1. 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

2. 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)

3. 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?

4. 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

5. 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

6. 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.)

7. Map of training and certification for mental health peer provider services

8. 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

9. 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

10. Map of Medicaid billing for Mental Health Peer Support

11. 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)

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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