1. 4th ANNUAL ADDICTIONS & MENTAL HEALTH CONFERENCE Person Centre Care....Walking The Talk Mississauga Halton LHIN Enhancing & Sustaining Peer Support Initiative Mon May 30 th 3-4:30 PM MC1 Real People. Real Lives. Inspired Growth. TOGETHER

2. Presenters: Debbie Jones is the Director for TEACH, a peer initiative of Support & Housing-Halton. Debbie has more than 20 years of experience working in health care research and community-based organizations. Debbie brings the rich textures of her lived experience to her work. Betty-Lou Kristy is the Substance Use Systems Lead for the Sustaining Peer Support Initiative. A bereaved mother, in recovery for 17 years, Betty- Lou has been engaged at provincial systems level as a "lived experience/family" advocate helping to frame policy, governance & programming. Christina Jabalee is the Peer Support System s Lead for the Sustaining Peer Support Initiative in the MH LHIN. She has been a TEACH staff member since 2013 & previously worked with the Schizophrenia Society of Ontario for several years in family work. Christina draws her passion to support positive change in health care from her lived experience & her degree in social work. Presenters: Debbie Jones is the Director for TEACH, a peer initiative of Support & Housing-Halton. Debbie has more than 20 years of experience working in health care research and community-based organizations. Debbie brings the rich textures of her lived experience to her work. Betty-Lou Kristy is the Substance Use Systems Lead for the Sustaining Peer Support Initiative. A bereaved mother, in recovery for 17 years, Betty- Lou has been engaged at provincial systems level as a "lived experience/family" advocate helping to frame policy, governance & programming. Christina Jabalee is the Peer Support System s Lead for the Sustaining Peer Support Initiative in the MH LHIN. She has been a TEACH staff member since 2013 & previously worked with the Schizophrenia Society of Ontario for several years in family work. Christina draws her passion to support positive change in health care from her lived experience & her degree in social work.

3. Laying the Foundation

5. 5 What is peer support work?

6. Peer support is… “Peer support is a naturally occurring, mutually beneficial support process, where people who share a common experience meet as equals, sharing strengths and hope, allowing people to learn ways of coping from each other. Formalized peer support begins when persons with lived experience, who have received specialized training, assume unique designated roles…to support an individual’s expressed wishes.” Source: Addictions and Mental Health Ontario’s, Best Practices in Peer Support “Peer support is not scripted. It does not follow steps. It is about relationships. It comes from the heart through insight and knowledge gained from experience.” Source: Mental Health Commission of Canada, Guidelines for the Practice and Training of Peer Support.

7. What & Who is TEACH? TEACH is the LHIN recognized “Consumer Survivor Initiative” for Mississauga, Halton and South Etobicoke. Established in 1999, TEACH is the peer support initiative for Support & Housing – Halton

8. TEACH programs and activities have been developed using an evidence-based approach steeped in evaluation and research. Self Esteem Workshop Anxiety Management Workshop Evolution Concurrent Disorders Group CheckPoint Weekly Drop-In Group Core Skill Peer Support Training ElderTalk Older Adults Group Circle of Care Family Supports Just Be You Youth Drop-In Group Peer Outreach Support Services & Education (POSSE); youth program offers social justice/human rights & harm reduction Feeling Like Youth (FLY) trains youth to be peer support/mentors TEACH Core Skills Training is recognized as the regional peer support training for volunteers and paid employees across the Mississauga Halton LHIN mental health and addictions system

9. In 2012, TEACH published a report on Best Practices in Peer Support & Recovery. The report examined evidence based approaches to peer support and recommended that research and evaluation in peer support should engage the approaches of Social Sciences rather than Medicine to collect evidence and determine evolving best practices. A greater focus on qualitative methods, participatory research and engagement of people with lived experience to determine emerging best practices. Through its leadership in peer support best practices, the MH LHIN identified TEACH to lead the Sustaining Peer Support Initiative and provided the resources to hire two systems leads to spearhead the initiative.

