The Center for Rehabilitation and Recovery provides assistance to the New York City mental health provider community through expert trainings, focused technical assistance, evaluation, information dissemination and special projects.

Peer Support Services: The Next Game Changer in Behavioral Health?

Over the past thirty years, major shifts in the mental health care landscape led New York State to envision an environment of partnerships among stakeholders in the system, from managed care plans to service providers, and from peers to families.

Here in New York, the efforts to reform Medicaid have focused on qualities that define quality care today. In behavioral health, this translates into person-centered, recovery-oriented treatment, which embraces shared decision-making and hope, and encourages recipients of care to find individual paths towards wellness. It also recognizes the close links between physical health and behavioral health. Evidence-based practices are being encouraged, system-wide, and providers are being asked to focus on outcomes.

Against this backdrop, peer support services stand out as a potential star. From counseling to wellness coaching, peer support services exemplify the State's philosophy. Further, research increasingly supports the idea that peer services improve patient outcomes.

For an up-to-the-minute view of this potential game changer, RECOVERe-works editor Elizabeth Saenger, PhD, interviewed two authors of the best-practice article on peer support services that was featured in the December 2013 issue of Psychiatric Services. Allen Daniels, EdD, a health consultant, and key participant at the annual Pillars of Peer Support Services Summits, provides an overview. Susan Bergeson, Vice President of Consumer Affairs for Optum’s behavioral health business, explains what you need to do to get reimbursed for peer services by managed care, and what you can do if that undertaking is too much.

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Peer Support Services and the Changing Landscape: An Interview with Allen Daniels, EdD

Question: What kinds of peer support services are there, and what is the evidence base for them?

Dr. Daniels: In addition to mental health and addiction, there are increasing roles for peer providers in chronic illness self-management support, and physical health. Peer support in mental health has been researched, but it has been difficult to assess, since there is not a single treatment intervention method, and therefore the evidence is mixed. Studies show that it is very helpful, that it does no worse than professional services.

Question: How successful are peer services at reducing the rate of re-hospitalization?

Dr. Daniels: A number of studies show some cost-effective impact, and benefit, ranging from reductions in re-hospitalizations, better rates of engagement and activation, and improvement in physical well-being, emotional well-being, and again, recovery and self-management.

Question: What are the indications for coverage with peer support services in terms of Medicaid?

Dr. Daniels: Medicaid issued a letter to the state Medicaid directors indicating that it could be covered under State plan amendments, and it is now being covered in approximately thirty states. A problem arises, however, when you think about insurance and reimbursement processes. Usually those are determined by medical necessity criteria, and level of care guidelines, but Medicaid did not stipulate either. Its letter does give some direction about supervision, the role of the peer specialist, and the certification of that workforce within each state, but until the article we published in Psychiatric Services in late 2013, nothing outlined criteria for what level of care and for what duration of service people should receive care by peer specialists.

Question: What do you think will happen with that?

Dr. Daniels: I think it depends whether you are looking across Medicaid, or across health reform exchange care, or commercial plans. We are beginning to see more managed care organizations looking to deploy the peer support specialist workforce. The Veterans Administration has recently committed to training a large number of peer support specialists in 2013-2014. So the uptake of this workforce, and its deployment, is moving forward very strongly.

Question: Does Medicaid pay for peer services in New York?

Dr. Daniels: I believe that in New York, they are covered through the Medicaid plans, but not strictly as a Medicaid reimbursable service. So it is up to the managed care companies to contract with agencies that provide peer services and decide how they can use these services to improve outcomes and reduce costs.

Question: So agencies would have more of an incentive to show that what they are doing with peer support services really works, because these services are not covered unless the managed care agencies want them?

Dr. Daniels: Correct, and I think we are going to see states increasingly moving to managed care plans for their Medicaid. So in the future, contracts will be set up between the state and the managed care plans, and the managed care plans will then set up their criteria for deploying that work force, and decide how those services are reimbursed. Agencies are going to have to explore how to be competitive in a market place that is insurance- and managed-care based. Historically they have tended to be funded by grants and contracts that supported just delivery of services. So the evolution of managed care for many behavioral health agencies will be in some ways challenging, and in others, not so challenging.

Question: Not so challenging in what ways – to look at the positive first?

