The International Journal of Psychosocial Rehabilitation

Creation of the Pillars of Peer Support Services:
Transforming Mental Health Systems of Care

Emily A. Grant Ph.D.
(Corresponding Author)
Wyoming Survey and Analysis Center
University of Wyoming

1000 E. University Ave.
Laramie, Wyoming 82071

Allen S. Daniels, Ed.D.
Healthcare Consultant

Ike G. Powell CPRP
Director of Training
Appalachian Consulting Group, Inc.

Larry Fricks
Vice President of Peer Services
Depression and Bipolar Support Alliance

Lisa Goodale M.A.
Director of Peer Services
Depression and Bipolar Support Alliance

Sue Bergeson MBA
Vice President, Consumer Affairs
OptumHealth Public Sector

Grant EA, Daniels AS, Powell IG, Fricks L, Goodale L & Bergeson S (2012).Creation of the Pillars of Peer Support Services
Transforming Mental Health Systems of Care.  
International Journal of Psychosocial Rehabilitation. Vol 16(2) 20-27

The Pillars of Peer Support Services Summit was supported by: Substance Abuse and Mental Health Services Administration (SAMHSA) and Center for Mental Health Services (CMHS), National Association of State Mental Health Program Directors (NASMHPD), Depression and Bipolar Support Alliance (DBSA), Wichita State University Center for Community Support and Research, Appalachian Consulting Group (ACG), Carter Center, OptumHealth, and Georgia Mental Health Consumer Network. Special acknowledgements are also due to Peggy Clark, MSW, MPA, Technical Director Center for Medicaid State Operations at the Center for Medicare and Medicaid Services, and the participants from each of the represented states.

The Pillars of Peer Support Services Summit convened in November 2009, to examine the multiple levels of state support necessary for a strong peer support workforce. Summit participants developed and agreed upon a set of Pillars of Peer Support Services.  Twenty five “pillars” of peer support services propose a framework for states interested in developing or expanding peer support programs.

Key Words:
Peer Support, Program Development, Mental Health Workforce

Peer support is becoming an established role in the spectrum of mental health care (Salzer, Schwenk, & Brusilovskiy, 2010; Grant, 2009).  In general, peer support occurs when people share common concerns or problems and provides emotional support and coping strategies to manage problems and promote personal growth (Davidson, Chinman, Kloos, Weingarten, Stayner, D, & Tebes, 1999).  Peer support has demonstrated productive outcomes in areas of substance abuse, parenting, loss and bereavement, cancer, and chronic illnesses (Kyrouz, Humpherys & Loomis, 2002; White, 2000), and has now being implemented in mental health systems of care.

Peer support can be an integral part of the behavioral health workforce (Morris, Hoge, Morris, Adams, & Daniels, 2009). Settings for care include mental health centers, inpatient /outpatient settings, emergency rooms, and crisis centers (Salzer et al, 2010; Fricks, 2005).  Certified Peer Specialists (CPSs) work with consumers assisting in regaining balance and control of their lives and supporting recovery (Chinman, Young, Hassel & Davidson, 2006; Sabin & Daniels, 2003; Orwin, Briscoe, Ashton & Burdett, 2003).  A key differentiating factor in the CPS role from other existing mental health services is that, in addition to traditional knowledge and competencies, the CPS operates out of their lived experience and experiential knowledge (Mead, Hilton & Curtis, 2001).  The CPS works from the context of recovery, utilizing language based upon common experience rather than clinical terminology, and person-centered relationships to foster strength based recovery (Davidson et al., 1999). 

Multiple studies document favorable results from inclusion of peer supporters on treatment teams (Mead & MacNeil, 2006; Davidson et al., 2003; Felton, Stastny, Shern, Blanch, Donahue, Knight & Brown, 1995).  Information provided by peers who have the lived experience often appears more credible than that provided by mental health professionals who do not have firsthand experience with this issue (Woodhouse & Vincent, 2006).  When CPSs are part of hospital-based care, inpatients have shorter stays, decreased re- admissions, and subsequent reduction in overall treatment costs (Chinman, Weingarten, Stayner & Davidson, 2001).  Other studies also suggest use of peer support can reduce need for more formal mental health services over time (Simpson & House, 2002; Chinman, et. al, 2001; Klein, Cnaan, & Whitecraft, 1998). 

The formal role of peer support in the mental health system is still relatively new.  Center for Medicaid Services deemed mental health peer support a reimbursable service beginning in 2001 (Fricks, 2005). To be eligible for Medicaid reimbursement, training, continuing education, supervision, and care coordination requirements must be established and met (Smith, Centers for Medicaid and Medicare Services, 2007). Certification is defined at the state level, contingent on completing necessary training and demonstration of core competencies.  As of yet, national standards for practice or training have not been established. 

