Peer Providers in Behavioral Health: Best Practices and Challenges from Four Leading States UCSF Joanne Spetz, Susan Chapman, Lisel Blash, Krista Chan California Institute for Behavioral Health Solutions Kimberly Mayer, Victor Kogler January 25, 2017

What is a peer provider? “A person who uses his or her lived experience of recovery from mental illness and/or addiction, plus skills learned in formal training, to deliver services in behavioral health settings to promote mind-body recovery and resilience.” (Kaplan, SAMHSA, 2008)

Key Research Questions How have states have implemented CMS-approved billing for peer providers in MH and SA? What are the models of care in states with successful practices in peer provider employment in MH and SA? What are the specific roles and functions of the peer provider in MH and SA care teams? What are the skills and training required of peer providers? How do training and certification requirements vary across states? What is the impact of implementing peer provided services on the roles and responsibilities of other members of the healthcare team? How accepted are MH and SA peer providers by other members of the healthcare team? How does the implementation of peer provided services impact the level of service integration?

Methods Landscape analysis of related literature National panel of experts convened in Feb 2015 Identified 4 states: Arizona (MH), Georgia (MH, SUD), Texas (MH, SUD), Pennsylvania (MH, SUD) Identified best practice organizations through snowball sampling Site visits of 3-5 days to each state Interviewed state government reps, management and staff at a variety of organizations Peer-led, traditional BH, for-profit, non profit

Findings: Landscape Analysis Job titles vary Outreach specialist Telephone support specialist Peer educator Resident counselor Forensic peer specialist Peer evaluator Employment/job coach Peer navigator Peer whole health and wellness coach

Findings: Landscape Analysis Peer providers work in a variety of settings Peer-run organizations - non-clinical rehabilitation and recovery Traditional care settings- MH clinics, detox centers, psychiatric hospitals Increasingly in forensic settings and primary care settings Training and Certification Hours, curriculum, certification vary widely by state A few commonly used curriculums (Appalachian, CCAR, etc.)

Map of training and certification for mental health peer provider services

Findings: Landscape Analysis Evidence of efficacy Less hospitalization, higher medication adherence Much research lacks rigor and longitudinal data Challenges in peer provider services Acceptance from non-peer colleagues Stigma of lived experience Friction between traditional and recovery-oriented models

Findings: Landscape Analysis Policy and Financial Infrastructure 2007 CMS ruling authorized Medicaid billing; 36 states allow MH billing, fewer allow SUD billing Other funding: state and county funding, block grants

Map of Medicaid billing for Mental Health Peer Support

Case Study Sites Arizona 3 provider and training organizations; Department of Health Services (DHS), Division of Behavioral Health Services Pennsylvania 4 MH and 2 SUD provider organizations; 1 SUD certification board; 1 SUD training and advocacy organization; Office of Mental Health and Substance Abuse Services (OMHSAS) Georgia 1 MH provider, advocacy, and training organization; 1 MH provider organization; 1 SUD advocacy and training organization; 1 SUD provider organization; 3 community service boards (both MH and SUD); Department of Behavioral Health and Developmental Disabilities Texas 3 MH provider organizations; 1 MH training and certification organization; 2 SUD provider organizations; 1 SUD certification board; Department of State Health Services (DSHS)

Findings: Case Studies (AZ, PA, GA, TX) Policy environment Medicaid billing authorization key to sustainable funding In GA and AZ, class action lawsuits expanded behavioral health access & use of peers Some states and programs mandate use of peers Training and Certification Statewide training and certification required for billing Number of training organizations varies MH and SUD trainings and certifications are often separate Documentation for billing commonly cited as training challenge Growth is other certification; e.g., Whole Health Coach

Findings: Case Studies Funding Importance of Medicaid varied 2 states were expansion states under ACA SUD peer services often less billable than MH Ideological and infrastructure challenges to billing Employment Little consistent data available on employment numbers, settings Workforce and funding shortages drive demand for peers Low wages and little opportunity for career growth Workplace accommodations beneficial for retention

Findings: Case Studies Roles Growing number of roles and organizations using peers: Peer run, traditional BH, community based, housing, forensic, crisis centers Can work individually or with licensed providers in MH, SUD, or co-occurring disorders Commonly work off-site in the community Supervisor relationship important to peers’ acceptance

State Highlights: AZ Developed training standards for any agency to certify peers and bill Medicaid, whether in MH or SUD PA A large number of MH peers working in innovative settings SUD peers more concentrated in regions with funding GA MH and SUD certifications are separate, but DBHDD works closely with both 2 peers per agency is a requirement Developed a Medicaid billable whole health training TX Use of MH peers in state hospital and Local Mental Health Authorities (LMHAs) Like PA, SUD peers have been reliant on funding other than Medicaid

Summary Report Training and Certification Required for Medicaid billing States vary from single trainer and curriculum to multiple vendors Certification primarily state based States vary in whether MH and SUD certification combined or separate Growth is other certification; e.g., Whole Health Coach

Summary Report Employment Few states track level of employment after training Work is often part time; low wages Reentry into workforce important component to recovery Roles and Settings Peers employed in an increasing number of roles and settings Peers are central component of the recovery model Acceptance from professional workforce varies

Summary Report Billing and Funding Medicaid reimbursement a key factor in growth and development of peer provider role Medicaid billing greater for MH than SUD Medicaid expansion states have increased share of revenue from Medicaid billing Other sources of funding; state and county funding, block grants, other grants Funding decisions may be at state, regional, or county level

Summary Report: Policy Implications Training should be standardized to assure quality and allow mobility Employment data needed to better assess supply and demand More research needed on efficacy and outcomes Need for career advancement opportunities and sustainable wages Workplace accommodations essential for employees in recovery Coordination between MH and SUD trainings to address co- occurring disorders Billing requirements should not undermine a recovery-oriented model

Next steps for California California Consortium of Addiction Programs and Professionals (CCAPP) has been approved by IC&RC to begin issuing certifications for Peer Recovery Specialists SB 614 would have established MH certification but was “gut and replaced” DHCS has been reluctant to put peers in the state Medi-Cal plan Advocates are working on new legislation

New study funded by CHCF Susan Chapman – Principal Investigator Peer support in California for transitions of care Incarceration to the community Hospitalization to the community Updated literature review Fast-growing profession Lack of consensus on core components of the role or core competencies needed 41 states have training and certification Variation in quality, content, and rigor of training programs Evidence suggests better client outcomes but not definitive