Dr. Daniels: Many community-based agencies that provide mental health and substance-use services have built continuum of care systems that provide a broad range of services that are often needed by a managed care plan. So the infrastructure in many ways is there. What sometimes isn't there is the structure for reimbursement, and billing, and financial models for their operation to function on an insurance plan (fee for service) reimbursed model.

Question: How can behavioral health organizations address the challenge of the new marketplace?

Dr. Daniels: I think the important first step is to understand how health plans operate, and to understand how that is different from ways in which they may have had their care funded in the past. The better they understand how these plans operate, the better they will be able to accommodate a new system. The other piece this relates to is health plans are increasingly looking at the whole health of individuals, not just the behavioral health. So, many agencies are either looking at now or are going to have to look at, how they integrate the care and services across the full continuum of healthcare.

Question: What kinds of questions do agencies ask you about the changing landscape, both agencies providing peer support services, and agencies that are not?

Dr. Daniels: Let me answer that a little differently. I think the challenge is going to be that oftentimes peer support services have been provided as part of an integrated treatment team, which may receive a bundled payment for those services, and if the reimbursement approach evolves to either a fee-for-service or risk-based capitation, then each of those requires different strategies for managing reimbursement.

Another challenge for agencies providing peer services comes from the question “Are these services health-based services?” If they are, they could be reimbursed by health insurance plans or Medicaid. And, they need to be structured and operated like other health services, with medical record documentation, and other components of standard care. Some peer-run organizations are more oriented to providing social support, versus intentional professional services. They may find that a medical model of service could be a conflict. For example, clubhouses and other psychosocial services might, or might not, be considered medical services. The best comparable example is Alcoholics Anonymous. That is a fabulous peer-based service, but it's not a medical service that would be reimbursable under a benefit plan.

Interview conducted and edited for RECOVERe-works.

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Going Beyond a Wing and a Prayer: An Interview with Susan Bergeson

Question: How do peer support services help clients?

Ms. Bergeson: Peer support services help support the engagement, and activation, of people with lived experience, so they are engaged in their own care, and activated to support their own wellness. Peer support is going to reduce stigma, because it is not just the external stigma that gets me ashamed of seeking services; it's the internal stigma that I have about having these illnesses.

Peer support provides hope in concrete ways. “If this person has done it, I can do it, too.” And it normalizes feelings and experiences. And it also helps peers access free community resources in a way that says, “No need to worry or be ashamed about this–I've accessed this stuff too.”

Question: What kinds of questions do agencies tend to ask you?

Ms. Bergeson: They are always asking, “How do we set up peer services?” And frankly, the first thing you have to figure out is whether the state reimburses for these services. If they don't, then you need to approach a managed care company to make a return-on-investment argument. And that is not all that hard. You can say, “Look, we could have these kinds of outcomes – a 30% to 40% reduction in hospital days.”

You might want to think about contracting with a local peer-run organization that is already successfully doing this. You could create a partnership, where it brings to the table what it knows how to do very successfully, and you're bringing to the table what you know how to do very successfully.

On the other hand, if you want a stand-alone peer support entity within your organization, then you need to look very carefully at socializing your staff, so staff doesn't keep trying to push peer support into case management, or into administration, or, even worse, into mini-therapy, because peer support is none of those things. But those are roles most organizations find comfortable.

You need to make sure that your staff team understands what peer services are, and what supports peer providers offer; have a good supervisor in place for peer providers; and make sure the person you are hiring to do the peer support is not isolated. You could do that by hiring several peers, or you can do that by connecting them to a peer support community to receive advice and mentorship, so that they can succeed.

Question: Do agencies which offer peer services differ from those which don’t in terms of values or company culture?

Ms. Bergeson: Some organizations are very concerned about opening their doors to peer support. They fear that peers will offer bad advice, or get in the way of a member healing. Research doesn't support that. Research shows that people who are engaged in peer support are more activated, more likely to take their medications, and less likely to be in the hospital, or socially isolated. So part of the challenge for organizations which are not open to peer support is to ask, “If I have these fears, how do I set up a system that allows me to move through those fears?”

You don't have to do everything at once. One simple thing you could do is connect with a group like the Depression and Bipolar Support Alliance (DBSA), or National Alliance on Mental Illness (NAMI), or Mental Health America (MHA). They have very strong systems, very good outcomes, and research behind them, and invite them to offer free support groups. You don't have to be reimbursed for it, you don't have to pay for it, but you can offer these groups as a service within your system, and simply connect to something going on already, and you can feel confident, because they have a great deal of oversight.

