Designing Programs and Policies
to Encourage Peer Services
Over the past two decades, the consumer
movement for individuals with mental illness has played a prominent role in
the development of peer provided services. The Americans with Disabilities
Act, the Surgeon General’s Report on Mental Health, and the President’s New
Freedom Commission on Mental Health firmly planted the notion that
consumers have a valued role in the provision of mental health support.
More recently, the Centers for Medicare & Medicaid Services (CMS)
released a guidance letter to Medicaid directors regarding peer support
services. The letter provided information regarding supervision, care
coordination, training, and credentialing of peer support services.
Review
the August 2007 Guidance Letter from CMS: Using Peer Support Services
Under Medicaid
From this formal recognition emerged interest, implementation, and research
on consumer-operated programs. CMS has expressed its continued interest in
assisting state policymakers to design programs and policies that encourage
the use of peer provided services. Specifically, CMS requested the ILRU
Community Living Partnership create this series of issue briefs to
stimulate discussions among state policymakers regarding the various models
of peer services, identify practices to include these models into the traditional
mental health services network, and to examine financing strategies that
can support peer provided services.
This issue of NewsCLIPS highlights three new issue briefs and a new
promising practice report providing various strategies that policymakers
can undertake when developing and supporting each of the peer support
models.
Models of Peer Support
Q. What is the
difference between the two models of peer support: Consumer-operated
service programs and Peer providers?
A.
Consumer-operated service programs (COSPs) are peer run or administratively
controlled and operated by mental health consumers, and are independent and
autonomous from traditional mental health agencies. Peer providers as
practitioner model employs consumers for staff positions within more
traditional clinical mental health and psychosocial rehabilitation programs
that are not necessarily governed or operated by consumers. These
individuals are part of a staff team.
For additional information about Models of
Peer Support refer to page 3
Choosing a Model
Q. There are many
things to consider in choosing a model. Which is best for my jurisdiction?
A. There are
certain discussions and decisions that may suggest one model over another.
Review this set of considerations to help decide.
1. Which services
are “purchasing” priorities for the next fiscal year.
2. Defining the
services which should:
a. Provide specificity to the service definitions delineated in rules or a
Medicaid state plan amendment.
b. Describe the intent, purpose, features, use, and expected outcomes of
the service.
c. Identify specific programmatic requirements (e.g. Types of allowable
interventions, requirements for on- and off-site service delivery,
Operating hours, Community versus clinic- or programmatic-based
requirements, Minimum contacts).
3. Include
allowable staff credentials for delivery and supervision of each service,
staff ratios, schedules, and training requirements.
4. The provider may
have to comply with other state laws regarding the storage and dispensation
of medications, so a licensed practitioner or licensed facility may have to
be used to deliver the service.
5. The purchaser
should project the costs for the service and the potential funding streams
that will support the service. The funding stream may also determine which
model of peer supports a purchaser pursues.
For additional information about Choosing A
Model refer to page 8
Integration Challenges
Q. What are the
challenges of integrating a peer provider into a mental health setting?
A. Barriers
include staff attitudes, funding, role confusion, hiring and supervision
practices, and confidentiality. Despite the progress many agencies have
made, there is still significant stigma that recovery is not possible, and
sometimes these professionals feel threatened by peer professionals.
Funding and reimbursement issues that can present obstacles to hiring peer
providers include perceptions by some that peer providers are less valuable
than billable staff since they don't contribute to the agency’s bottom line
and can’t generate enough revenue to cover the costs of the position and
overhead.
Role
conflict and confusion is another barrier, as peer providers have
experienced difficulty in redefining their roles boundaries when they
become employees
Traditional mental health providers may continue to view peer professionals
as “only” a consumer. Fellow consumers may have difficulty with a friend
and/or peer making the change to a paid professional. Employing peer
providers can create issues regarding confidentiality if not identified and
addressed appropriately, including their right to control disclosure of
their peer status. Traditional mental health providers also contend that
client records should not be shared with peer providers for fear that they
will disclose this information to their agency’s consumers. However,
safeguarding this information may have larger consequences.
For additional information about Integration
Challenges refer to page 5
Organizational Inclusion
Q. What is
organizational inclusion and how do you address it?
A. Organizational
inclusion is understanding and promoting the unique perspective that peer
providers can bring to the entire process of rehabilitation and treatment. This
can be addressed by: reframing organizational mission and policies to
emphasize “organizational inclusion” when hiring peer providers; being
clear about the purpose and structure of the peer provider program,
including clear goals and identifying staff positions that will need to be
filled; and assessing the agency’s readiness to accept and include peer
providers.
