DSRIP Breakthrough Webinar Series

Transformative Workforce Approaches: Peer Specialists

  • Slides are also available in Portable Document Format (PDF, 362KB)

Larry Fricks
Deputy Director, SAMHSA-HRSA Center for Integrated Health Solutions

Harvey Rosenthal
Executive Director, New York Association Psychiatric Rehabilitation Services

Shannon Mace
Director of Practice Improvement, National Council for Behavioral Health

The National Council for Behavioral Health


March 2016

Today´s Presenters

Larry Fricks and Harvey Rosenthal

History of Peer Support

Larry Fricks
Deputy Director, SAMHSA-HRSA Center for Integrated Health Solutions

The National Council for Behavioral Health

History of Peer Support

  • In the United States, peer support traces back to 1772 when Native Americans formed social support groups to help recover from alcohol use problems by sharing experiences of hope and strengths to practice mutual support and self-management
  • Alcoholics Anonymous founded 1935 - Preamble: "AA is a fellowship of men and women who share their experience, strength and hope with each other, that they may solve their common problem and help others recover from alcoholism."

First Medicaid Approval of Billable Peer Support Services in 1999 Georgia State Plan Amendment

  • Primary role to provide direct services designated to support service recipients in regaining control over their own lives and recovery process
  • Model competence and possibility of recovery
  • Support service recipients in developing the perspective and skills that facilitate recovery

CMS 2007 Peer Support Services Guidelines

  • Letter for States Requiring Training, Continuing Education, Supervision, and Care Coordination:

    "Peer support services are an evidence-based mental health model of care which consists of a qualified peer support provider who assists individuals with their recovery from mental illness and substance abuse disorders."

Roles of Peer Providers

  • The impact of lived experience:
    • Peer providers with lived experience of behavioral health recovery provide support that promotes hope
    • Peer providers use their lived experience plus training skills to activate recovery self-management focused on what´s strong rather than what´s wrong
    • Peer providers promote trust and bond with other peers by sharing the negative impact of illness like poverty, stigma, discrimination, and social exclusion
  • Key skills taught to peer providers in training:
    • Compassionate listening
    • Sharing stories of recovery
    • Goal setting for recovery and resiliency
    • Activating self-management
    • Connecting with community
    • Building supportive relationships
    • Accessing formal and informal resources
    • Promoting trauma informed care

NYS Peer Service Models

Shannon Mace
Director of Practice Improvement

The National Council for Behavioral Health

Overview: OASAS Peer Services

  • Medicaid Reimbursable Peer Services can be provided in outpatient settings by Certified Recovery Peer Advocates
  • SUD clients who are HARP eligible, by virtue of their SUD diagnosis and another chronic condition, may receive HCBS peer services which are currently available through NYC HCBS approved peer service providers. They will also be available through upstate HCBS approved peer service providers in October 2016 for upstate HARP eligible SUD clients
  • Friends of Recovery New York (FOR-NY) received increased funding to develop a statewide infrastructure to assist individuals, families and communities to support recovery
  • OASAS supports 4 existing Recovery Community and Outreach Centers (RCOC) and plans to expand with an additional 6 Centers in 2016
  • RCOCs rely on volunteers and Peer Support workers to deliver and link to community based prevention, treatment and recovery support services
  • New initiatives include funding for Peers and Family Navigators within Emergency Departments, particularly to bridge individuals to treatment following an opioid overdose
  • OASAS announced funding for 7 new Clubhouses for youth and young adults that will utilize peers for the delivery of recovery support services
  • OASAS, OMH, SUD and MH providers are collaborating on a SAMHSA grant entitled, Bringing Recovery Supports to Scale Technical Assistance Center (BRSS-TACS)
  • To request a presentation on peer integration from a BRSS-TACS team member, please contact recovery@oasas.ny.gov.
  • OASAS supports the Recovery Implementation Team (RIT) which addresses policy and practice issues from the perspective of peers and peer stakeholders
  • OASAS Providers use other types of peers through grant funding and alumni groups to mentor and provide support to individuals during and after treatment

NYS Department of Health AIDS Institute: HIV, Hepatitis C and Harm Reduction Peer Credentialing

