Growing Peer Support: Specialized Servicesat a Time of Crisis

Growing Peer Support: Specialized Servicesat a Time of Crisis

October 27, 2020

1 Abstract

Peer support specialists are a growing workforce of skilled individuals who use their lived experience with mental health or substance use conditions to connect with service users and provide them with needed supports. The need for comprehensive and engaging support for individuals who have mental health conditions and substance use disorders is continuing to rise among U.S. residents, and peer support specialists can be mobilized—and their numbers increased—to improve access to support and outcomes for persons with these disorders. Additional federal and state policy action is needed to ensure that effective peer support reaches those in need. To leverage the opportunities presented by peer support specialists, policymakers should take the following steps: ensure adequate funding for peer services; build and expand the organizations that employ peers; protect against state and local cuts to peer services; ensure access to phone, video, and digital peer support; and increase training, certification, and ongoing education opportunities for peer specialists. An investment in the peer support workforce can not only address the immediate and growing mental health and substance use needs in the U.S., it can also help shape a future system of services rooted in empowerment, hope, connection, human rights, and lived experience.

2 Peer Support

Peer support specialists are individuals with lived experience of mental health conditions or substance use disorders, or co-occurring disorders, who receive training to provide support to others. In 2007, the Centers for Medicare and Medicaid Services (CMS) identified peer support as an evidence-based practice (1). Peer specialists connect with individuals through their shared experience and offer support in a variety of ways, including supporting individuals to navigate community resources, learn self-help and self-management skills, build networks of support, manage physical health conditions, and meet personal goals, such as attaining employment or education (2). The services are rooted in hope, reciprocal relationships, informed decision making, human rights, and a comprehensive understanding of broader, nonclinical needs, goals, and resources available to individuals (3).

Peers have demonstrated their ability to make a difference on the individual and organizational levels and, more broadly, in the behavioral health landscape.

Peers have demonstrated their ability to make a difference on the individual and organizational levels and, more broadly, in the behavioral health landscape. For individuals with mental illnesses, research has shown that peers help reduce depression, hospitalization, and substance use (4). There is also evidence that peer support services improve a person’s sense of empowerment, engagement in services, and physical health (4, 5). When providers, organizations, and systems hold limited views about the capacities and prognoses of individuals with psychiatric diagnoses, peers provide direct challenges to these narratives to help usher a transformation toward a focus on recovery (6). In the behavioral health care field, peers are more than just a way to extend the traditional mental health workforce—peer support specialists represent the growing understanding that systems and services need to center activation, community, quality of life, and hope. Through their lived experience, peer specialists improve what already exists and design new programs, policies, and organizations that meet people’s needs in ways that are most important and relevant to them.

The growing evidence and focus on systems change have led to a rapid expansion in the availability of peer services—with more than 30,000 certified peer specialists in the U.S.—and growing interest in the workforce among decision makers and leaders in behavioral health services (7). In addition to the growth in overall workforce numbers, the number of settings where peers provide services is also expanding. These settings include community mental health centers, primary care offices, prisons, crisis centers, warm lines, apps, mobile crisis teams, schools, drop-in centers, and psychiatric hospitals, among others (8, 9).

The COVID-19 pandemic and its adverse effects on mental health and well-being have called attention to shortages in staffing, investment, and creativity in how systems address behavioral health. Peer support services were needed to address fundamental gaps and issues in behavioral health services long before peer support specialists were asked to help address the current and anticipated mental health problems associated with COVID-19. This paper provides policy recommendations to promote the growth of peer support services in the short and long terms. Where appropriate, we address issues relevant to the coronavirus pandemic, but the recommendations go beyond COVID-19, even as it currently effects everything
we do.

3 Policy Approaches to Expand Peer Support Services

Policy reform is needed to advance America’s mental health systems, and to be more effective, systems must give peer support specialists a central role in order to become more effective at scale. Mental health services can be confusing, impersonal, piecemeal, and demoralizing—if services are even available. Because peer services focus on empowerment, relationship, connection to resources, and community, an investment in peer services can help create systems shaped by what matters most to individuals, supporting them to live the lives they want in their communities of choice. Additionally, peer services can address concerns across other policy areas by supporting people in maintaining their physical health, achieving goals in areas such as education and employment, transitioning from hospitalization or incarceration, and engaging in and shaping their communities (10, 11).

Peer services can address concerns across other policy areas by supporting people in maintaining their physical health, achieving goals in areas such as education and employment, transitioning from hospitalization or incarceration, and engaging in and shaping their communities.