For additional information about Organizational
Inclusion refer to page 6
Peer Provider Salary
Q. How do you
set the salary of a peer provider?
A. If available,
states should gather salary information from organizations that are
employing peer providers to more accurately predict the salaries within a
COSP or traditional mental health agency. State purchasers should use
caution in relying solely on current salaries for peer providers, as
consumer providers are paid relatively low wages compared to other staff in
traditional mental health agencies. Lower costs will be offset by greater
costs attributed to higher staff turnover.
The
hourly wage reported for peer providers is 8-33% less than the hourly wage
for professionals rendering the same service
State purchasers may want to consider “proxy” salaries from other states or
other in-state personnel classifications (e.g. mental health tech support,
bachelor level, or paraprofessionals) to project personnel costs for peer
providers.
For additional information about Peer
Provider Salary refer to page 3
Unique State Strategies
Q. What are
some real examples of unique state strategies?
A. The New Mexico
Behavioral Health Purchasing Collaborative (BHPC) is comprised of 18 state
agencies that purchase mental health and addiction services. The primary
purpose of the BHPC is to develop an efficient quality-driven statewide
system of behavioral health care that promotes behavioral health and well
being of children, adults and families; encourage a seamless system of care
that is accessible and continuously available; and emphasize health
promotion, prevention and early intervention, resiliency, recovery and
rehabilitation.
The BHPC contracts with a Statewide Entity (SE), ValueOptions, to integrate
administrative systems and to streamline administrative operations among
services funded by each agency in the Collaborative. The SE is
contractually required to develop peer and family specialists.
For additional information about Unique
State Strategies from Wisconsin, Michigan and Georgia refer to page 9
Peer Support Research
Q. What do
research findings reveal about peer-delivered services?
A. A review of the
research literature regarding peer support, which found that 1) when
provided in addition to other mental health services, a majority of studies
suggest peer support helps participants improve psychological outcomes and
reduce hospitalization; and 2) a majority of studies suggest peer providers
perform as well as non-peers when peer-delivered services are an
alternative to traditional mental health services.
Together, these research findings suggest that peer-delivered services can
be a useful option for people who choose these supports. States are
increasingly considering peer support as they transform their mental health
system to emphasize recovery.
For additional information about Promising
Practices & Research refer to page 3
Clearinghouse Resources
A Sample of Documents on Peer Supports:
ILRU Community Living Partnership Issue Briefs
Organizational Models for Peer Support: Policy Issue #1
www.hcbs.org/moreInfo.php/doc/2403
Introducing and Supporting Peer Providers in Traditional Mental Health
Provider Networks: Policy Issue #2
www.hcbs.org/moreInfo.php/doc/2404
Financing Peer Provided Services: Policy Issue #3
www.hcbs.org/moreInfo.php/doc/2405
Medicaid Coverage of Peer Support for People with Mental Illness: Available
Research and State Examples
www.hcbs.org/moreInfo.php/doc/2483
CMS State Medicaid Directors Letter: Using Peer Support Services Under
Medicaid
www.hcbs.org/moreInfo.php/doc/2015
Community Living Brief: Consumer/Survivor-Operated Mental Health Services
www.hcbs.org/moreInfo.php/doc/674
Workforce Strategies: Introducing Peer Mentoring in Long-Term Care Settings
www.hcbs.org/moreInfo.php/doc/729
Peer Mentor’s Mentoree Training & Resource Manuals
www.hcbs.org/moreInfo.php/doc/2021
State Produced Resource:
Bridging Resources to Peer Mentor Support
www.hcbs.org/moreInfo.php/doc/1754
From Maintenance to Recovery: How Consumers are Transforming the Mental
Health System
www.hcbs.org/moreInfo.php/doc/830
Job Descriptions for Peer Support Programs
www.hcbs.org/moreInfo.php/doc/2147
Peer Power Mentoring Program Toolkit – Wisconsin
www.hcbs.org/moreInfo.php/doc/2370
Peer Support Training Manual - Ohio Advocates for Mental Health
www.hcbs.org/moreInfo.php/doc/2142
Using Peer Support to Enhance ACT Teams
www.hcbs.org/moreInfo.php/doc/2145
ACT Peer Support Evaluation Findings
www.hcbs.org/moreInfo.php/doc/2144
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