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Peer Workers in the Behavioral and Integrated Health Workforce: Opportunities and Future Directions

      The growth of the peer workforce in behavioral health services is bringing opportunities to organizations and institutions that serve people living with mental and substance use disorders and their families. Peer workers are defined as people in recovery from mental illness or substance use disorders or both that possess specific peer support competencies. Similar roles are identified for families of people in recovery. Peer support has been implemented in a vast range of behavioral health services, including in the relatively new use of peer support in criminal justice and emergency service environments. Behavioral health services are striving to integrate peer workers into their workforce to augment existing service delivery, in part because peer support has demonstrated effectiveness in helping people with behavioral health conditions to connect to, engage in, and be active participants in treatment and recovery support services across all levels of care. This article describes the experiences that organizations and their workforce, including peer workers, encounter as they integrate peer support services into the array of behavioral health services. Specific attention is given to the similarities and differences of services provided by peers in mental health settings and substance use settings, and implications for future directions. The article also addresses the role of peer workers in integrated behavioral and physical healthcare services.

      Supplement information

      This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

      Introduction

      Since the 1980s, people with experiences of mental illness, addiction, and trauma have become increasingly involved in systems designed to provide care to people with behavioral health conditions. They participate in advisory boards, patient councils, and as employees of treatment and community support services. Known collectively as peer workers, they are a provider workforce with a tantamount of experience that is unique from other provider roles. They perform a wide range of roles in many different service models, such as Wellness Recovery Action Plan, Seeking Safety, and Motivational Interviewing. This article will highlight factors that promote the growth of the peer workforce, describe multiple program models that hire peer workers, and explore opportunities and challenges faced by the peer workforce that thwart the ability to attain legitimacy in non-healthcare settings.

      Background

      Behavioral health conditions are common in the U.S. In 2015, there were an estimated 43.6 million adults aged 18 years or older in the U.S. experiencing mental illness within the past year. Of these, an estimated 9.8 million adults are classified as having a serious mental illness, with just over half participating in any treatment. The same survey estimated that 20.2 million adults (8.4%) had a substance use disorder and of these, 7.9 million people had both a mental disorder and substance use disorder.
      Center for Behavioral Health Statistics and Quality
      2015 National Survey on Drug Use and Health.
      National legislation that supports healthcare parity has eliminated several barriers to accessing behavioral health services; however, reluctance to engage in treatment services because of negative perceptions about behavioral health conditions, and an overall lack of services and supports continue to contribute to the low level of engagement in behavioral health services. Shortages of behavioral health providers are often cited as a barrier to meeting the treatment and support needs of individuals living with behavioral health conditions, and their families.
      • Hoge M.A.
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      Building the mental health workforce capacity needed to treat adults with serious mental illnesses.

      Knickman J, Krishnan KRR, Pincus HH, et al. Improving Access to Effective Care for People Who Have Mental Health and Substance Use Disorders. Discussion Paper, Vital Directions for Health and Health Care Series. Washington, DC: National Academy of Medicine. https://nam.edu/wp-content/uploads/2016/09/Improving-Access-to-Effective-Care-for-People-Who-Have-Mental-Health-and-Sustance-Use-Disorders.pdf. Published 2016. Accessed July 9, 2017.

      Development and deployment of a trained and competent peer workforce with its mission of helping people manage their conditions through the delivery of peer support services emphasizing self-management, mutual support, and attaining recovery goals is a critical adjunctive component of meeting the needs of people with behavioral health conditions.
      • Myrick K.
      • Del Vecchio P.
      Peer support services in the behavioral healthcare workforce: state of the field.
      Although informal peer support has long been a part of the process of recovery from behavioral health conditions, hiring or collaborating with peer workers is a relatively recent phenomenon.
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      Peer support services in the behavioral healthcare workforce: state of the field.
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      Recovery: a common vision for the fields of mental health and addictions.

      White W. Sponsor, recovery coach, addiction counselor: the importance of role clarity and role integrity. Philadelphia, PA: Philadelphia Department of Behavioral Health and Mental Retardation Services. https://oasas.ny.gov/recovery/documents/WhiteSponsorEssay06.pdf. Published 2006. Accessed July 9, 2017.