The number of peer support specialists can also be increased more quickly than many other parts of the workforce. The primary value of peer support specialists comes from their lived experience, which provides them with years of informal training in building their perspective. Formal training requirements for peer support specialists vary across the states, and the most common length of training for certified peer specialists is 40 hours (12). This length of training means that investment in the peer support workforce requires a less intensive initial investment in training than for other mental health workers and that the peer support workforce can be built more quickly to respond to rising needs. Less intensive training requirements do not mean that peers should be considered less valuable or as less expensive substitutes for existing roles. In addition to their formal training, which provides skills to implement in their work, their lived experience provides valuable insight, perspectives, and means of connection that cannot be attained through training or formal education.

Currently, the ongoing impact of COVID-19 has had significant negative effects on mental health in the U.S. (13). The high demand for mental health services that existed before the pandemic will likely increase, particularly as the economic impact of COVID-19 results in unemployment and a lack of basic resources for so many. Individuals who have never accessed mental health services will likely seek care in primary care settings, emergency departments, crisis centers, or the many other locations where peers can provide impactful services. Adequate investment in the peer support workforce means integrating peer specialists across all settings where people seek care. Peer specialists can help individuals in distress prevent or disrupt cycles of crises no matter where these individuals enter the system.

The number of peer support specialists can also be increased more quickly than many other parts of the workforce.

There is a clear need to both expand and rethink behavioral health services in the U.S. despite the potential of peer specialist services to address some of the core issues in the field, such as high rates of rehospitalization or low engagement in services, policy and funding barriers that prevent the expansion of peer specialist services remain. Critical to addressing these barriers is engaging peer specialists and individuals with lived experience at all levels and decision-making points in scaling and implementing peer support. Peers should be in oversight and key leadership positions to ensure fidelity and to avoid the potential damage of not adequately training and designing the workforce initiative. Because of the unique nature of the work and its underlying values, a lack of lived experience among leadership can contribute to the cooptation of peer support, shifting peers into non-peer roles and fundamentally changing the nature of the service (14). Ensuring that leaders have lived experience and that peer support specialists serve in leadership roles can help address some of the tensions faced by peer specialists who are integrating into health care teams, including maintaining peers’ status as community leaders and as advocates for themselves, for those they support, and for better service systems.

To meet and expand the peer support specialist services available to individuals with mental health challenges, policymakers and leaders should take the following actions:

  1. Ensure adequate funding sources for peer services.
  2. Build and expand the organizations that employ peers.
  3. Protect against state and local cuts to peer services.
  4. Ensure access to phone, video, and digital peer support.
  5. Increase training, certification, and ongoing education opportunities for peer specialists.

Ensure Adequate Funding Sources for Peer Services

  • Convene insurers, peers, and employers to determine how to effectively align payment policies across payers and coverage types to expand access to these services.
  • Allow for broader coverage of peer support services in Medicare Advantage and reimburse for peer support under traditional Medicare.
  • Consider the entire cost of peer services, including fair wages and necessary components of peer work, in setting rates for peer support services.

As health care continues to move toward integration, peers are increasingly reimbursed by more health insurers for their work as part of behavioral health care teams.

One of the often-cited challenges for peer services is funding. Most funding for peer services comes from state and local dollars and Medicaid, whether through state plans or waivers, with some notable recent innovations (6, 15). As health care continues to move toward integration, peers are increasingly reimbursed by more health insurers for their work as part of behavioral health care teams. As health care financing moves from a focus on volume to value, peers are frequently offered as a powerful way to improve outcomes while reducing costs in these models. In 2019, CMS encouraged Medicare Advantage plans to pay for peer services as an alternative to opioid prescriptions for pain management (16). Commercial insurers are also increasingly interested in peer support, particularly related to substance use disorders. For example, New Jersey’s largest commercial insurer reimburses for phone-based peer support services for individuals with opioid use disorder (17). Despite this shift, there are barriers to accessing peer services, particularly for non–Medicaid-eligible individuals.

To address these reimbursement and funding challenges, both federal and state policy change is important. Federally, Congress can create a reimbursement pathway under traditional Medicare to increase access to these services by allowing peer support specialists to bill Medicare for peer support services. Peer support specialists are currently not reimbursable providers under Medicare Part B, and as a result, peer support services codes are not currently covered. At the state level, states should work with the peer community to ensure that the current approach under Medicaid supports effective care and then support commercial insurers and Medicare Advantage plans to align payment policies with Medicaid to the extent feasible under federal law. States can convene a working group that provides a forum for insurers to determine how to effectively harmonize their reimbursement approaches to improve access to peer support—a strategy used in other areas, such as the implementation of patient-centered medical homes, where states seed-funded independent working groups that supported alignment of reimbursement and measurement practices across payers (18). The inclusion of peers in the working group will be critical to ensure that solutions are feasible in practice and grow the field.

