Peer Support Specialists have become an important part of service delivery in North Carolina. With the opportunities within Medicaid Transformation and the focus on integrated care, it would seem that their importance will only increase. There are some efforts in North Carolina to build upon what we have currently–to show that Peer Support Services can assist in the integration of physical and behavioral healthcare. Nationally, SAMHSA has identified four functions for Peer Support Specialists in integrated care:
There is a strong co-occurring connection between health and behavioral health status. We know that individuals in this country with a major mental illness die 14 to 32 years earlier than the general population because they often have co-occurring mental health and physical health needs. In 2011, Thomas Insel a former Director of the National Institute on Mental Health (NIMH) wrote, “The unavoidable fact is that we will not improve overall longevity or contain health care costs in this nation without addressing the needs of the nearly 5 percent of Americans with serious mental illness. This is a population that not only dies early; they have multiple chronic diseases requiring expensive care, often in emergency rooms and intensive care units. We need better strategies for dealing with this urgent public health issue and we need to ensure that whether these strategies are collaborative care for depression or an innovative medical home for those with serious mental illness, we implement these interventions where the need is greatest.”
We gathered Subject Matter Experts to discuss the possibilities, benefits and challenges of using CPSSs to help achieve integrated care. You can find Part 1 of our discussion on Integrated Care – “How do we Define Healthcare Integration?” here.
Would it be beneficial to Medicaid beneficiaries and uninsured individuals with behavioral health diagnoses if CPSSs are trained to assist in integrated care? What would that look like?
Yes, having individuals with lived experience assisting in integrated care would be beneficial to Medicaid beneficiaries and uninsured individuals with behavioral health diagnoses. As stated in the SAMHSA’s 4 domains, people have needs in several different areas, all of which impact their overall health. Utilizing peers, for example, in our behavioral health emergency department and inpatient units, allows us to utilize interventions focused on recovery principles, to include hope and purpose.
Peers mentor and educate our patients on topics of daily management that will increase the individual’s physical and emotional health and they help to explain that these two things go hand-in-hand. Peers work to understand the individual’s access to healthy foods and exercise routines, then help the individual plan their daily activities based on their finances, interests, and abilities. They also discuss purpose, they ask questions like “what gets you out of bed in the morning?” and “what brings you joy?” and establish routines around those things. They also explore things impacting health, for instance, asking questions like, “are you eating breakfast with your medication to ensure that it works for you?”.
Peers convey hope through sharing their lived experience: recognizing when to share experiences and when to listen. They discuss ongoing personal efforts to enhance health, wellness, and recovery.
In an inpatient setting, peers participate in Multidisciplinary Treatment Teams: advocating from a peer perspective. They help to educate family/supportive individuals about recovery principles and link families to community resources and support groups such as NAMI, AA, and community peer agencies.
Our Peer Bridger Program focuses mostly on the SPMI population and involves linking individuals to resources, helping individuals attain independent living, and maintaining social support. Patients are referred by our employed peers on the inpatient units and are met by peers employed by community providers on the unit prior to discharge. This “warm-hand-off” has been effective in jump starting the peer relationship at a critical time for the patient.
We’ve also found peers to be enormously helpful in our First Episode Psychosis Program. The “Eagle Program” is for individuals ages 15-30 and involves a team-oriented approach to helping the individual and their family members to manage symptoms and meet treatment goals. A core component of this team is a CPSS.
I agree with Mr. Armstrong. The answer is a resounding YES. With Medicaid transformation and behavioral health integration with physical health, these are exciting times. Peer support specialists have demonstrated consistent abilities to connect, instill hope, and provide ongoing support to clients with behavioral health concerns. These unique skills can be translated to physical health as well. As research has shown, individuals with behavioral health tend to have co-morbid physical health concerns. The RI International Durham team has integrated peer support specialists into our crisis facility which also has a co-located physical health clinic through Lincoln Community Healthcare. Here this integration is enhanced by the peers being able to connect with individuals when they first arrive to the crisis facility, supporting them through the assessment process, encouraging goals related to physical health as well as behavioral health, and if needed accompany the individual to the physical health appointment onsite. We have found peers to be so beneficial that we currently have more peers on shift than any other discipline.
We have found peers to be so important that we have recently started a peer bridge service run strictly by peer support specialists. Here the individual is followed in the community after discharging from the facility based crisis unit, supported through curriculum models like Whole Health Action Management (WHAM) and Illness, Management, and Recovery (IMR). The individuals are transported to first behavioral health appointments, pharmacy for behavioral health and psychical health medications, and assisted with linkages to basic needs which impact whole person care. We have found this service to be essential for individuals who have difficulty connecting to community care after a behavioral health crisis.
And finally, we are currently starting a peer navigation program through grant funding from Durham County which will allow RI peer support specialists to connect with individuals in the local ERs once the ER professionals have been identified as having behavioral health concerns especially opiate use disorder. This is a program that has been a year in the making as the community has been concerned with the amount of overdoses and individuals reports to the ERs for seemingly medical reasons. This program will be completely staffed by peer support specialists and provide a resource with transportation in the community to link individuals to their next level of care. That next level of care mostly likely will be the RI Durham crisis facility for induction of buprenorphine for those who qualify but we are prepared to assist with referrals and assistance to all levels of need. And continue to support the transition into ongoing recovery focused treatment including longer term Medication Assisted Treatment (MAT) needs.
Peer Supports are a perfect conduit to connecting peers to a PCP. All of us have barriers to better health/recovery and assisting peers overcome many of these barriers leads to an enhanced commitment for whole health collaborative. Peer Support Specialists develop a rapport with the peer by attending support groups together, developing a WRAP plan and open discussion about what is/is not working. This interaction has tremendous power in helping peers focus on recovery, better health goals and stability.
In the initiatives that are underway, what are the challenges that keep us from expanding the work of CPSSs in integrated care?
As effective as utilizing peers has been, there are challenges involved in their use as well. One of the largest hurdles is reimbursement. The reimbursement rates, like many behavioral health rates are extremely low, making it difficult to sustain if relying on billing. It is also difficult to scale the cost as the impact of peers is sometimes difficult to quantify. In addition, the service definitions are extremely narrow. It is difficult to utilize peers at full capacity due to difficulty being able to bill according to the service definitions. One way we have overcome that obstacle is by employing our own peers as part of our treatment team and not billing.
I agree with Victor and would like to emphasize sustainable reimbursement especially for state funded individuals. Grant funding works but eventually runs out. I believe there is a need for continued research on the use of peer support specialists which can include their impact on physical health.
And second I will say training. In North Carolina, peer support specialists are so important but there is a varied amount of training and experience for the same title. Until we increase our initial training requirements to become certified, the responsibility for training will be on the agencies. Not every agency is set up to provide the support, supervision, and training for peer support specialists to excel. RI has overcome this by providing our own internal extensive training which includes training on physical health.
I agree with Victor, the Peer definition should be updated to reflect the importance of the peer support profession. In the past, it was seen as an auxiliary service. Peer Support involvement should be viewed as a team approach to develop a comprehensive positive approach to long term outcomes. Since peer supports can spend more time with peers, you can involve them in activities they excel in and look for opportunities they may want to consider but haven’t due to the illness or barriers.