      In the 1970s, self-help groups and advocacy organizations led by people living with mental or substance use disorders emerged as pioneers resolute in improving mental health treatment services in a climate of economic crisis and system restructure and shifting negative attitudes about mental health.
      • Davidson L.
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      • Rowe M.
      Peer support among adults with serious mental illness: A report from the field.
      • Tomes N.
      The patient as a policy factor: A historical case study of the consumer/survivor movement in mental health.
      National and international efforts addressed prejudice while promoting changes in a troubled mental health services system to eradicate discrimination on the premise that some non-clinical needs of people living with a mental illness could be addressed by mutual supports of others with similar experiences.
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      Work transitions for peer support providers in traditional mental health programs: unique challenges and opportunities.
      • Mowbray C.T.
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      • Collins M.E.
      Consumers as mental health providers: First-person accounts of benefits and limitations.
      The federal Community Support Program in Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Mental Health Services facilitated some of the initial efforts helping establish peer support services and research, which demonstrated the important role funders have in shaping the inclusion of peer workers in diverse roles in mental health services.
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      How governments and other funding sources can facilitate self-help research and services.
      • Bluebird G.
      Redefining consumer roles: changing culture & practice in mental health care settings.
      Formal peer support in mental health began in the 1980s with the recognition of the value of the perspectives of people with lived experiences of using mental health services and the expansion of drop-in centers and other consumer-run organizations.
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      • Lehman A.
      Consumers as service providers: the promise and the challenges.
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      The working alliance and consumer case management.
      Through the 1990s, there was limited integration of mental health peers in select portions of the mental health system, such as outreach and consumer case management. Research on these limited roles showed potential benefits, including decreased hospitalization rates and improved quality of life.
      • Solomon P.
      • Draine J.
      The efficacy of a consumer case-management team: two-year outcomes of a randomized trial.
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      Benefits and challenges of using consumer staff in supported housing services.
      In 2003, the President’s New Freedom Commission report proposed a set of goals designed to transform the mental health system into a recovery-oriented system of care and recommended the development of a strong peer workforce.

      President’s New Freedom Commission on Mental Health. President’s Mental Health Commission recommends transforming America’s mental health care system. http://govinfo.library.unt.edu/mentalhealthcommission/press/july03press.htm. Published 2003. Accessed July 9, 2017.

      In 2005, the Department of Veterans Affairs began to fund a number of new positions for veterans with lived experiences of behavioral health conditions to provide recovery support services to other veterans with behavioral health needs.
      • Chinman M.
      • Lucksted A.
      • Gresen R.
      • et al.
      Early experiences of employing consumer-providers in the VA.
      By 2017, the Department of Veterans Affairs employed more than 1,200 peer workers in a variety of the Department’s programs
      • Chinman M.
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      • Smith J.
      • et al.
      Provision of peer specialist services in VA patient aligned care teams: protocol for testing a cluster randomized implementation trial.
      and it is anticipated that peer support services will expand in the coming years.
      • Buck J.A.
      The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act.
      Center for Substance Abuse Treatment
      What are peer recovery support services?.
      Peer recovery coaching, as it is known in the field of substance use treatment, did not launch formally until the early 2000s. Although the substance use treatment workforce has long included people in recovery, they were employed in roles of counselors and did not provide peer recovery support.

      Peer Definitions and Roles

      SAMHSA, the federal agency responsible for the quality of behavioral health services, defines a peer worker as “a person who uses his or her lived experience of recovery from mental illness and/or substance use disorder, plus skills learned in formal training [evidence-based interventions, such as Wellness Recovery Action Plan, Seeking Safety, Cognitive Behavior Therapy, Motivational Interviewing], to deliver services in behavioral health settings to promote mind–body recovery and resilience.”
      Center for Substance Abuse Treatment
      What are peer recovery support services?.
      There are other definitions, but all distinguish between peer providers and clinical providers as the ability to draw from lived experiences and experiential knowledge to help others.

      Peer providers: who are peer providers? SAMHSA–HRSA Center for Integrated Health Solutions website. www.integration.samhsa.gov/workforce/team-members/peer-providers%23whoarepeerproviders. Accessed July 9, 2017.

      • Gagne C.
      • Olivet J.
      • Davis L.
      Equipping Behavioral Health Systems and Authorities to Promote Peer Specialist/Peer Recovery Coaching Services: Expert Panel Meeting Report.
      Many in the behavioral health field now recognize the unique contributions that those with lived experience of mental and substance use disorders can make to another person’s recovery process. Peer workers may also play a critical role in the transformational changes necessary to develop recovery-oriented behavioral health services and systems as they assist the field to implement the system’s overall mission of helping people lead meaningful lives in the community.

      Peer providers: who are peer providers? SAMHSA–HRSA Center for Integrated Health Solutions website. www.integration.samhsa.gov/workforce/team-members/peer-providers%23whoarepeerproviders. Accessed July 9, 2017.

      As the role of peer workers has evolved, it has become increasingly revised and adapted for diverse job titles for work in a range of environments to a variety of people. This is exemplified by the results of a 2010 national survey of certified peer specialists in which 291 respondents reported 105 different job titles.

      What is peer support? Peers for progress website. http://peersforprogress.org/learn-about-peer-support/what-is-peer-support. Accessed July 9, 2017.