Employers can also be a key ally, because coverage of peer support could decrease their health care costs and improve worker productivity, and employer coalitions, such as the Pacific Business Group on Health, have long been advocates for sustained reform (19). Some creativity may be required about reimbursement approaches as a result of legal barriers, and insurers may have to provide subscriptions to peer-run organizations for members in need, as they currently do with certain wellness services, or specify that some amount of capitated funding to provider organizations is to be set aside to contract with peer-run organizations. For example, in New York, providers are increasingly being required to contract with community-based organizations to participate in value-based payment contracts with health insurers, and some providers have used this opportunity to contract with peer-run organizations (20).

Most importantly, fair compensation is critical for acknowledging the value of the work, centering the dignity and well-being of the individuals serving as peer support specialists and advancing economic equity more generally.

Any approach to payment for peers should include consideration of a living wage, health insurance and other employee benefits, training, supervision and certification costs, flexible work hours, and reasonable productivity expectations, including considering the time necessary for continued outreach, engagement, and travel. Although peer support specialists provide value in cost savings and outcomes, many are paid low wages, which may discourage individuals from entering or staying in the workforce (6). Additionally, low reimbursement can limit the number of organizations willing to offer peer support services. Most importantly, fair compensation is critical for acknowledging the value of the work, centering the dignity and well-being of the individuals serving as peer support specialists and advancing economic equity more generally.

 

Build and Expand the Organizations that Employ Peers

  • Train organizational leadership and staff to understand the peer support role and peer support supervision in non-peer-run organizations.
  • Ensure that health care and small business resources reach peer-run organizations, including supporting
    these organizations to access resources—especially relief funds associated with the COVID-19 pandemic.
  • Engage peer-run organizations and organizations that employ peers in economic development initiatives addressing the needs of small businesses in low-income communities.

Paid peer support specialists typically provide services as parts of existing systems or of stand-alone peer support programs. Even when peers are working as part of traditional health care organizations and teams, many peer-run organizations prefer to contract with the organizations, as opposed to having peers employed directly by the organization (21). This model allows peers to receive supervision from peers and to be part of a peer-run organization where they can receive support from others, avoiding many of the common challenges of peers in clinical settings, such as working with supervisors who do not understand peer support or being asked to perform non-peer roles.

The Peer Support Toolkit, developed by the City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services, provides a comprehensive guide to addressing these common barriers in organizations.

In non-peer-run organizations, major barriers to effective peer support services include opposition in the organizational culture, lack of clarity on peer roles and job duties, and lack of effective supervision, with many supervisors of peers having little experience or training in what peers do and do not do (2). The Peer Support Toolkit, developed by the City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services, provides a comprehensive guide to addressing these common barriers in organizations (22). The National Association of Peer Supporters has also developed National Practice Guidelines for Peer Specialists and Supervisors (10). Funding should be dedicated to ensure that staff, supervisors, and peers are adequately prepared to work as teams.

Unfortunately, in addition to barriers related to traditional staff and organizational culture, peer-run and peer-employing organizations have faced chronic underinvestment, and economic concerns resulting from COVID-19 have created new threats for both models of employing peers. Bolstering peer support organizations needs to be part of America’s long-term economic recovery and vision for community resources and supports. A number of policies provide funding and other organizational supports to health care and behavioral health–related organizations, as well as to small businesses more broadly, and peers should be supported to access these resources. Technical assistance should be bolstered for peer support organizations through increasing funding for existing pathways, such as that of the Consumer and Consumer Supporter Technical Assistance Centers funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and Statewide Consumer Networks, to help them leverage existing resources for sustainability and growth.

Bolstering peer support organizations needs to be part of America’s long-term economic recovery and vision for community resources and supports.

Federal, state, and local health and economic development policies should consider how they may better include peer-run and peer-employing organizations in funding allocations and help the organizations access these funds, especially given the current availability of relief funds associated with the COVID-19 pandemic. For example, community development financial institutions (CDFIs), nonprofit banks that use their lending and other resources to promote economic equity, and other community development organizations are increasingly interested in advancing health equity (23). CDFIs have been a part of the federal and state policy response for ensuring that COVID-19 relief funds reach communities facing the greatest economic impacts, and intentionally supporting connections between CDFIs and peer organizations could better advance their common goals of improved health and economic well-being.