10. “We are at a pivotal moment in time—and have perhaps a once in a lifetime opportunity—to seize the experience, the wisdom, the success, the learning, the passion of all those years and make them truly count, to capture the essence of peer support and help transform the mental health system in ways we’re yet to discover. More importantly, one day soon, every person who struggles with mental ill–health (and/or substance use) will have someone in their life who ‘gets it’… a peer support worker.” Karen Liberman, Mental Health Advisor and former Executive Director, Mood Disorders of Ontario Source: Mental Health Commission of Canada, Guidelines for the Practice and Training of Peer work

11. Where did the funding come from for all these new positions? “The Mississauga Halton LHIN’s System Integration Group for Mental Health and Addictions (SIGMHA) has identified Peer Supports as number one in its identified service needs ranking priorities for mental health and addictions for fiscal year 2014- 2015”. – Ed Castro, MH LHIN. SIGMHA’s membership includes the Executive Directors/Chief Executive Officers and Clinical Directors/Managers of all the MH LHIN Mental Health & Addictions funded agencies, hospitals and some non-LHIN funded agencies. When new permanent funding for Substance Use and Mental Health came from the Ministry of Health and Long Term Care, the LHIN & SIGMHA identified two streams of peer support. The Enhancing and Sustaining Peer Support Initiatives in the Mississauga Halton region. Eleven mental health and addiction health service providers within the LHIN received funding for 38 newly created peer support positions. As part of the Sustaining Peer Support Initiative, the LHIN provided funding to hire a Peer Support Systems Lead and a Substance Use Systems Lead to help build the infrastructure and bridge the many stakeholders affected by this initiative.

12. 12 How we got grounded

13. Punjabi Community Health Services

14. Types of Peer Support Roles Best Practices in Peer Support - Final Report AMHO As this workforce develops there is a greater need to create new roles and define the boundaries between them. The peer support roles include but are not limited to: Peer support workers who provide support for personal and social recovery to people with mental health and/or substance use problems, including in acute mental health services, housing, supported employment, community support and so on. Peer advocates who empower individuals or groups of people with mental health and/or substance use problems to advocate for their rights and needs on a range of issues in a variety of settings. Peer educators who provide education from a lived experience perspective for other peers, mental health and/or addiction workers or community members. Peer navigators who assist people to find, choose and gain access to a full range of community resources, networks and services. Peer advisors who work in partnership with mental health service providers to give lived experience/family perspectives at all levels of planning, implementation and evaluation, and provide feedback to service users. Peer researchers and evaluators who use lived experience knowledge and participatory processes to inform their work. Peer managers who lead services.

15. 6 Core Competencies- AMHO Core Competencies Peer Support Work in Addictions The committee identified the following six core competencies: Self-Assessment/Self-Evaluation - The ability to complete a self-assessment and/or annual self- evaluation using competencies in order to identify potential areas for training and development. Interpersonal skills - The ability to demonstrate intentional listening skills, the ability to engage peers, the ability to demonstrate intentional sharing and the ability to demonstrate how to encourage others to take the necessary steps forward. Working with changes and transitions - The ability to demonstrate support for transitions and the ability to demonstrate support to overcome transitions. Supervision - the ability to work with supervision provided by an organization and/or evaluations provided by a sponsoring agency. Personal Development and Learning - the ability to develop and demonstrate a variety of skills for personal development and learning to include but not limited to compassion fatigue, boundary training, confidentiality, role definition, how to be objective, personal safety and nonviolent crisis intervention. Access to information tool kit with current information - the ability to access and utilize resources that are provincial, regional based and or interactive material from the Internet.