  • On the Peer Certification tab at www.hivtrainingny.org, you can find:
    • FAQ about the Peer Certification process for Peer Workers
    • NYS AIDS Institute Peer Worker Code of Ethics
    • Core Competencies for HIV Peer Workers
    • Core Competencies for HCV Peer Workers
    • Core Competencies for Harm Reduction Workers
    • Peer Certification Course Catalogue which outlines training requirements for earning certification
    • Foundational Training Standards for HIV and HCV Peer Workers
    • Organizational Readiness Assessment for Implementing Peer Delivered Services

Peer Bridger Model

Harvey Rosenthal
Executive Director, New York Association Psychiatric Rehabilitation Services
Member, Medicaid Redesign Team, Behavioral Health Workgroup,
Value Based Payment Steering Committee

The National Council for Behavioral Health

DSRIP Behavioral Health Service Domains

  • Community Crisis Stabilization Services
  • Transitional Support
  • Activation
  • Integrated Health and Behavioral Health
  • Mental, Emotional and Behavioral Health Promotion

New York Association of Psychiatric Rehabilitation Services (NYAPRS)

  • A peer-led state and national change agent that is dedicated to improving services, social conditions and policies for people with psychiatric disabilities and/or diagnoses by promoting their recovery, rehabilitation, rights and full community inclusion
  • Strategies:
    • Advocate
    • Educate
    • Demonstrate

NYAPRS Peer Bridger Model

  • Developed in 1994 by NYAPRS to assist state hospital residents with long or frequent stays in 6 state hospitals to successfully transition to the community
  • Support individuals to successfully transition from hospital to community
  • Training hospital and community providers on recovery and peer support

Key Values and Value

  • Trusted, safe relationships
  • Person driven and directed
  • Acceptance, empathy and example
  • Hope, respect and dignity
  • Empowerment and choice
  • Honesty and shared accountability

1994 Typical OMH State Hospital Bridger Involvement

  • First 2 - 3 Months: Relationship building, emotional support, encouragement for recovery and community living goals
  • Second 2 - 3 Months: Solidify involvement in peer support group; exposure to community resources
  • Last 3 - 4 Months: Post-discharge support, skill teaching, solidify connections to community supports and resources
  • Continuity: Even after discharge, ongoing relationships with peer support meetings

State Hospital Program Mission

"We support each other to get out of the hospital, stay out of the hospital and get the hospital out of us."

Program Evaluation Data

  • 1998 National Health Data Systems:
    • In the 2 years prior to involvement in our program, 60% of program participants had been hospitalized
    • After enrollment in the program,19% of the participants were re-hospitalized during the following year
    • This is a 40% reduction
  • 2009 NYAPRS Program Evaluation Data:
    • 71% (125 of 176) of program participants were not readmitted in the year following discharge from the hospital

Unique Appeal of Peer Support

"She talked to me. She talked straight at me. She´s the only one who did this. She´s got a knack for going on the underlying thing and really getting at it. And I´ve never had anyone look me straight in the eye, and actually relate to somebody. And I love her for it."

Source: MacNeil dissertation, 2003

2008 - 2011 NYS Chronic Illness Demonstration Program (CIDP)

"To improve health outcomes and reduce costs for persons with chronic and complex medical and behavioral health conditions...who were exempt or excluded from mandatory managed care."

"The CIDPs utilized multifaceted interventions and were designed to enhance the member-provider relationship, promote improved self-management and reductions in emergency department visits and inpatient hospitalization admissions."

Source: NYS DOH Chronic Illness Demonstration Project.

NYAPRS Peer Wellness Coaching Role within Optum´s Queens CIDP Initiative

  • Seek out identified Medicaid recipients to explain program and encourage enrollment
  • Crisis stabilization
  • Utilize tools to discuss and plan for improved health self-management
  • Relapse prevention and crisis support and diversion
  • Help participants to identify and engage with a range of community-based supports

NYAPRS Peer Bridger Competencies

  • Successful management of recovery
  • Trained facilitators in Mary Ellen Copeland´s Wellness Recovery Action Program
  • Trained in Shery Mead´s model of Intentional Peer Support
  • Completed the Rutgers credentialed program on Peer Wellness coaching
  • OASAS certified Addiction Recovery Coach