 

Protect Against State and Local Cuts to Peer Services

  • Prevent cuts to existing state-funded and locally funded peer support services.
  • Fund evaluation and demonstration projects to study and measure the individual and system-level impacts of peer support services.

Peer support services are reimbursable under Medicaid in most states; however, state and local funding plays a significant role in paying for peer services, particularly for individuals who are not Medicaid eligible. This is especially true in states that did not implement the Medicaid expansion under the Affordable Care Act. Current discussions of state budget cuts and the budget
cuts following the last recession paint a concerning picture for mental health services and peer support given the current and potential economic impact of COVID-19.

According to the National Association of State Mental Health Program Directors, state budgets cut more than $4.35 billion in mental health services between 2009 and 2012, following the Great Recession (24). The uncertainty and lost tax revenue during the COVID-19 pandemic make it unclear what will happen with state budgets, how much federal spending will be able to make up for states’ lost revenue, and how long the economic impact will last (25). Using data from the previous recession, one study projected that the combination of economic impact and unique circumstances of COVID-19 could result in an additional 75,000 lives lost to suicide, alcohol, and drugs (26). Alongside this, we can anticipate significant suffering and costs, as data show that far more individuals attempt suicide or receive medical care related to mental health crises, compared with the number who die by suicide (27).

Given the current and potential mental health impact of COVID-19, it is critical that states maintain investment in existing behavioral health services, including peer support services. Peer support is an essential part of the treatment continuum and plays a critical role in keeping people engaged in their communities and in reducing cycles of rehospitalization and emergency department use. Cutting these supportive community-based services can result in spending elsewhere, whether in hospitals, emergency departments, jails, or prisons. Cuts made to peer support services could result in far more expensive costs across health care and other systems—and states would likely lose money rather than save.

States should also evaluate their peer support programs to demonstrate the value of peer support services and ensure that their current approach achieves that value. States can conduct evaluations to determine the impact of peer support on health outcomes and total costs—cognizant that peers likely affect a wide range of outcomes and potential savings that should be captured to the extent possible. For the relatively low resources spent on an evaluation, a state can produce evidence about the budgetary impacts of its peer support investments and better understand the value of maintaining and even expanding peer support in the face of budget challenges to achieve further savings. For example, the Connecticut Department of Mental Health and Addiction Services was one of the funders of a pilot study of the impact of peer support on reducing psychiatric readmissions, which guided states’ understanding of the cost-effectiveness of various approaches to addressing behavioral health needs (28, 29).

 

Ensure Access to Phone, Video, and Digital Peer Support

  • Payers should align rules around virtual and phone-based peer support with those of other behavioral health services providers and continue relaxed reimbursement requirements for video and phone-based peer support services.
  • Continue efforts to provide individuals receiving services access to technology, broadband, data, and smartphones to ensure that individuals have access to needed support.

Phone, video, and digital supports are emerging practices for peer specialists, although payment barriers have limited their use. The pandemic has created a new impetus for the use of these means of providing support. In response to lockdowns and social distancing, necessity forced many to offer and reimburse for phone, video, and digital peer support (30). Organizations are also utilizing social media, apps, and other digital platforms to stay engaged and support those with whom they work (9).

Despite previous reservations about paying for virtual and phone-based peer support, the services are proving popular and effective. The services remove barriers, such as access to transportation and added travel time for appointments, particularly for rural populations or individuals experiencing homelessness. This approach is also attractive to young people who spend significant amounts of time in a digital environment. For example, an Oregon-based nonprofit, Youth Era, uses certified youth peer support specialists to provide virtual drop-in hours and peer support through virtual gaming and streaming platforms, Discord and Twitch (31).

The addition of these resources across peer support services has helped organizations adapt to the current crisis but should be sustained even when social distancing requirements are relaxed and ultimately removed. Legislation has been introduced to designate funding to the Department of Health and Human Services to support the training, transition, and expansion of virtual peer support services provided by certified peer specialists (32). In addition to funding the upfront costs, payers should ensure continued payment for existing and newly expanding virtual and phone-based peer support services.

Offering video and phone-based peer support provides an option for peer specialists to further engage individuals in ways that activate them.

One of the major strengths of peer support services is engaging people who are typically not engaged with services. Offering video and phone-based peer support provides an option for peer specialists to further engage individuals in ways that activate them. Unfortunately, barriers such as limited or lack of access to technology, broadband, phones, and data can prevent individuals from accessing peer support who might benefit the most. The Federal Communication Commission’s COVID-19 Telehealth Program and its Lifeline Program for Low-Income Consumers have helped providers and service users stay connected by covering the cost of technology, telecommunications, and internet access. Although this funding and these changes are necessary and specific to COVID-19, funding should also be designated to cover any necessary costs for equipment or use of technology, particularly for service recipients, on an ongoing basis (33, 34).