16. For sustainability we must stay true to: Values that Define Peer Support Hope and Recovery Self-Determination Empathetic and equal relationships Health and wellness Dignity, respect and social inclusion Integrity, authenticity and trust Lifelong learning and personal growth Guidelines for the Practice and Training of Peer Support; Mental Health Commission of Canada (Dec 2013)

17. What have we done so far? Peer Position Network Peer Position Supervisor’s Network Job Fairs/Charity Village Job Searchers workshops Hire peers Guidelines and workshop FAQ Local and provincial partnerships/relationships Trainings (Core Skills and PS4PS) Our Beautiful Minds annual knowledge transfer event

18. Some of the Topics Covered in the 2 Day Core Skills Peer Support Training Getting Grounded: Discussing Peer Work Locally, Provincially, Nationally & Globally within the Mental Health and Substance Use Systems Peer Guidelines and Principles Recovery Philosophy, Harm Reduction Philosophy Overview: Substance Use, Addictions, Mental health, Mental illness, Navigating the Systems Advocacy Highlighting Group Facilitation Skills Finding Your Place on the Team Boundaries and Limitations Diversity and Inclusion and Personal Bias Beginning, Sustaining and Ending Relationships- Your Role in Their Journey How to Stay Grounded to the Foundation of Peer Work Your Recovery and Wellness, Self-Care and Minimizing Compassion Fatigue Networking!

21. “Define the Role Of Peer Support?” Elevator Speech (27 peers from Paid Peer Network) Peer support enhances already existing services by further humanizing the system through positive illustration of lived experience, by walking with a person we encourage them to see hope and build trust as they continue their journey. Peer support enhances existing services bringing a safe, non-judgmental environment through a shared bond. Peer mentors are people who support personal experience, non-clinical and field based. They can also provide safety nets, coaching and a focus on life skills. Peer mentors offer, hope, respect and validation. We walk with you through your ups and downs. Peers work across the spectrum of mental health and addictions. A peer worker is qualified by lived experience to act as a navigator and is dedicated to guiding individuals in their recovery. As an equal, they provide hope, empowerment and connection through support and understanding.

22. What are the initial findings? Emerging Themes

23. What are the initial findings The need to increase/create substance use & addiction capacity within formalized peer support The need for meaningful input from lived experience, family members (carers) to help shape evaluation, assessment tools & methodologies There was a lack of awareness, support and knowledge exchange among current supervisors and peers in the region so networks were formed to support this AND the development of a Community of Practice.

24. What are the initial findings? (Continues) Issues brought forward by the Peer Support Workers’ Supervisors focused on HR, legal, and policy and procedures - How to address for newly developed peer support positions within their agencies: Through discussion at the Supervisors’ network, participants found that the solutions could be found among existing HR policies, agency policies and procedures, accreditation or through the human rights code, professional associations such as the College of Social Workers, etc A focus on all staff wellness not just peer support workers (National standards on psychological health& safety in the workplace)

25. Issues brought forward by the Peer Workers focused on the integration of peer workers into settings that follow a medical model approach to care. Through discussion at the peer workers’ network, it was determined that these issues are best resolved by going back to peer support values. Values such as Hope and Recovery, Empathetic and Equal relationships, Self Determination, Dignity, Respect and Social Inclusion, Integrity and Authenticity, etc. By ensuring that peer workers are grounded in these values, their roles have become clearer. What are the initial Findings (Continues)

26. Network(s) Prioritized Emerging Themes Compared Members of each network (paid peer network) (supervisors network) were asked; “Please rank the following topics in order of where you need the most support /focus right now.” Then it was collated to provide this preliminary comparison. Network(s) Prioritized Emerging Themes Compared Members of each network (paid peer network) (supervisors network) were asked; “Please rank the following topics in order of where you need the most support /focus right now.” Then it was collated to provide this preliminary comparison. Paid Peer Network Emerging Themes Listed in Order of Priority Education/training /social /networking Define peer work, role, elevator speech Documentation- same as co-workers? Mediator role/advocate with work team Manage work triggers How to start up brand new program Maintain personal recovery plan Workplace support self-care Tension medical model vs recovery model Dual relationships (peer was a client) Need for validation How/when self-disclosure Outed by title Paid Peer Supervisors Network Emerging Themes Listed in Order of Priority Human Resources/Legal Issues Define peer work and role Support peer to define work and program Common peer trainings Organizational culture shift Increase non-peer staff knowledge re: Peers Peers involved & have a voice Peers self-care Relief pool for vacancies or leave of absence Coverage for peer on a hiring panel Team Info sharing Peers treated equal