      Regardless of job titles, peer workers generally (1) connect through lived experience; (2) mentor, coach, or teach; (3) link to community resources; and (4) facilitate the achievement of recovery goals.
      Center for Substance Abuse Treatment
      What are peer recovery support services?.
      • Gagne C.
      • Olivet J.
      • Davis L.
      Equipping Behavioral Health Systems and Authorities to Promote Peer Specialist/Peer Recovery Coaching Services: Expert Panel Meeting Report.
      • Salzer M.S.
      • Schwenk E.
      • Brusilovskiy E.
      Certified peer specialist roles and activities: results from a national survey.
      • McDaid C.
      Recovery Coaches and Delivery of Peer Recovery Support Services: Critical Services and Workers in the Modern Health Care System.
      Table 1 lists services and supports provided by peer workers, locations where they work, and the people they work with as described by the literature and peer workers’ job descriptions. For example, one peer may provide peer support and teach life skills to people with criminal justice involvement, whereas another provides recovery coaching to an older adult living with behavioral and comorbid health conditions.
      Table 1Services and Supports Provided by Peer Workers
      Services/SupportsSettingsPopulations
      • Peer support
      • Outreach
      • Housing services and supports
      • Transportation
      • Food, clothing, basic needs
      • Parenting training
      • Child care
      • Recovery skills training and support
      • Life skills training
      • Employment coaching
      • Educational support
      • Legal services
      • Evidence-based practices
      • Recreation
      • Service navigation
      • Health and wellness support
      • Home
      • Recovery housing
      • Street outreach
      • Shelters
      • Emergency rooms
      • Inpatient settings
      • Outpatient programs
      • Health centers
      • Primary care settings
      • Courts, jails, prisons
      • Community spaces
      • Social service centers
      • Sports and recreation centers
      • Recovery high schools
      • College campuses
      • Job sites
      • Youth and young adults
      • Older adults
      • Family members
      • People with criminal justice involvement
      • People who are homeless
      • Homeless youth
      • People living with HIV
      • People with physical health comorbidities
      • People with mental health and substance use disorders
      • Mothers with children
      • Pregnant women
      • High users of emergency services
      HIV, human immunodeficiency virus.
      The expansion of peer roles came with the recognition that people with mental or substance use disorders, and co-occurring conditions, benefit from the availability of services and supports over time to reduce symptoms and to accomplish goals. Access to recovery support services can emphasize illness self-management while focusing on recovery, improvement of functional outcomes, and increased participation in life domains.

      Peer providers: who are peer providers? SAMHSA–HRSA Center for Integrated Health Solutions website. www.integration.samhsa.gov/workforce/team-members/peer-providers%23whoarepeerproviders. Accessed July 9, 2017.

      • Solomon P.
      Peer support/peer provided services underlying processes, benefits, and critical ingredients.
      Behavioral health conditions are often considered chronic health conditions and, as such, people learn illness self-management strategies and have access to ongoing services and supports to manage the condition’s symptoms over time. Historically, the mental health system recognized the chronic nature of many serious mental health conditions and provided treatment services over time with little emphasis on illness self-management and recovery; by contrast, substance use treatment was characterized by episodic availability of treatment services with an emphasis on self-management and recovery.
      • Gagne C.
      • White W.
      • Anthony W.
      Recovery: a common vision for the fields of mental health and addictions.

      Daniels A, Grant E, Filson B, Powell I, Fricks L, Goodale L, eds. Pillars of peer support: transforming mental health systems of care through peer support services. www.pillarsofpeersupport.org/final%20%20PillarsofPeerSupportService%20Report.pdf. Published 2010. Accessed July 9, 2017.

      Selected Models of Peer Support

      Historically, peer support within the mental health system has been described as generally occurring in three different service settings or models: (1) naturally occurring mutual support groups, such as Alcoholics Anonymous; (2) peer-run services and recovery services organizations; and (3) clinical or rehabilitation settings that employ peers as providers.
      • Myrick K.
      • Del Vecchio P.
      Peer support services in the behavioral healthcare workforce: state of the field.
      • White W.L.
      Nonclinical addiction recovery support services: history, rationale, models, potentials, and pitfalls.
      This paper focuses on the third model, clinical and rehabilitation settings. In the substance use field, peer workers are generally known as peer recovery coaches who provide peer support services within three distinct program models: (1) the clinical treatment model; (2) recovery community organizations; and (3) the business model, which delivers recovery support services through a fee-for-service structure.
      • Myrick K.
      • Del Vecchio P.
      Peer support services in the behavioral healthcare workforce: state of the field.
      • Davidson L.
      • Chinman M.
      • Kloos B.
      • Weingarten R.
      • Stayner D.
      • Tebes J.K.
      Peer support among individuals with severe mental illness: a review of the evidence.
      Newer models of peer support services are being implemented across the country.