 

Increase Training, Certification, and Education Opportunities for Peer Specialists

  • Invest in training, certification, and ongoing education opportunities for peer specialists that are shaped and led by peers and people with lived experience.
  • Fund programs for new and existing peer specialists across mental health conditions, substance use disorders, and co-occurring disorders, with a focus on recruiting from diverse populations, including the LGBTQ+ community, youth, BIPOC (Black, Indigenous, and people of color) communities, justice system–involved individuals, and non–English-speaking or multilingual individuals.
  • Invest in peer training that includes a focus on measuring quality and pathways and barriers to employment, including an effort to re-engage trained and certified peer specialists who are not working.
  • Invest in higher levels of certification and reimbursement for peer specialists who demonstrate significant experience and knowledge in the field.
  • Designate funding to provide continuing education to existing peers to support them in adapting to current changes and broader resources.
  • Include peer support specialist workforce development in any federal workforce development initiatives to address unemployment.

Forty-eight states have or are in the process of developing peer support certification (35). Each has a different standard for peer specialist training and certification, which is required to bill Medicaid for peer support in states and by many employers. Investment in training should defer to existing state-approved training. Funding can be directed through grants administered by SAMHSA and by resources made available through the Health Resources and Services Administration, particularly its Behavioral Health Workforce Education and Training Program that already invests in peer training. A significant amount of funding for peer training was passed in the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act in 2019 that more directly deals with peer support and substance use disorders.

Any strategy to increase the number of trained and certified peer specialists should emphasize recruiting and engaging individuals from underserved communities, ensuring mandatory cultural competency training, and recruiting individuals who speak multiple languages. The behavioral health workforce is largely unrepresentative of the U.S. racial-ethnic, cultural, and linguistic diversity, and many individuals, particularly Black and Indigenous individuals and people of color (BIPOC), have historically faced and continue to face harm, discrimination, and violence under current systems (36). The same communities are also being disproportionately affected by the health and economic effects of COVID-19, creating an even greater need for support among individuals who may rightfully not trust general medical and mental health providers and systems (37). A critical component of why peers can better engage individuals in resources and support is shared identity and lived experience; therefore, having a workforce reflective of the communities served is necessary to engage people and shape resources and support. Efforts related to expanding peer support services should center these experiences and perspectives and ensure that individuals from underserved communities are included as providers, in leadership roles, and developers of resources.

For example, the National Alliance on Mental Illness’s STAR (Support, Technical Assistance, Resource) Center and the University of Illinois at Chicago’s National Research and Training Center on Psychiatric Disability developed and piloted a tool, Cultural Competency in Mental Health Peer-Run Programs and Self-Help Groups, that provides guidance and steps for peer programs to assess and improve their cultural competency (38). Peer organizations can utilize tools such as this to update existing practices and trainings and should use ongoing recommendations from peers to ensure recruitment, engagement, and support of peers who represent the diversity of the U.S.

Longer-term consideration and investment should go into researching and standardizing the critical components in each training, particularly as peer specialists are required to work in different settings and on health care teams.

In addition to modifying existing resources, funding for peer-support organizations should include set-aside funds to determine the barriers and solutions to recruitment, engagement, and advancement of diverse staff and leadership. Because these activities are not reimbursed, they may be difficult to prioritize for many organizations that are already facing financial difficulties. Including funding for these activities supports organizations in giving diversity and inclusion the priority they need. Initiatives that assess the quality of and improve upon existing training should also be prioritized. Funded programs and organizations should assess and improve their training, recruitment, and advancement. Priority should be given to funding work and organizations led by underrepresented communities.

Despite investment in and discussion of the importance of peer support, many trained and certified peers are not supported in achieving and sustaining employment.

Investment in training should include quality metrics to ensure that training standards meet the quality needed to provide support to and empower individuals. Inconsistency of core competencies across states and peer support trainings remain a barrier for effectively growing the workforce (6). Some states and trainings utilize the standards outlined in SAMHSA’s Core Competencies for Peer Workers and the International Association of Peer Supporters’ National Practice Guidelines (10, 11). Longer-term consideration and investment should go into researching and standardizing the critical components in each training, particularly as peer specialists are required to work in different settings and on health care teams.