You can also give a page of great research-based online tools and services that members can access. For example, Wellness Recovery Action Plan (WRAP) is an evidence-based practice, and you can get a Smart Phone App for that. You can give people links to advice about doing yoga breathing, since research shows that reduces anxiety. You can offer people a list of things they can access when they are at home, that help them move forward to recovery, as a way to ease yourself into this new role.

Question: What do you see as the biggest problems and opportunities for social service agencies regarding peer support services?

Ms. Bergeson: You have to spend time to start this, and it’s always hard to peel out enough time in systems where we are all running as fast as we can. But if you're going to do this, you really have to say, “OK, we're committed to the concepts of recovery and resiliency. We know that peer support is part of that, and we're going to set some time aside to tackle it,” and talk to managed-care network partners, and look at the financial model that you are going to put in place, and referral streams. So the biggest obstacle is peeling out the time, getting intentional, and not relying on a wing and a prayer.

Interview conducted and edited for RECOVERe-works.

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 How Agencies Can Measure Recovery as Part of Peer Integration

Steven R. Anderson

The integration of peer relationships into behavioral health care delivery, or peer integration (PI), may be viewed as a measure of the utilization of peer support services by professional agencies. As defined by SAMHSA, peer support services (PSS) are services that are planned, operated, administered, and/or evaluated by individuals who have disclosed a current or past psychiatric diagnosis. Identified as peers, these individuals are able to provide valuable social support to people with mental illness.

Using the following measures, agencies can measure the extent to which non-peer staff may hold attitudes toward peers and recovery that can impede peer integration, and keep agencies from making the most of peer staff.

A questionnaire that can be used to assess staff attitudes is the Recovery Attitudes Questionnaire (RAQ-7).  This simple scale includes seven statements that are measure beliefs regarding the possibility of recovery.  Two such statements include “Recovering from mental illness is possible no matter what you think may cause it,” and, “People in recovery sometimes have setbacks.”

Programs can also assess the extent to which their organization promotes recovery using the Recovery Oriented Service Evaluation (AACP-ROSE).  This tool, developed by the American Association of Community Psychiatrists, focuses on four domains: administration, treatment, supports, and organizational culture. 

For more information on measuring recovery, look at “Measuring Recovery: A Toolkit for Mental Health Service Providers in New York City,” published in 2013 by the Bureau of Mental Health at the NYC Department of Health and Mental Hygiene. 2013.    You may also find it useful to look at “Can We Measure Recovery? A Compendium of Recovery and Recovery-Related Instruments”, by Ralph, Kidder & Phillips, from 2000.

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Snapshot: Out of Touch with Your Reality

Marylou Selo

On Wednesday, 2 September 1998, Swissair Flight 111 from JFK to Geneva crashed into the Atlantic Ocean southwest of Halifax.  I had been hospitalized for severe psychotic depression for several months, and did not care about any world events. I hardly spoke.  The word I uttered most often was, “No!”

However, as I was pacing the living room of psychiatric ward on that day, the voice of the newscaster somehow reached me.  I joined the other patients and the two nurses on duty on the couch and watched the horror scene.  During a news intermission, I turned to the male nurse, and said, “That could have been me landing in the ice-cold waters of Nova Scotia.  I was often on that flight.”

He gave me an incredulous look.  I continued, “Sometimes, even in first class, in the days that interpreters still flew in the same class as their clients.”  When the male nurse finished staring at me, he asked, “Who were your clients?”  I replied, “Lawyers, most of the time.  I am a conference interpreter by profession.”  The male nurse patronizingly put his arms around my shoulder and said condescendingly, “Dear Miss Selo, as long as you are with us, you are allowed to be whatever you want to be!”

He obviously lacked the imagination to see the disheveled, depressed woman as a professional of equal standing, and totally missed the opportunity to help me into the real world.

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Mental Illness and Violence

Elizabeth Saenger, PhD

New ideas about violence and mental illness are few and far between. Thus it was refreshing to see Sherry Glied and Richard G. Frank on “Mental Illness and Violence: Lessons From the Evidence” in the American Journal of Public Health last month. In a mere two pages, this essay constructs a relevant, statistics-backed social framework for stakeholders who grapple with the public, and private, association between violence and psychiatric diagnosis.