      Peer Workers on Integrated Healthcare Teams

      Peer workers have joined the expanding number of integrated healthcare services, providing services to the growing number of Americans with complex physical and behavioral healthcare needs. The majority of adults (52.2%) had at least one type of condition—mental illness, substance use, or chronic medical condition—with substantial overlap across the conditions including 1.2%, or 2.2 million people, reporting all three conditions.
      • Walker E.R.
      • Druss B.G.
      Cumulative burden of comorbid mental disorders, substance use disorders, chronic medical conditions, and poverty on health among adults in the USA.
      One in four Americans experiences a behavioral health illness each year, and the majority of those individuals also experience comorbid physical health conditions.
      • Walker E.R.
      • Druss B.G.
      Cumulative burden of comorbid mental disorders, substance use disorders, chronic medical conditions, and poverty on health among adults in the USA.
      Integrated health services are often based in a healthcare clinic, but may be delivered outside the clinical environment. Peer workers are delivering wellness coaching services, which include illness self-management, to help individuals in their pursuit of personal health and wellness goals.
      • Brasher D.
      • Rossi L.D.
      Meaningful Roles for Peer Providers in Integrated Healthcare: A Guide.
      • Swarbrick M.
      • Murphy A.A.
      • Zechner M.
      • Spagnolo A.B.
      • Gill K.J.
      Wellness coaching: a new role for peers.
      • Swarbrick M.A.
      Integrated care: wellness-oriented peer approaches: a key ingredient for integrated care.
      In addition to providing support for illness self-management, peer workers are collaborating with integrated healthcare teams to provide support by linking to other health or community resources. Often, a peer worker in this role is called a peer navigator because they assist a person to navigate their way through the healthcare and insurance systems. Several recent studies of using peer navigators have shown the effectiveness of employing peer workers in this role.
      • Kelly E.
      • Duan L.
      • Cohen H.
      • Kiger H.
      • Pancake L.
      • Brekke J.S.
      Integrating behavioral health care for individuals with serious mental illness: a randomized controlled trial of a peer health navigator intervention.
      • Corrigan P.W.
      • Pickett S.
      • Batia K.
      • Michaels P.J.
      Peer navigators and integrated care to address ethnic health disparities of people with serious mental illness.
      • White H.
      • Whelan C.
      • Barnes J.D.
      • Baskerville B.
      Survey of consumer and non-consumer mental health service providers on assertive community treatment teams in Ontario.

      Peer Workers on Crisis Service Teams

      Peer providers may work as a member of teams that provide crisis services to people with urgent behavioral health needs. There are two dominant models of peer support in crisis services: (1) mobile crisis team and (2) crisis stabilization units; the main difference being one is portable throughout the community, including a person’s home, and the other is site-based, usually within a hospital emergency department.
      • White H.
      • Whelan C.
      • Barnes J.D.
      • Baskerville B.
      Survey of consumer and non-consumer mental health service providers on assertive community treatment teams in Ontario.
      Teams usually comprise psychiatrists, nurses, social workers, therapists, substance use disorder specialists, and peer workers. Teams provide services to prevent or ameliorate a behavioral health crisis, such as responding to an opioid overdose; providing treatment and support to a person seeking treatment for a substance use disorder; and reducing distressing symptoms of mental illness.
      Behavioral Health Service Definitions: A Supplement to SAMHSA Description of a Modern Addictions and Mental Health Service System.

      Two kinds of roles for OTP peers under the Affordable Care Act. Addiction Treatment Forum website. http://atforum.com/2013/04/two-kinds-of-roles-for-otp-peers-under-the-affordable-care-act. Published April 21, 2013. Accessed July 9, 2017.

      Peers work in direct services alongside other treatment providers and may stay connected to provide peer support services in the community.

      Peer Workers in Medication-Assisted Treatment for People With Opioid Use Disorders

      Peer workers, usually known as peer recovery coaches, are employed by providers of medication-assisted treatment (MAT) to provide individual coaching and support, and to conduct education and support groups within the programs. MAT is much more effective with ongoing services and supports, and peer recovery coaches can provide this support and help people link to services.
      • Portillo S.
      • Goldberg V.
      • Taxman F.S.
      Mental health peer navigators: working with criminal justice-involved populations.
      MAT has become a critically important service in the wake of the opioid epidemic in the U.S. and peer recovery coaches are assisting people using MAT to adhere to treatment and to regain valued roles in the community.

      Peer Workers in Criminal Justice Settings

      Peer workers in criminal justice settings, often known as forensic peer specialists, have had personal involvement with criminal justice settings and have received training to provide support and mentoring along the continuum of criminal justice involvement. Peer workers are employed in specialty courts to serve as mentors and coaches for people with behavioral health needs. Specialty courts that use peer services include mental health courts, drug courts, and veteran treatment courts. Peers also work in re-entry, helping people exiting jail or prison to transition to community life by supporting them in setting and achieving their goals.
      • Davidson L.
      • Rowe M.
      Peer Support Within Criminal Justice Settings: The Role of Forensic Peer Specialists.
      • Bond G.R.
      • Drake R.E.
      Making the case for IPS supported employment.