Despite investment in and discussion of the importance of peer support, many trained and certified peers are not supported in achieving and sustaining employment. Peer training programs should include support in finding employment as peer specialists. This could include practicum opportunities or partnerships with community organizations or health care providers. States should invest in re-engaging trained and certified individuals who are not currently employed and determining the barriers that caused them to leave the field, such as low wages, lack of career pathways, loss of disability benefits, or nonsupportive staff or organizational culture (15, 39). Research currently being conducted to examine the experiences of certified peer specialists may shed light on the reasons why certified peers may not stay in the workforce (40).

One means of improving the quality and standardization of peer support services is providing higher levels of certification. Although entry-level peer support is an important option for individuals just starting in the workforce, many peers are interested in pursuing careers as peer specialists. Employers and payers are also interested in ensuring reliable and higher levels of knowledge and skills from peer specialists. Similar to levels of licensure for health care professionals, such as nurses and social workers, a higher level of certification could help improve the quality and outcomes of services. For example, Mental Health America developed the National Certified Peer Specialist (NCPS) Certification, which requires previous state certification and a minimum of 3,000 hours of experience providing direct peer support, to address these issues on a national level (41). Minnesota also offers higher levels of certification for peer support specialists. Individuals who complete the state-approved training and are certified by the state are classified as Certified Peer Specialist Level 1, and peer specialists who provide a minimum of 4,000 hours of supervised experience delivering peer support are considered Certified Peer Specialist Level 2 (42). Like other health care professionals, peer support specialists with higher levels of certification and experience should be reimbursed at higher rates.

For current peer specialists, training should be available to support them as they continue to adapt to changes, including information on emerging COVID-19 relief programs. This includes training to provide virtual, phone-based, and digital peer support and to work as part of teams in new and emerging health care and non–health care settings. As service delivery and public resources quickly change, peers should be prepared to learn and adapt to new programs and emerging trends in peer support service delivery through technical assistance and continuing education. This could be ensuring that peers are included and targeted with information through a proposed emergency mental health conditions and substance use disorders Technical Assistance Center (TAC) and through utilizing existing TACs, Statewide Consumer Organizations, and SAMHSA grants for information dissemination and training.

For current peer specialists, training should be available to support them as they continue to adapt to changes, including information on emerging COVID-19 relief programs.

In line with safety precautions during COVID-19, many organizations have converted their peer trainings to online approaches. Although states should offer in-person services when appropriate, virtual peer training can make the resource more accessible for peers, particularly peer specialists working in rural and frontier areas, to train more peers now and in the future.

With widespread unemployment and growing demands on mental health services, building the peer workforce is also an opportunity to provide employment opportunities for individuals looking to serve others. Historically, many jobs in peer support have served as pathways to employment for people after periods of unemployment. With so many individuals currently out of work, large-scale investment in the peer support specialist workforce can be a pathway to employment. Federal workforce development initiatives should include peer support, along with other behavioral health staffing.

With widespread unemployment and growing demands on mental health services, building the peer workforce is also an opportunity to provide employment opportunities for individuals looking to serve others.

This sentiment aligns with the existing movement toward a caring economy, where individuals are engaged to work as certified nursing aids or caretakers are paid to support individuals in their lives. It also aligns with calls to invest in community health workers to support individuals in the community with contact tracing (43). Implementation of large-scale investment in the peer support specialist workforce should center the leadership of individuals with lived experience and the peer support community to maintain the ethics and values of peer support.

4 Conclusion

Peer support specialists play a distinct and important role in promoting mental health and should be integral to shaping the future of the U.S. approach to addressing mental health conditions and substance use disorders. Despite the growing interest in peer support services, barriers in financing, funding, training, and certification have limited their expansion. To address the growing need for mental health supports and improve and transform existing systems and services, policymakers and leaders should prioritize overcoming these barriers and disconnects. Efforts to increase access to peer support services can help shape services, organizations, and systems to emphasize strengths, empowerment, hope, and the importance of lived experience in ways that improve outcomes for people accessing services.