27. Investigating The State of Peer Support Work in Ontario: Findings and Implications Ontario Peer Development Initiative and The Self-Help Alliance November 2014 Prepared by : Taylor Newberry Consulting Challenges: Having unclear role expectations, not being involved in decision-making Lack of clarity with other staff about peer role, feeling power imbalances with non- peer staff Difficult to maintain appropriate boundaries while focusing on building rapport and balancing professionalism Fear of judgment, job security and income, if peers have to use accommodation options Contemporary peer support is highly similar and often mirrors the functions of other support workers. Emerging Themes from Provincial Literature

28. Continuing: Emerging Themes from Provincial Literature Peers want more frequent supervision and feedback to understand their performance. Need supervision from a peer too. Peer workers could benefit from mentoring each other Top 5 peers trainings wanted from peers: Conflict resolution, relationships and boundaries, mental health, managing challenging situations, understanding differences and diversity Beyond lived experience workers felt employers were looking for strong interpersonal skills such as active listening, compassion, flexibility and empathy. Also, ASIST, First Aid, CPR, NVCI, WRAP, PREFER and OPDI Core Essentials Role clarity will improve over-time if there is a commitment to integration of peer roles and staff education and awareness and Co-workers and the system in general need greater education and awareness around job roles of peer support positions Investigating the State of Peer Support Work in Ontario: Findings and Implications Ontario Peer Development Initiative and The Self-Help Alliance November 2014 Prepared by : Taylor Newberry Consulting

29. Emerging Themes from International Literature Peer Support in Mental Health and Addictions: A Background Paper Prepared by Mary O-Hagan for Kites Trust May 2011 New Zealand Unresolved issues and challenges in peer work: Definitional Issues- friendship vs. peer, boundaries How to manage the tensions between peer values and the values played out in the mental health system and stay true to peer support Attitudes and Culture- longstanding marginalization and inequality- can create lower expectations of peer initiatives.

30. Continuing: Emerging Themes from International Literature The need to be regarded as “equal but different” Rationale for placing peers in mainstream service is so they will help bring about culture change Lack of professional development opportunities for most peers. Emphasis in mainstream trainings can be quite different from peer work Poorly fitting mainstream organizational structures, the need to improve the preparations and training of existing staff * There is no study thus far that compares peers to their co-workers perception of work environment in many of these areas

31. The Enhancing and Sustaining Peer Support Initiative is innovative and transitional; moving towards the co- production of a dignified, welcoming and recovery focused model of care with emphasis on the human dynamic, resiliency, empowerment, mentorship and non-punitive qualifiers and judgements. Transformation of the health care system is complex and dynamic.

32. Taking the time to do it right! We have put together a team that includes LHIN leads, the system leads, a consultant and others to research, explore and identify different methodologies and tools that will ensure the process is strongly routed in the values of peer work in order to build a sustainable and applicable foundation. In many instances the clinical/medical models for governance, data collection, outcome measurements, work plans and project charters are not an ideal fit nor do they speak to the true organic value and intention of peer work. “There is a need to build methodologies and outcome measures consistent with peer support values of empowerment, participation, recovery and hope” Peer support in Mental Health and Addictions: A Background Paper. Prepared by Mary O’Hagan for Kites Trust May 2011

33. Making the links Building the relationships

34. We have our fingers in all the pies..........beyond multi- tasking Linking Regionally, Provincially, National & Internationally Explorations, Connections, Relationship Building & Alignments

35. Identifying & Mapping: How we are working together......

36. More Identifying & Mapping: How we are working together......

38. Underpinning the process

39. Project Charter, Work plan, Timelines, Indicators and Outcome Measurements This project is innovative and emergent. It is occurring in a complex system. It is also social change and system change. The evaluation of the Sustaining Peer Support Initiative Project needs, therefore, to reflect both the project’s need for Developmental Evaluation and the funder’s need for reporting on some predetermined outcomes. This project is innovative and emergent. It is occurring in a complex system. It is also social change and system change. The evaluation of the Sustaining Peer Support Initiative Project needs, therefore, to reflect both the project’s need for Developmental Evaluation and the funder’s need for reporting on some predetermined outcomes.