      Peer Workers in Supported Employment Programs

      Since the 1990s, the mental health system has developed supported employment programs for people with mental health disorders with or without a substance use disorder to help them acquire and retain jobs of their choice. The most common model of supported employment is known as individualized placement and support (IPS), which has demonstrated positive outcomes for people with mental health conditions.
      • Marshall T.
      • Goldberg R.W.
      • Braude L.
      • et al.
      Supported employment: assessing the evidence.
      The level of research evidence for supported employment has been graded as high, based on 12 systematic reviews and 17 RCTs of the IPS model.
      • Marino L.A.
      • Dixon L.B.
      An update on supported employment for people with severe mental illness.
      Supported employment consistently demonstrated positive outcomes for individuals with mental disorders, including higher rates of competitive employment, fewer days to the first competitive job, more hours and weeks worked, and higher wages.
      • Marino L.A.
      • Dixon L.B.
      An update on supported employment for people with severe mental illness.
      A growing literature, which is exploring the cost effectiveness of IPS compared with traditional vocational services, favors IPS.
      • Kern R.S.
      • Zarate R.
      • Glynn S.M.
      • et al.
      A demonstration project involving peers as providers of evidence-based, supported employment services.
      In mental health services, peer workers have provided services and support for participants in supported employment programs, demonstrating the feasibility and benefits of having peers as part of the supported employment team.
      • Chinman M.
      • George P.
      • Dougherty R.H.
      • et al.
      Peer support services for individuals with serious mental illnesses: assessing the evidence.

      Peer Workers on Assertive Community Treatment Teams

      One of the earliest roles for peer workers in the mental health system was serving as a member of an Assertive Community Treatment team.
      • Solomon P.
      Peer support/peer provided services underlying processes, benefits, and critical ingredients.
      • Wright-Berryman J.L.
      • McGuire A.B.
      • Salyers M.P.
      A review of consumer-provided services on assertive community treatment and intensive case management teams: implications for future research and practice.
      Assertive Community Treatment is an evidence-based practice that provides intensive services in the environments where people with severe mental illness live. Some Assertive Community Treatment and intensive case management teams have integrated peer workers as team members.
      • Bond G.R.
      • Drake R.E.
      Making the case for IPS supported employment.
      Peer workers have been successful in outreach, engagement, and linking people to resources in the community.
      • Solomon P.
      Peer support/peer provided services underlying processes, benefits, and critical ingredients.

      Evidence for Peer Support Services

      There is a growing body of research on peer support services, although the research on peer support services in mental health and substance use fields has been mired with methodologic difficulties.
      • Chapman S.
      • Blash L.
      • Chan K.
      The Peer Provider Workforce in Behavioral Health: A Landscape Analysis.

      Pitt V, Lowe D. Hill S, et al. Consumer–providers of care for adult clients of statutory mental statutory mental health services. Cochrane Database Syst Rev. 2013;(3):CD004807. https://doi.org/10.1002/14651858.CD004807.pub2.

      The Cochrane Review of 11 studies of peer support in mental health services stands as an important critique of the existing research literature, citing many studies with unclear or high risk of bias because of poor randomization or lack of blinding of the outcome assessment.
      • Bassuk E.L.
      • Hanson J.
      • Greene R.N.
      • Richard M.
      • Laudet A.
      Peer-delivered recovery support services for addictions in the United States: a systematic review.
      The authors conclude that there is “low quality” evidence that including peer workers on the care team results in small reductions of clients’ use of crisis and emergency services, and also no evidence of harm from the use of peer providers.
      • Bassuk E.L.
      • Hanson J.
      • Greene R.N.
      • Richard M.
      • Laudet A.
      Peer-delivered recovery support services for addictions in the United States: a systematic review.
      A similar meta-analysis in the substance use field concluded that peer participation in recovery support interventions appeared to have beneficial effects on participants and made a positive contribution to substance use outcomes.
      • Laudet A.B.
      • Humphreys K.
      Promoting recovery in an evolving policy context: what do we know and what do we need to know about recovery support services?.
      Although researchers can conclude that there is evidence for the effectiveness of peer-delivered recovery support services, additional research is necessary to determine the effectiveness of different approaches and types of peer support, and effectiveness among different target populations.
      • Simpson A.
      • Flood C.
      • Rowe J.
      • et al.
      Results of a pilot randomised controlled trial to measure the clinical and cost effectiveness of peer support in increasing hope and quality of life in mental health patients discharged from hospital in the UK.
      Despite methodologic challenges in conducting research on peer-delivered services, Chinman and colleagues
      • Wright-Berryman J.L.
      • McGuire A.B.
      • Salyers M.P.
      A review of consumer-provided services on assertive community treatment and intensive case management teams: implications for future research and practice.
      observed in a literature review of peer service effectiveness that across service types, improvements have been shown in the following outcomes: reduced inpatient service use, improved relationship with providers, better engagement with care, higher levels of empowerment, higher levels of patient activation, and higher levels of hopefulness for recovery.
      • Davidson L.
      • Chinman M.
      • Kloos B.
      • Weingarten R.
      • Stayner D.
      • Tebes J.K.
      Peer support among individuals with severe mental illness: a review of the evidence.
      • Kelly E.
      • Fulginiti A.
      • Pahwa R.
      • Tallen L.
      • Duan L.
      • Brekke J.
      A pilot test of a peer navigator intervention for improving the health of individuals with serious mental illness.
      These conclusions suggest that peer support services are a means to support recovery after treatment and to help people attain other goals, such as employment, education, housing, and social relations. Others have concluded that peer support can alter treatment patterns to reduce the cost of care.
      • Sledge W.H.
      • Lawless M.
      • Sells D.
      • Wieland M.
      • O’Connell M.J.
      • Davidson L.
      Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations.
      Peer interventions have been found to increase the use of primary care over emergency services,
      • Kelly E.
      • Fulginiti A.
      • Pahwa R.
      • Tallen L.
      • Duan L.
      • Brekke J.
      A pilot test of a peer navigator intervention for improving the health of individuals with serious mental illness.
      reduce psychiatric rehospitalizations,
      • Kelly E.
      • Fulginiti A.
      • Pahwa R.
      • Tallen L.
      • Duan L.
      • Brekke J.
      A pilot test of a peer navigator intervention for improving the health of individuals with serious mental illness.
      • Landers G.M.
      • Zhou M.
      An analysis of relationships among peer support, psychiatric hospitalization, and crisis stabilization.
      and make patients more active in treatment.
      • Sledge W.H.
      • Lawless M.
      • Sells D.
      • Wieland M.
      • O’Connell M.J.
      • Davidson L.
      Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations.
      Research studies of peer support in physical medicine indicate that peer support may be a cost-effective and cost-saving strategy for providing services for a chronic health condition.
      • Chinman M.
      • Oberman R.S.
      • Hanusa B.H.
      • et al.
      A cluster randomized trial of adding peer specialists to intensive case management teams in the Veterans Health Administration.