References

  1. Guidance to states interested in peer support services under the Medicaid program [CMS letter]. Baltimore, Centers for Medicare and Medicaid Services, Center for Medicaid and State Operations, 2007. Available here https://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD081507A.pdf.
  2. Klee A, Chinman M, Kearney L: Peer specialist services: new frontiers and new roles. Psychol Serv 16:353–359, 2019.
  3. Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health. Geneva, United Nations, Office of the United Nations High Commissioner for Human Rights, 2017. Available here https://www.ohchr.org/en/issues/health/pages/srrighthealthindex.aspx.
  4. Value of Peers. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2017.
    Available here https://www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/value-of-peers-2017.pdf.
  5. Cook JA: Peer Support: Whole Health and Resiliency. Presented at the Pillars of Peer Support Services Summit, Atlanta, Sept 26–27, 2011. Available here http://www.cmhsrp.uic.edu/download/PeerSupportWholeHealthAndResiliency.pdf.
  6. Myrick K, del Vecchio P: Peer support services in the behavioral healthcare workforce: state of the field. Psychiatr Rehabil J 39:197–203, 2016.
  7. Jenkins GT, Shafer MS, Janich N: Critical issues in leadership development for peer support specialists. Community Ment Health J 56:1085–1094, 2020.
  8. Blash L, Chan K, Chapman S: The Peer Provider Workforce in Behavioral Health: A Landscape Analysis. San Francisco, University of California, San Francisco, UCSF Health Workforce Research Center on Long-Term Care, 2015. Available here https://healthworkforce.ucsf.edu/sites/healthworkforce.ucsf.edu/files/Report-Peer_Provider_Workforce_in_Behavioral_Health-A_Landscape_Analysis.pdf.
  9. Fortuna KL, Venegas M, Umucu E, et al: The future of peer support in digital psychiatry: promise, progress, and opportunities. Curr Treat Options Psychiatry 6:221–231, 2019.
  10. National Practice Guidelines for Peer Supporters. Norton, MA, International Association of Peer Supporters, 2011. Available here https://inaps.memberclicks.net/assets/docs/nationalguidelines_updated.pdf.
  11. Core Competencies for Peer Workers in Behavioral Health Services. Rockville, MD, Substance Abuse and Mental Health Services Administration, 2018. Available here https://www.samhsa.gov/sites/default/files/programs_campaigns/brss_tacs/core-competencies_508_12_13_18.pdf.
  12. Kaufman L, Kuhn W, Manser SS: Peer Specialist Training and Certification Programs: A National Overview, 2016. Austin, University of Texas at Austin, School of Social Work, Texas Institute for Excellence in Mental Health, 2016. Available here http://sites.utexas.edu/mental-health-institute/files/2017/01/Peer-Specialist-Training-and-Certification-Programs-A-National-Overview-2016-Update-1.5.17.pdf.
  13. Panchal N, Kamal R, Orgera K, et al: The Implications of COVID-19 for Mental Health and Substance Use. Washington, DC, Kaiser Family Foundation, 2020. Available here https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/.
  14. Byrne L, Stratford A, Davidson L: The global need for lived experience leadership. Psychiatr Rehabil J 41:76–79, 2018.
  15. Chapman SA, Blash LK, Mayer K, et al: Emerging roles for peer providers in mental health and substance use disorders. Am J Prev Med 54(suppl 3):S267–S274, 2018.
  16. Advance Notice of Methodological Changes for Calendar Year (CY) 2020 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2020 Draft Call Letter. Baltimore, Centers for Medicare and Medicaid Services, 2019. Available here https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2020Part2.pdf
  17. Washburn L: NJ’s largest insurer to offer free peer counselors for recovering addicts. Woodland Park, NJ, Record (NorthJersey.com), Oct 18, 2018. Available here https://www.northjersey.com/story/news/health/2018/10/18/nj-largest-insurer-offer-peer-counselors-recovering-addicts/1670585002.
  18. Wirth B, Takach M: State Strategies to Avoid Antitrust Concerns in Multipayer Medical Home Initiatives. Issue Brief. New York, Commonwealth Fund, 2013. Available here https://pcmh.ahrq.gov/citation/state-strategies-avoid-antitrust-concerns-multipayer-medical-home-initiatives.
  19. Stremikis K, Connors C, Hoo E: Intensive Outpatient Care Program: A Care Model for the Medically Complex Piloted by Employers. New York, Commonwealth Fund, 2017. Available here https://www.commonwealthfund.org/publications/case-study/2017/sep/intensive-outpatient-care-program-care-model-medically-complex.
  20. A Path toward Value Based Payment: Annual Update. Albany, New York State Department of Health, Medicaid Redesign Team, 2019. Available here https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_library/2019/docs/sept_redline2cms.pdf.
  21. Ostrow L, Hayes SL: Leadership and characteristics of nonprofit mental health peer-run organizations nationwide. Psychiatr Serv 66:421–425, 2015.