My favorite observation is that:

The journalist’s search for a mental illness explanation of aberrant acts will almost always succeed. Epidemiological research suggests that nearly half the population—whether or not involved in crime—experience some symptoms of mental illness over the course of their lifetimes…. The very high lifetime prevalence of illness and treatment seeking helps explain why virtually every story of a violent act can be linked to some clues of psychological abnormality or mental health treatment—even though the rate of violent behavior of any type among people who meet diagnostic criteria for mental illnesses is estimated to be only about twice as high as the rate among those who never experience a mental illness.

Step-by-step, Glied and Frank dispel the myth that deinstitutionalization is responsible for increased violence, and recommend against trying fruitlessly to decrease violence by curtailing civil liberties to restore institutionalization. Instead, the scholars argue, society should focus on “targeting identifiable subpopulations at elevated risk of violence,” such as conduct disorders, and substance use disorders, for intervention.

They conclude by acknowledging that this recommendation will not go far enough, for most “people with mental health problems do not commit violent acts, and most violent acts are not committed by people with diagnosed mental disorders.”

Glied S, Frank R. Mental Illness and Violence: Lessons from the Evidence. Am J Public Health. Published online ahead of print December 12, 2013: e1-e2. Doi:10.2105/AJPH.2013.301710.

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Research Corner

Elizabeth Saenger, PhD

Prescribing Psychotropic Medications in the Absence of a Psychiatric Diagnosis

A look at the database of a private insurance company with 5.1 million patients showed that 58% of the patients who received psychotropic medications did not appear to have an FDA-approved reason for these prescriptions. For people aged 50 to 64, and those who did not see specialists in psychiatry, this figure was even higher.

Are physicians overprescribing the classes of drugs under consideration, from antidepressants to antipsychotics? The authors search for alternatives to this obvious explanation, and raised the possibility that prescribers were reluctant to record psychiatric diagnoses lest their patients be stigmatized. The researchers also explore the idea that medications might be continued after the reasons for prescribing them had gone away; that prescribing might be driven by patient or caretaker requests, influenced by direct-to-consumer advertising; that continued need for a medication might exist, while documentation of that fact was missing; and so on.

With the clarion call for further research, the authors conclude that large numbers of outpatients “were prescribed a variety of psychotropic medication in the absence of a psychiatric diagnosis. This practice may represent incomplete record keeping or possible exposure of patients to the risks of psychotropic medications without clear indications for use.”

Wiechers IR, Leslie DL, Rosenheck RA. Prescribing of psychotropic medications to patients without a psychiatric diagnosis. Psychiatr Serv. 2013;64:1243-1248. doi: 10.1176/appi.ps.201200557.

Haldol, Please!

As the patents on the latest antipsychotics have expired, drug manufacturers have reformulated these products as long-acting injectable. These reformulations, or patent-extenders, enable companies to continue to charge a premium.

But are these long-acting injectable antipsychotics any better? Do they really increase adherence to medication, as their adherents claim? Or do these formulations keep patients away because they don’t want injections?

A study from Taiwan supplies an unexpected answer. A sample of more than 10,000 patients with frequent hospitalizations was assigned to one of five conditions (two oral antipsychotics vs three long-acting injectable.). The use of different formulations (oral vs injectable) did not affect the likelihood of rehospitalization: 27.3% of each group was rehospitalized. What was surprising, however, is that one of the three the long-acting injectables - haloperidol (Haldol) - had a lower rate of rehospitalization (22.5%).  Haldol has been around a long time and is significantly cheaper.

In short, what was most effective was both old and cheap.

Huang S-S, Lin C-H, Loh E-W, Yang H-Y, Chan CH, Lan T-H, Antipsychotic formulation and one-year rehospitalization of schizophrenia patients: A population-based cohort study. Psychiatr Serv. 2013;64”1259-1262.

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For information on State and Federal News That May Affect You… check the Coalition’s website for briefs and reminders about state and federal issues that may affect you, from updates on the HARP to deadlines for certifications of compliance, and from job openings to events. You can also subscribe to Coalition Briefs, and receive a semi-monthly update on behavioral health in New York, by contacting [email protected].

Opinions in this newsletter may not reflect the views of the Editor or the Coalition of Behavioral Health Agencies, Inc.

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