Peer Wellness Coaching Training Curriculum

  • Course developed by CSPNJ & UMDNJ
  • Topics covered include:
    • Wellness Model and Wellness Narratives
    • Coaching Method
    • Role of Wellness Coach
    • Lifestyle Factors for Health & Wellness
    • Metabolic Syndrome, Smoking Cessation, Nutrition, Physical Activity, Sleep and Rest, Heath Habits
    • Heath Literacy

Wellness Tools

  • Wellness Recovery Actions Plans
  • Advance Directives
  • Health Literacy Education
  • Shared Decision Making, Person-centered Planning
  • Whole Health Peer Support
  • Whole Health Action Management groups

8 Dimensions of Wellness

(We have so much to offer!)

Wellness Diagram (clockwise)

  • Emotional - Coping effectively with life and creating satisfying relationships
  • Financial - Satisfaction with current and future financial situations
  • Social - Developing a sense of connections, belonging, and a well-developed support system
  • Spiritual - Expanding our sense of purpose and meaning in life
  • Occupational - Personal satisfaction and enrichment derived from one´s work
  • Physical - Recognizing the need for physical activity, diet, sleep and nutrition
  • Intellectual - Recognizing creative abilities and finding ways to expand knowledge and skills
  • Environmental - Good health by occupying pleasant, stimulating environments that support well-being

Adapted from Swarbrick, M. (2006). A Wellness Approach. Psychiatric Rehabilitation Journal, 29(4), 311-314.

Source: SAMHSA Eight Dimensions of Wellness.

Evidence-Based Outreach and Engagement

  • Relationship, reliability and trust building are central
  • Meet people where they are:
    • Regarding what they identify as immediate needs
    • And where they live, bringing services to them rather than expecting them to visit a service agency for help
  • Relentlessness - especially to overcome bad addresses and other barriers
  • Repeated contact - follow-up is essential
  • Linkage to supports, services and social networks

Why Do These Individuals Not Show Up, Follow Through and Get Better?

  • Unstable housing or homelessness
  • Poverty and joblessness
  • Inadequate social supports, isolation
  • Hopelessness
  • Addictions
  • Trauma, chronic sense of chaos and crisis
  • Disorganization and chaos
  • Multiple medical needs

Three Legs of the Stool

  • NYAPRS credentialed peer wellness coaches: outreach and engagement, crisis stabilization, development of wellness self-management and community life skills, relapse prevention, crisis support and ER and inpatient diversion
  • Optum care manager: coordination, linkage and advocacy
  • Optum nurse: medical assessment, services and referrals

Critical CIDP Role

  • Our Queens peer wellness coaches helped find, engage and enroll over 1/3 of identified beneficiaries
  • They helped Optum staff successfully connect with numerous community agencies that proved helpful in finding or serving this group
  • Our coaches´ inclusion in Optum´s weekly team case rounds "gives the team the opportunity to learn from our peer partners, and hear an additional viewpoint" on how to best respond. It is also "a great opportunity to get additional referrals to peer support"

NYAPRS Wellness Coaching Impact: One Person´s Outcomes

  • 37 year old Indian man born in Jamaica diagnosed with bipolar, substance use and kidney disease
    • 2009 - prior to enrollment: 7 detox stays (4 different facilities)
      $52,282 behavioral health Medicaid spend
    • 2010 - 1 detox, 1 rehab (referred by the CIDP team)
      $20,650 abstinent for 1 year
    • 2011 - 1 relapse with detox/rehab
      No claim

NYAPRS/Optum Peer Bridger Project

  • 2010 contract to work with 200+ identified NYC/LI Medicaid Managed Care beneficiaries who have had multiple re-hospitalizations
  • Goals were to reduce re-hospitalization rate by 40% and to improve ´community tenure´ by 15%
  • Similar objectives to CIDP: increase hope, support and self care, increase connection to healthcare and reduce avoidable ER/inpatient use

Outreach Process

  • Upon receipt of a referral from Optum, referrals are assigned to Peer Bridgers based on home address of the referred individual (cars, cellphones, tablets)
  • Peer Bridgers are expected to make initial contact within one week of receipt of referral
  • Peer Bridgers make six (6) or more attempts, either in person, via phone or mail, to contact each referral before a case is closed
  • Brochures are left if no one is home