      Organizational Readiness: Hiring and Retention of Peer Workers

      Since the early 1990s when peers were hired to provide peer support in mental health programs, the field has been working to standardize the role through training and technical assistance to organizations hiring peer workers. One such effort was the development of core competencies. In 2015, SAMHSA led an effort to identify critical knowledge, skills, and abilities, leading to core competencies needed by anyone who provides peer support services to people with or in recovery from a mental health or substance use condition. SAMHSA via its Bringing Recovery Supports to Scale Technical Assistance Center Strategy initiative convened diverse stakeholders from the mental health and substance use recovery fields to achieve this goal.

      Core competencies for peer workers. Substance Abuse and Mental Health Services Administration website. www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/core-competencies.pdf. Updated November 19, 2015. Accessed July 9, 2017.

      In conjunction with subject matter experts, SAMHSA conducted an environmental scan and an inclusive process to identify 60 core competencies across 12 different categories for peer workers in behavioral health.

      Core competencies for peer workers. Substance Abuse and Mental Health Services Administration website. www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/core-competencies.pdf. Updated November 19, 2015. Accessed July 9, 2017.

      The goal is that these core competencies will inform peer training programs, job descriptions, performance reviews, and career development for peer workers.

      Training of Peer Workers

      Training programs and requirements for participation differ widely by state and organization in terms of the training’s structure and content. They also differ by the number of hours of training required (from 30 to more than 100) and the number of volunteer or work experience hours needed (none to more than 500).

      Pitt V, Lowe D. Hill S, et al. Consumer–providers of care for adult clients of statutory mental statutory mental health services. Cochrane Database Syst Rev. 2013;(3):CD004807. https://doi.org/10.1002/14651858.CD004807.pub2.

      In the training of mental health peer workers, many curricula are based on the curriculum from the Appalachian Consulting Group, which developed its training to be delivered in 24 one-hour sessions that cover topics ranging from ethics to problem solving.
      Peer specialist core recovery curriculum training. Appalachian Consulting Group website. http://acgpeersupport.com/services. Accessed July 9, 2017.
      For peer recovery coaches, many states and organizations have been using the Recovery Coach Academy training developed by the Connecticut Community for Addiction Recovery.

      Recovery coach academy. Center for Addiction Recovery Training website. http://addictionrecoverytraining.org/recovery-coach-academy. Accessed July 9, 2017.

      Beyond basic peer training required for certification, additional trainings have been created to prepare peers to develop advanced skills such as conducting groups or supervision, or specialized skills in topics such as supported employment, or focused on populations with co-occurring disorders or criminal justice involvement.

      Certification of Peer Workers

      Forty states now have a certification process in place for mental health peer support specialists, and 13 states have certification for substance use disorder peer recovery coaches.

      Pitt V, Lowe D. Hill S, et al. Consumer–providers of care for adult clients of statutory mental statutory mental health services. Cochrane Database Syst Rev. 2013;(3):CD004807. https://doi.org/10.1002/14651858.CD004807.pub2.

      These states have either created their own approved training and certification standards, or work with national training and certification organizations to establish peer support standards. As a part of the definition of a peer provider, certification often requires lived experience of mental illness or substance use disorder or both, and there are efforts to develop a national certification for peer workers. Currently, the Association for Addiction Professionals offers a Nationally Certified Peer Recovery Support Specialist certification that requires 125 hours of approved education, 1,000 hours of paid or volunteer work in the field, 1 year of recovery, and passage of the Nationally Certified Peer Recovery Support Specialist exam.

      Nationally Certified Peer Recovery Support Specialist. National Association for Addiction Professionals website. www.naadac.org/ncprss. Accessed July 9, 2017.