40. CHARTER This Charter is intended to help guide stakeholders with expectations, risk/mitigation and roles and responsibilities throughout the project life cycle of the Sustaining Peer Support Initiative, a project funded by the Mississauga Halton Local Health Integration Network (LHIN). Purpose of the Sustaining Peer Support Initiative : The Sustaining Peer Support Initiative will support the overall vision of the MH LHIN for optimal health care through the following: Enhanced capacities of, supports to and empowerment of people with lived experience and families; A more coordinated and integrated mental health and addiction system of support; The recognition and integration of peer supports as a viable and valued part of addiction and mental health treatment and recovery, and; Enhanced local networks of peer support and improved connection to other regional, provincial and national network initiatives and systems.

41. The work of the Initiative will be guided by four key values At all times we will value The voice of People with Lived Experience and their Families When we make decisions, the perspective of People with Lived Experience and their families will be the primary lens through which we will evaluate options

42. Key values Continued…. At all times we will value Inclusion and diversity We will develop and support relationships that promote equity and diversity, and that honour each individual’s option to choose his/her recovery journey. We will encourage the involvement of our colleagues in all of our initiatives.

43. Key values Continued… At all times we will value Moving toward clarity As a ground-breaking initiative, we recognize and appreciate the need to function and succeed in an environment that creates a great deal of ambiguity and uncertainty. While challenging to navigate, these situations can represent excellent opportunities for us to build, create a new reality using and creating evidence based decision making for peer support in the Mississauga Halton LHIN region and beyond. We will make every effort to communicate clearly with our stakeholders about our situation, our aspirations and goals.

44. Key values Continued… At all times we will value Transparency In order for this Initiative to be successful, in collaboration with a diverse set of stakeholders, we will make every effort to be transparent. This transparency will extend in all directions, to all stakeholders and to the larger community that will, as the mental health and addictions system starts to transform, become transformed itself.

45. 45 What do you think are potential challenges to evaluating this initiative?

46. Methodologies, Evaluation & Governance Identified Constellation Collaboration Governance Model What is it? The Constellation Model of Collaborative Governance is a complexity-inspired framework designed to 'hold' collaborations within dynamic systems. It supports multi-organization partnerships and networks within complex systems. The Constellation Model is a strategy for pursuing social change in a dynamic universe and there is a transferable 'essence' of the model when it needs to be adapted. Theory of Change What is it? A theory of change (TOC) is the product of a series of critical-thinking exercises that provides a comprehensive picture of the early- and intermediate-term changes in a given community that are needed to reach a long-term goal articulated by the stakeholders. It is a tool for developing solutions to complex social problems by conducting “backwards mapping” to identify the preconditions necessary to achieve that goal. Developmental Evaluation Model What is it? Developmental Evaluation supports innovation development to guide adaptation to emergent and dynamic realities in complex environments. Innovations can take the form of organizational changes, policy reforms, and system interventions.

47. Sustaining Peer Support Initiative Evaluation Framework Overall Approach is Developmental Evaluation (DE) Developmental evaluation assumes that the evaluation questions will change over time as part of the adaptive learning cycle Types of Questions Posed (list is not exhaustive): What is developing or emerging as the innovation takes shape? What variations in effects are we seeing? What do the initial results reveal about expected progress? What seems to be working and not working? What elements merit more attention or changes? How is the larger system or environment responding to the innovation? How should the innovation be adapted in response to changing circumstances? How can the project adapt to the context in ways that are within the project’s control?