Method and Results
Pillars of Peer Support Services Summit 
As a first step in creation of standards for peer support services, representatives from all U.S. states that had a Medicaid recognized peer support program (23 states) were brought together to discuss essential components of peer support programs. Information gathered during this summit, as well as a set of recommendations that was created are detailed in this report to answer the following questions:

1) What is the current state of Peer Support Services across the United States?
2) What supports must be in place for a successful peer support program?

To answer the first question, each state was asked to complete a survey on peer support services in their state.  The survey was sent out via email to be completed and submitted before attending the summit. Surveys were returned by 22 of 23 participating states (some states did not provide information on all questions).  The survey consisted of eight questions about number of CPS, certification particulars and reimbursement rates. Three additional questions were asked on the unique experiences of each state. Survey results provide a comprehensive accounting for how states are using peer support, their roles, and the opportunities and challenges they face. 

Peer Support Specialists Employed in State Systems and Rates of Reimbursement

The range of consumers employed in each state varied widely from 9 to 500. Of the 21 respondents, 10 states currently employ at least 50 CPSs.  The range for reimbursements was between $3.00 and $19.00 per 15 minute billable unit. The average rate of reimbursement was $10 per 15 minute unit.  One state reported reimbursement on a monthly basis of $150.00.  Tracking billable services is an essential aspect of billing for peer support services.  Twenty states indicated that they track by billing codes and one state reported using service logs.

Training and Certification of Peer Support Specialists
 Most states (n = 14) reported a minimum number of training hours required for certification.  However, six states have module-based training. Of the states requiring a minimum number of training hours, the range is 40 to 80 hours, with typical trainings of 40 hours.  All but 2 of the 17 states who responded to the question regarding certification indicated they had standard certification processes. The most common certifying agent is the state department of mental health (n = 17). Some states use other entities including advocacy groups (n = 2) and academic institutions (n = 2).

Barriers to Implementation of Peer Support Services at the State Level
All states (n = 22) reported experiencing barriers to implementing peer support services.  The most common barriers reported were acceptance of CPSs at mental health centers, financial issues, overall understanding of the CPS role, and individual CPS issues. Individual CPS issues include: dual role stress; loss of disability benefits due to income; fear to ask for help; fear of job loss; lack of anonymity; misunderstanding own role; burn out and turn over.
Pillars of Peer Support Services

To answer the second question: “What supports must be in place for a successful peer support program?” three qualitative questions were posed to each state: 

1.    What do you think are the strengths, unique qualities or innovations of your program?
2.    What infrastructure do you believe must be in place at the state level to run a successful peer support program? 
3.    What recommendations would you make to states attempting to set up this kind of program for the first time?
During the summit, each state had a few moments to answer these questions by describing their program characteristics and their recommendations to the other participants. Afterwards, Appalachian Consulting Group and the Summit planning committee proposed a potential set of standards for the implementation of successful peer support programs. This list was drafted based on experiences of the Appalachian Consulting Group (who has developed a model of peer support training that is reportedly used by several states) and the planning committee.  The states were split into work groups to examine this proposed list and modify it based on what their own experiences implementing CPS programs, as well as they experiences the shared from all other participating states. Proposed changes were then assimilated by the summit work groups and a new list immerged.  There was consensus for the list and support for adoption from all participating states.  This list, titled the Pillars of Peer Support Services, is to be a resource for states in their work with the CPS workforce, as well as a tool for states beginning or expanding their programs. 

The Pillars of Peer Support Services
Created by State Representatives at the Carter Center: Pillars of Peer Support Services Summit November, 2009

A state’s Peer Support Specialist Certification Program is strengthened when…

1…there are Clear Job and Service Descriptions that define specific duties that allow Certified Peer Support Specialists to use their recovery and wellness experience to help others recover.

2 …there are Job-Related Competencies that relate directly to the job description and include knowledge about the prevalence and impact of trauma in the lives of service recipients as well as trauma’s demonstrated link to overall health in later life.

3…there is a Skills-Based Recovery and Whole Health Training Program which articulates the values, philosophies, and standards of peer support services and  provides the competencies, including cultural competencies and Trauma Informed Care, for peer support specialist duties.

4…there is a Competencies-Based Testing Process that accurately measures the degree to which participants have mastered the competencies outlined in the job description. 

5…there is Employment-Related Certification that is recognized by the key state mental health system stakeholders, and certification leads directly to employment opportunities that are open only to people who have the certification.