Outreach Challenges

  • Incorrect or insufficient data on home addresses and phone numbers
  • Inability to gain access to inpatient hospital settings, which increases the project´s dependence on accurate information on referral addresses and phone numbers

Findings from 2013 Optum External Peer Evaluation for NYAPRS Peer Bridger Initiative

6 months pre-post, members who enroll in the program show:

  • Significant decreases in the percentage who use inpatient services
    • 47.9% decrease (from 92.6% to 48.2%)
  • Significant decreases in the number of inpatient days
    • 62.5% decrease (from 11.2 days to 4.2)
  • Significant increases in the number of outpatient visits
    • 28.0% increase (from 8.5 visits to 11.8)
  • Significant decreases in total BH costs
    • 47.1% decrease (from $9,998.69 to $5,291.59)

*Among subsample of enrollees in NY (N = ) and WI (N = 130) with continuous eligibility 6 months pre-referral and 6 months post-referral and at least one behavioral health claim during that period

Other Peer Run Service Models

  • Peer Crisis Diversion: warm lines, respite house
  • Peer Bridging: from state and Medicaid hospitals, adult and nursing homes, homeless shelters, criminal justice settings
  • Peer Wellness/Recovery Coaches
  • Rights Protection and Advocacy
  • Life Coaching: work, economic self sufficiency
  • Peer Supported Housing
  • Peer ombudspersons

Other NYS Peer Service Outcomes Program Evaluation Data

  • 90% of PEOPLE Inc.´s Rose House crisis respite guests did not return to hospital in the following two years in the Hudson Valley (2010)
  • Mental Health Peer Connection´s Life Coaches helped 53% of individuals with employment goals to successfully return to work in the Buffalo, NY area (2010)
  • Western NY´s Housing Options Made Easy helped 70% of residents to successfully stay out of hospital in the following year (2011)

Key Factors to our Success

  • Harm reduction model
    • E.g. crisis stabilization
  • Wrap around funds allow us to address most pressing needs at the outset
    • E.g. crisis housing
  • We are available "off-hours" because crisis seldom happens from 9am to 5pm

NYAPRS/HealthFirst Peer Bridger Initiative

  • Contracted to work with 500 individuals:
    • Working closely with telephonic case managers
    • 98% of engagements in the community
    • 318 individuals referred had 2 or more hospitalizations
    • 49 individuals had 4+ admissions, all with SUD diagnosis
    • 60% male and 40% female
  • July - August 2014:
    • 373 referrals, 256 enrollments (68.63%)

Contacts with Engaged Members

  • The number of contacts (either by phone or face-to-face) between the Peer Bridger and the enrolled individual ranges from 1 to 78 contacts
  • The total amount of time spent with enrolled individuals (either by phone or face-to-face) ranges from 1 to 72 hours
  • The average number of contacts between the Peer Bridger and an enrolled individual is 18 contacts and the average number of hours spent with enrolled individuals is 15 hours

Preserving the Integrity of Peer Support

  • We are not assistant case managers or transportation aides; nor are we "cheap staff who get people to take their medicine"
  • On the other hand, we can help a person with appointments and medications if they define those needs as part of their self-identified wellness and recovery plan
  • Specialized supervision

Protecting the Integrity of Peer Support

  • Peers frequently work for subcontracted peer run agencies and are supervised by other peers
  • Peers who are embedded in traditional settings without peer supervision are at risk for co-optation
  • Peer support offers a unique relationship and role that other agencies typically miss, using them as assistant case managers or ´medication compliance´ specialists
  • Groups are developing competency, training, credentialing and accreditation standards for peer delivered services

Peer Bridger Compensation

  • In the 1990´s, we began with part-time bridgers who wanted to remain on disability benefits
  • Peer support specialists is now a fully developed career path
  • According to a new survey developed for the College for Behavioral Health Leadership, annual salaries for peer support specialists average $17 per hour in New York State, including healthcare and retirement plan

Concluding Remarks

Further Reading and Resources

Thank You!

Larry Fricks



Harvey Rosenthal



Shannon Mace