      Mental Health America has collaborated with the Florida Certification Board to develop a national certification for peer support specialists. This national certification is intended for peers who have at least 12 months’ experience as a peer specialist and have completed training in topics related to whole health, trauma-informed care, and adult learning.

      Mental Health America. Nationally Certified Peer Specialists Core Competencies: Draft for public comment. https://cabhp.asu.edu/sites/default/files/mha-national_peer_draft_core_competencies.pdf. Accessed June 23, 2017.

      The certification enables peer support specialists to move throughout the U.S. without needing to be recertified in different states. The National Federation of Families for Children’s Mental Health provides the only National Certification for Parent Family Peers. National Federation of Families for Children’s Mental Health is responsible for providing oversight to the development and administration of the Certified Parent Support Provider certification. The credential was designed to meet the standards of ethical and professional practice for parent support services and the proficiency and competency of parent support providers. Certification promotes ethical practice and creates mobility of workers across states. It brings to the workforce parents with experience in successfully helping their own children.
      • Stroul B.
      • Walker J.
      • Kallal J.
      • Harris R.
      Becoming a Medicaid Provider of Peer Support: A Guide for Family-Run Organizations.

      Job Satisfaction and Career Advancement

      Generally, peer support workers report high satisfaction with their job duties and work environments.
      • Chang B.H.
      • Mueller L.
      • Resnick S.G.
      • Osatuke K.
      • Eisen S.V.
      Job satisfaction of Department of Veterans Affairs peer mental health providers.
      • Cronise R.
      • Teixeira C.
      • Rogers E.S.
      • Harrington S.
      The peer support workforce: results of a national survey.
      However, challenges exist for peer workers, other providers, and behavioral health organizations as they move toward peer-integrated workforces.
      • Myrick K.
      • Del Vecchio P.
      Peer support services in the behavioral healthcare workforce: state of the field.

      Core competencies for peer workers. Substance Abuse and Mental Health Services Administration website. www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/core-competencies.pdf. Updated November 19, 2015. Accessed July 9, 2017.

      Nationally Certified Peer Recovery Support Specialist. National Association for Addiction Professionals website. www.naadac.org/ncprss. Accessed July 9, 2017.

      Peer support specialists sometimes report experiencing prejudice from other staff with respect to being included in work and social activities.
      • Cronise R.
      • Teixeira C.
      • Rogers E.S.
      • Harrington S.
      The peer support workforce: results of a national survey.
      Role conflict and ambiguity are seen as ongoing challenges.
      • Cronise R.
      • Teixeira C.
      • Rogers E.S.
      • Harrington S.
      The peer support workforce: results of a national survey.
      • Kuhn W.
      • Bellinger J.
      • Stevens-Manser S.
      • Kaufman L.
      Integration of peer specialists working in mental health service settings.
      • Moran G.S.
      • Russinova Z.
      • Gidugu V.
      • Gagne C.
      Challenges experienced by paid peer providers in mental health recovery: a qualitative study.
      Often, a lack of clear job descriptions and the resulting role confusion has led to uncertainty about how much of their lived experience to share.
      • Moran G.S.
      • Russinova Z.
      • Gidugu V.
      • Gagne C.
      Challenges experienced by paid peer providers in mental health recovery: a qualitative study.
      • Hamilton A.B.
      • Chinman M.
      • Cohen A.N.
      • Oberman R.S.
      • Young A.S.
      Implementation of consumer providers into mental health intensive case management teams.
      • Gates L.B.
      • Mandiberg J.M.
      • Akabas S.H.
      Building capacity in social service agencies to employ peer providers.
      • Alberta A.J.
      • Ploski R.R.
      • Carlson S.L.
      Addressing challenges to providing peer-based recovery support.
      • Hardin P.
      • Padron J.
      • Mandersheid R.
      A major source of job dissatisfaction remains the relatively low wages paid to peer workers.
      • Cronise R.
      • Teixeira C.
      • Rogers E.S.
      • Harrington S.
      The peer support workforce: results of a national survey.
      Currently, very few behavioral health organizations provide peer workers with opportunities for career advancement. A white paper titled “U.S. Peer Leadership and Workforce Development” presented a hypothetical career track that involved continuing education and entering professional healthcare provider roles.
      • Gates L.B.
      • Akabas S.H.
      Developing strategies to integrate peer providers into the staff of mental health agencies.