  22. Peer Support Toolkit. Philadelphia, City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services, 2017. Available here http://dbhids.org/wp-content/uploads/1970/01/PCCI_Peer-Support-Toolkit.pdf.
  23. Schuchter J, Jutte DP: A framework to extend community development measurement to health and well-being. Health Aff 33:1930–1938, 2014.
  24. Glover RW, Miller JE, Sadowski SR: Proceedings on the State Budget Crisis and the Behavioral Health Treatment Gap: The Impact on Public Substance Abuse and Mental Health Treatment Systems. Alexandria, VA, National Association of State Mental Health Program Directors, 2012. Available here https://www.kff.org/wp-content/uploads/sites/2/2012/12/summary-congressional_briefing_march_22_website.pdf/.
  25. McNichol E, Leachman M, Marshall J: States Need Significantly More Fiscal Relief to Slow the Emerging Deep Recession. Washington, DC, Center on Budget and Policy Priorities. 2020. Available here https://www.cbpp.org/research/state-budget-and-tax/states-need-significantly-more-fiscal-relief-to-slow-the-emerging-deep.
  26. Petterson S, Westfall JM, Miller BF: Projected Deaths of Despair from COVID-19. Oakland, CA, Well Being Trust, 2020. Available here https://wellbeingtrust.org/wp-content/uploads/2020/05/WBT_Deaths-of-Despair_COVID-19-FINAL-FINAL.pdf.
  27. Klonsky ED, May AM, Saffer BY: Suicide, suicide attempts, and suicidal ideation. Annu Rev Clin Psychol 12:307–330, 2016.
  28. Sledge WH, Lawless M, Sells D, et al: Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations. Psychiatr Serv 62:541–544, 2011.
  29. Waye KM, Goyer J, Dettor D, et al: Implementing peer recovery services for overdose prevention in Rhode Island: an examination of two outreach-based approaches. Addict Behav 89:85–91, 2019.
  30. Jadwisiak M: Peer support: a secret weapon in the fight against COVID-19. Mental Health Weekly 30:5, 2020.
  31. Virtual Support. Eugene, OR, Youth Era, 2020. Available here https://www.youthera.org/virtual-support/.
  32. Cortez Masto Introduces Legislation to Fund Virtual Peer Support Behavioral Health Programs [press release]. Las Vegas, NV, Catherine Cortez Masto, 2020. Available here https://www.cortezmasto.senate.gov/news/press-releases/cortez-masto-introduces-legislation-to-fund-virtual-peer-support-behavioral-health-programs.
  33. COVID-19 Telehealth Program. Washington, DC, Federal Communications Commission, 2020. Available here https://www.fcc.gov/covid-19-telehealth-program
  34. Lifeline Support for Affordable Communications. Washington, DC, Federal Communications Commission, 2020. Available here https://www.fcc.gov/consumers/guides/lifeline-support-affordable-communications.
  35. A National Overview of Peer Support Training and Certification Programs. Chicago, University of Chicago, Center on Integrated Health Care and Self-Directed Recovery, 2020. Available here
    www.center4healthandsdc.org/map-of-national-peer-training-programs.html.
  36. Demographics of the U.S. Psychology Workforce: Findings from the 2007–16 American Community Survey. Washington, DC, American Psychological Association, 2018. Available here https://www.apa.org/workforce/publications/16-demographics/report.pdf.
  37. COVID-19: Health Equity Considerations and Racial and Ethnic Minority Groups. Atlanta, Centers for Disease Control and Prevention, 2020. Available here www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html.
  38. Cultural Competency in Mental Health Peer-run Programs and Self-help Groups: A Tool to Assess and Enhance Your Services. Arlington, VA, National Alliance on Mental Illness STAR Center, and Chicago, University of Chicago, National Research and Training Center, 2010. Available here
    http://www.cmhsrp.uic.edu/download/CulturalCompetencyTool.pdf.
  39. Lapidos A, Jester J, Ortquist M, et al: Survey of peer support specialists: professional activities, self-rated skills, job satisfaction, and financial well-being. Psychiatr Serv 69:1264–1267, 2018.
  40. Certified Peer Specialist Career Outcomes Study. San Luis Obispo, CA, Live and Learn, 2020. Available here https://www.livelearninc.net/cps.
  41. National Certified Peer Specialist Certification. Alexandria, VA, Mental Health America, 2020. Available here https://www.mhanational.org/national-certified-peer-specialist-ncps-certification-get-certified.
  42. Peers: Link to Hope Initiative. Grand Rapids, MN, Link to Hope, 2020. Available here http://peerslinktohope.org/about-us/#:~:text=Certified%20Peer%20Specialist%20Level%202&text=Is%20qualified%20at%20the%20Mental,to%20persons%20with%20mental%20illness.
  43. Fraser M, Lane JT, Ruebush E, et al: A Coordinated, National Approach to Scaling Public Health Capacity for Contact Tracing and Disease Investigation. Arlington, VA, Association of State and Territorial Health Officials, 2020. Available here https://www.astho.org/COVID-19/A-National-Approach-for-Contact-Tracing.

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