence-based training models for peer-delivered services in a several categories, including adult mental health, children/family mental health, addictions recovery, and tobacco cessation. The website also features many other useful links and information regarding peer-delivered services.

Conclusion

Addictions and mental health services have benefitted from peer-delivered services and there are many health issues typically seen in primary care settings which could also potentially benefit from peer-delivered approaches. In fact, one could argue that anything that requires significant behavior change and support—diabetes, weight management, smoking cessation, to name a few—could, and would, benefit from peer approaches. With regard to behavioral health teams, addictions and mental health providers are most likely to recognize and value peer-delivered service, and therefore may be best able to advocate for introducing this partner to the primary care team. You may also be the one on the team who is most likely to work directly with peer providers, either on the team or as a community support. Helping your colleagues understand the value of peer-delivered services will potentially make your job more effective and, more importantly, may help your clients achieve the best outcomes.
 

Series Author: Wendy Hausotter, MPH

Series Editor: Traci Rieckmann, PhD, NFATTC Principal Investigator, is editing this series.
The Addiction Messenger's monthly article is a publication from Northwest Frontier ATTC that communicates tips and information on best practices in a brief format.

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