48. Evaluation Framework Continues… Year 1: Formative Evaluation Year 1 will be framed as a formative evaluation, focused on: Describing what has happened on the project to date Identifying the emergent outcomes the project is seeing Identifying what is going well and what could be improved Establishing some foundational methodologies / measurement instruments to be refined and modified as required in Years 2 and 3 Establishing baseline data against which future evaluations can be conducted, some of which will serve as project evaluation metrics Year 1: Formative Evaluation Year 1 will be framed as a formative evaluation, focused on: Describing what has happened on the project to date Identifying the emergent outcomes the project is seeing Identifying what is going well and what could be improved Establishing some foundational methodologies / measurement instruments to be refined and modified as required in Years 2 and 3 Establishing baseline data against which future evaluations can be conducted, some of which will serve as project evaluation metrics The evaluation will examine 6 spheres of impact (similar to an ecological model) – see next slide: 1.People receiving services 2. Peer Support Workers 3. Peer Support Supervisors 4.Agencies providing peer support 5.Mississauga Halton Mental Health and Addictions Systems 6. Regional, Provincial, National Mental Health and Addictions Groups/Initiatives The evaluation will examine 6 spheres of impact (similar to an ecological model) – see next slide: 1.People receiving services 2. Peer Support Workers 3. Peer Support Supervisors 4.Agencies providing peer support 5.Mississauga Halton Mental Health and Addictions Systems 6. Regional, Provincial, National Mental Health and Addictions Groups/Initiatives

49. Provincial and National Mental Health and Addiction Groups / Initiatives Individual with lived experience Mississauga Halton LHIN Mental Health and Addiction System Individual with lived experience Agencies Providing Peer Support-HSPs Individual with lived experience Peer Support Supervisors Peer Support Worker Peer Support Workers People Receiving Services Spheres of Initiative Influence/Impact Evaluation Framework Continues…

50. Stewardship Group (Leaders, experts & champions in peer support) Peer Support Supervisor Network Peer Support Worker Network Peer Support Systems Lead / Addiction Lens System Lead SIGMHA MH LHIN Formal Organizational and Institutional Sector Formal Organizational and Institutional Sector Dynamic and Complex Constellations ____ Communication ------- Accountability

51. Person Receiving Service: “I felt so alone and I wanted so badly to connect with someone who knew what I was going through. I was lucky to meet a peer mentor with X agency, during my recovery. At the time, recovery still seemed too good to be true and there was always the fear of relapse or that I was deceiving myself by thinking I was better. When I met the peer, my faith in recovery was sealed. She is kind, understanding and supportive. She always seems to understand where I am at--regardless of the stage I am in--and has been able to provide me with helpful insights, that I haven't been able to get from my psychiatrist or my counsellor.”

52. Peer Worker “I have been struggling with a concurrent disorder for most of my adult life. It is wonderful to be part of the recent growth, open acknowledgment, peer educational opportunities and most important for recognition of the connection between mental health and addiction in our region. “ Person Receiving Service : “I was told to ‘google’ my issues from another organization. You helped provide me the compassion and the compass I was looking for.” Supervisor: “ The medical team initially was hesitant to engage the role of peers. Now the psychiatrist wants the peer in the room with them for most appointments”. Agency E.D. : "Our Peer Mentor program has created a positive change in the organizational culture of our agency as a result of having the perspective of our Peer Mentors”

53. “In order to move to a recovery based mental health and addiction care system, it is critical that we allow for and appreciate the meaningful contribution of experiential knowledge to optimizing service direction and the appropriate exercise of choice." Ian Dawe, MHSc, MD, FRCP(C) Program Chief and Medical Director, Mental Health, Trillium Health Partners “Recognizing the important role peers play in both addiction and mental health treatment and recovery, the Mississauga Halton LHIN has increased peer support capacity, and invested to support service coordination, and training and development of peer support workers and supervisors. Enhancing peer supports is an essential component of a more coordinated and integrated mental health and addiction system that delivers high quality care for positive person experiences and outcomes to people in our communities.” — Bill MacLeod, CEO, Mississauga Halton LHIN Provincial/National System Impact Mississauga Halton LHIN Mental Health & Addiction System Impact

54. Our Emerald City When People With Lived Experience (PWLE) are trained and take on peer support positions within the substance use and/or mental health systems AND when they are seen and supported as valued members of the service team, capacity within these systems will grow. This will be reflected in more compassionate, responsive & equitable, recovery focused substance use and mental health systems and workplaces as well as in increased satisfaction among people using services. This initiative thrives to ensure every person will be recognized, appreciated and respected for the unique person they are on their unique journey and to ensure that care provision is adaptable to the fluctuations in peoples’ recovery.

55. Questions and Discussion Questions?