      Workplace Integration

      The employment and integration of peer providers into treatment-based care teams has led to a shift in care team structures, which has brought about transitional challenges as organizations strive to incorporate individuals with lived experience into a professional role. It is in these more traditional employment settings where friction may occur between a recovery-oriented model of care and the traditional treatment–oriented model.
      Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment for the Partners for Recovery Initiative under Subcontract No. 22774, CSAT Prime Contract No. HHSS283200700008I, Task Order No. HHSS28300002T.
      Organizations are encouraged to assess their mission, policies, practices, attitudes, and beliefs about recovery and program culture to ascertain their readiness to integrate peer workers. Table 2 lists characteristics of organizations that support the integration of peer workers into their workforce.
      Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment for the Partners for Recovery Initiative under Subcontract No. 22774, CSAT Prime Contract No. HHSS283200700008I, Task Order No. HHSS28300002T.
      Table 2Organizational Characteristics Indicating Readiness to Hire Peer Workers
      Characteristics
      Organizational values
      • A recovery-oriented mission
      • Defined peer roles that are permanent with secure funding
      • Clear job descriptions for peer workers
      • Equitable wages and benefits packages for peer workers
      Policies and practices
      • Policies and practices align with recovery-oriented values
      • Clear confidentiality policies and practices
      • Clear policies regarding relationships and personal boundaries
      • Inclusive hiring policies and practice
      • Policies that ensure regular communication among staff members
      • Policies that ensure routine performance evaluations that reflect the peer worker’s role
      Staff knowledge and attitudes
      • Staff believe that recovery is possible
      • Staff is knowledgeable about the benefits of peer support
      • Staff continue to develop their knowledge and understanding of peer support
      • Staff address their own prejudices about people with behavioral health conditions
      Supervision and support
      • Organization ensures the provision of regular supervision
      • Supervision is recovery-oriented and trauma-informed
      • Supervisors know how to use reasonable accommodations for colleagues with disabilities

      Funding of Peer Support Services

      Funding of peer recovery support services may be complex, and often requires braiding diverse sources of funding together to create robust peer support services. Initially, block grants provided by SAMHSA to states supplied funding for peer support services, but states have begun to diversify their funding sources.
      • Kaufman L.
      • Brooks W.
      • Bellinger J.
      • Steinley-Bumgarner M.
      • Stevens-Manser S.
      Peer Specialist Training and Certification Programs: A National Overview—2014 Update.
      Increasingly, Medicaid has become a funding source for peer support services, especially within mental health services. As of 2014, there were 36 states that billed Medicaid for mental health peer support services, and at least 11 states that could bill for peer support in substance use disorders or co-occurring conditions. The authority to bill Medicaid for peer support, along with the legislative mandates for mental health parity, may significantly improve prospects for peer provider employment.
      • Kaufman L.
      • Brooks W.
      • Bellinger J.
      • Steinley-Bumgarner M.
      • Stevens-Manser S.
      Peer Specialist Training and Certification Programs: A National Overview—2014 Update.
      • Belnap D.
      • de la Gueronniere G.
      Financing Recovery Support Services: Review and Analysis of Funding Recovery Support Services and Policy Recommendations.
      The current extent of Medicaid billing for peer support services is unknown; however, some organizations that could bill do not because of ideologic and technical reasons.
      • Belnap D.
      • de la Gueronniere G.
      Financing Recovery Support Services: Review and Analysis of Funding Recovery Support Services and Policy Recommendations.
      • Ostrow L.
      • Steinwachs D.
      • Leaf P.
      • Naeger S.
      Medicaid reimbursement of mental health peer-run organizations: results of a national survey.
      In addition to block grants, SAMHSA provides funding opportunities, such as Access to Recovery grants and the Recovery Community Services Program. Several states have funded peer support services through Temporary Assistance to Needy Families.
      • Belnap D.
      • de la Gueronniere G.
      Financing Recovery Support Services: Review and Analysis of Funding Recovery Support Services and Policy Recommendations.
      Depending on the location of the peer recovery support services, other funding sources may be available. For example, peer support services delivered in drug or other specialty courts might be funded through SAMHSA, state, or U.S. Department of Justice drug court funds.
      • Kaufman L.
      • Brooks W.
      • Bellinger J.
      • Steinley-Bumgarner M.
      • Stevens-Manser S.
      Peer Specialist Training and Certification Programs: A National Overview—2014 Update.

      Future Directions in Peer Support

      The behavioral and integrated health workforce exists in a rapidly changing healthcare environment that presents challenges and opportunities for the expansion of peer support services. Peers are trained in evidence-based interventions and an investment in research is needed to demonstrate evidence-based outcomes with the rigor of evidence-based practices. Many peer workers have been utilized in family psychoeducation within first episode psychosis as family peers or parent partners. Other new roles, such as community health workers, peer wellness coaches, peer whole health coaches, and peer navigators, are also promising opportunities to expand the peer workforce, address workforce shortages, and affect the outcomes of people with behavioral health conditions, including those who also experience complex physical health conditions. These new roles, coupled with expanded access to trained peer specialists across systems, should increase access to recovery-promoting services for individuals with behavioral health conditions and their families. The workforce should also include increased roles, training, certification, and reimbursement for family peers, and reimbursement of recovery coaches. Such practices would bring about increased use and reimbursement for all peer roles in commercial plans and use in employee assistance programs. Increasingly, people will understand the value and unique contributions that peer specialist programs bring to recovery-oriented services.

      Acknowledgments

      This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by the Substance Abuse and Mental Health Services Administration, Health Resources and Services Administration, U.S. Department of Health and Human Services or the U.S. Government.
      No financial disclosures were reported by the authors of this paper.

      Supplement Note

      This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under U81HP29300-03-02, Behavioral Health Workforce Research Center.

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