6…there is Ongoing Continuing Education, including specialty certifications, that exposes the peer support specialists to the most recent research and innovations in mental health, Trauma Informed Care and whole health wellness, while expanding their skills and providing opportunities to share successes, mentor and learn from each other.

7…there are Professional Advancement Opportunities that enable Certified Peer Support Specialists to move beyond part-time and entry level positions to livable wage salaries with benefits.

8…there are Expanded Employment Opportunities that enable Certified Peer Support Specialists to be employed in a variety of positions that take into account their own strengths and desires. 

9…there is a Strong Consumer Movement that also provides state-level support, training, networking and advocacy that transcends the local employment opportunities and keeps Certified Peer Support Specialists related to grassroots consumer issues.

10…there are Unifying Symbols and Celebrations that give Certified Peer Support Specialists a sense of identity, significance and belonging to an emerging profession or network of workers.

11…there are ongoing mechanisms for Networking and Information Exchange so that Certified Peer Support Specialists stay connected to each other, share their concerns, learn from one another’s experiences, and stay informed about upcoming events and activities.

12…there is Media and Technology Integration that connects Certified Peer Support Specialists with the basic and innovative information technology methods needed to do their work effectively and efficiently.

13…there is a Program Support Team that oversees and assists with state training, testing certification, continuing education, research, and evaluation.

14…there is a Research and Evaluation Component that continuously measures the program’s effectiveness, strengths and weaknesses and makes recommendations on how to improve the overall program. 

15…there are opportunities for Peer Support Workforce Development that help identify and prepare candidates for participation in the training and certification process.

16… there is a Comprehensive Stakeholders Training Program that communicates the role and responsibilities of Certified Peer Support Specialists and the concepts of recovery and whole health wellness to traditional, non-peer staff (peer specialist supervisors, administration, management and direct care staff) with whom the Certified Peer Support Specialists are working.

17…there are Consumer-Run Organizations that operate alongside government and not-for-profit mental health centers that intricately involve consumers in all aspects of service development and delivery and provide value-added support to the peer support workforce.

18…there are regularly-scheduled Multiple Training Sessions that demonstrates the state’s long-range commitment to training and hiring Certified Peer Support Specialists to work in the system.

19…there is a Train-the-Trainer Program for Certified Peer Support Specialists that demonstrates the State’s commitment to developing its in-state faculty for the on-going training.

20…there is Sustainable Funding that demonstrates the State’s commitment to the long-term success and growth of the program.

21…there is Multi-Level Support across all levels of the government, with champions at all levels, that demonstrates the State’s commitment to the program and continually promotes the valuable role of Certified Peer Support Specialists in the system

22…there is a Peer Support Specialist Code of Ethics/Code of Conduct that guides peer support service delivery.

23…there is a Culturally Diverse Peer Workforce that reflects and honors the cultures of the communities served.

24…there is Competency-Based Training for Supervisors of Certified Peer Support Specialists which reinforces fidelity to the principles of peer support and emphasizes the role of peer support specialists in building culturally competent and trauma informed systems of care that take into account the overall health and wellbeing of persons served.   

25…there is opportunity for Certified Peer Support Specialists to receive training in and deliver Peer Support Whole Health Services to promote consumer recovery and resiliency.

These Pillars of Peer Support Services are intended as a set of guiding principles for the development of state based programs.  They are also directly applicable to other organizations and roles that utilize the resources of Peer Support Specialists.

Discussion and Conclusion
The result of the Pillars of Support Services Summit was an active and lively review of peer support in state based mental health systems of care. As a part of the summit, data was collected and reported on the current status of peer support services.  To date this is the most comprehensive review of CPS in these systems.  This information will be useful in a variety of settings to endorse and expand peer support services across diverse systems of care. 

This study demonstrates that peer support has gained an important and effective role in state systems of mental health care. While there are ongoing challenges, it is clear that participating states have been successful in integrating peer support in their workforces and overall systems of care. In order for long term viability and success, a set of common principles for strategic development, implementation, promotion, and maintenance of peer support services in state systems of care is needed. 

The Pillars of Peer Support Services are intended to be both guidelines and resources providing a framework for future services to be built upon.  They have been adopted by a consensus group and can serve as tools to help move the field forward.  Recognition is due to the forward thinking states that participated in this summit to foster the evolving transformation of mental health services and strength based recovery. In the future, success and barriers to implementation of the Pillars should be studied.  This is a promising start to understanding the current state of CPS and also creating a set of standards for program implementation. Efforts should be made to continue the advancement of the Pillars of Peer Support Services to foster the growth and evolution of the peer support workforce.



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