In 2007 the Centers for Medicare and Medicaid Services released a letter approving the payment of peer-based recovery support services through state Medicaid programs (Smith, 2007). The letter described the value of peer-based recovery support (P-BRS) and described three rather minimal requirements – supervision, coordination of care and training/credentialing- that states would have to meet to include P-BRS in their Medicaid- funded systems of care.
Arizona, one of the first states to begin allowing providers to seek reimbursement for P- BRS, developed a practice protocol outlining the state’s requirements for organizations and individuals seeking reimbursement for the provision of P-BRS through the state’s Medicaid program (Arizona Department of Health Services, 2007). The state guidance describes the requirements for providing P-BRS by traditionally organized treatment organizations and mentions the possibility that consumer-operated service programs (COSP’s) might also be involved in the provision of these services. The authors of this article are employed as the CEO and COO of a COSP with facilities in south-central and south-western Arizona, United States and have a financial interest in the operation of the organization.
For several years the COSP’s--organizations certified to seek reimbursement through Medicaid but not licensed to conduct assessments, develop service plans or provide treatment services--relied on treatment organizations to provide these necessary components of the service delivery process. This requirement generated conflict between COSP’s and traditional treatment organizations, as many treatment organizations were loath to provide assessment/service planning and treatment services and then refer these Medicaid members to providers outside of their own doors. Although state regulations specified time limits for the provision of assessment and service planning, and for transfer of records to COSPs, these limits were routinely disregarded by treatment organizations. As a result, COSPs had difficulty obtaining the documents, yet were reluctant to engage in formal grievance processes for fear of further alienating the treatment organizations. These conditions exacerbated the marginalized status of the COSPs.
These conflicts led to a situation in which, rather than referring to the COSPs, many traditional treatment organizations began providing P-BRS by adding a peer-based component to their menu of services, while others simply added a few peer staff and announced the availability of P-BRS at their traditional service delivery sites.
In the intervening years there were changes in Arizona’s Medicaid system. These changes came about as a result of federal laws which required parity in as well as integration of primary care and behavioral health care, and they exacerbated the tension between COSPs and traditional treatment organizations in the state. Research into peer support services indicates that clinically trained staffs often believe that peer staff members are unreliable, unethical, and prone to being overwhelmed by their job responsibilities (Chamberlin, 1977; Chinman, Young, Hassell, & Davidson, 2006; Davidson & Bellamy, 2012; Hardiman, Therlot, & Hodges, 2005). Our experience in Arizona confirms that these factors were present, and in fact formed the basis for a situation in which many traditional treatment providers began to perceive COSPs as interlopers in their “professional” relationships with their members and in their business models. This appears to have continued, despite the fact that Arizona has changed the regulations governing assessments and service plans, and COSPs are now able to contract with individual behavioral health professionals to secure the assessments/service plans.
Rather than continue trying to persuade traditionally-organized providers in Arizona’s Medicaid-funded system of care that COSPs contribute substantially to the well-being of network members and enhance the effectiveness of the network as a whole, it is our belief that COSPs must take steps to define for ourselves a suitable role in the overall system of care. To date, no effort has been made in this regard: defining a clear role for peer-delivered services has not been part of a federal statement regarding their value nor a state document addressing implementation of peer services in the state (Arizona Department of Health Services, 2007; Smith, 2007). For this reason, we need to take this step now.
It is time for COSPs to reject the idea that we are involved in the provision of behavioral health services only with the forbearance of traditionally organized providers of these services. The attitudes behind the denigration of these services find their roots in the devaluing of peer providers, and the lower status (as seen through the eyes of clinically- oriented providers) of organizations that encourage them, This is a reflection of factors that drove the development or peer-run services to begin with the disempowerment and denial of agency that has characterized the clinical approach to recipients of behavioral health services (Mead, Hilton, & Curtis, 2001; Mead & MacNeil, 2006). We cannot expect clinicians to reject the decades of research, training and practice that provide the foundation for the medicalized culture that seeks to strip us of our agency, voice and dignity. We can, however, begin to act differently, and change the nature of the interactions we have with traditional clinical organizations and their staff.
In the United States, State of Arizona, we no longer require the assistance, and therefore the consent, of traditional treatment organizations to serve persons in the Medicaid-funded system of care. Further, a significant body of evidence has been emerging which convincingly describes what COSPs do well, and this obviates the need for individual peer- and family- operated organizations, or even groups of such organizations, to engage in efforts to ‘prove’ the effectiveness of the services we deliver. Rather than seeking to change the attitudes of traditional providers through education, we can change these attitudes through demonstrations of effectiveness within the systems of care we work in. We know what we do well, we know how we can best promote the well- being of Medicaid members seeking P-BRSS at our facilities, and we know how we contribute to the systems of care in which we operate.
Role of COSPs
So, what do COSPs do well and how might this contribute to the well-being of our individual members as well as the entire system of care? A body of literature describing aspects of health care at which COSPs excel has developed over the last twenty years, yet it is often overlooked--not only by traditional clinical organizations, but also by COSPs as well. When reviewing this literature, many of us find that we recognize those activities which our own organizations do well. Moreover, examining these unique abilities may help strengthen the resolve of COSPs to present themselves more confidently as valuable contributors to the systems of care in which we work.
First, P-BRS has been successfully provided by COSPs to persons with chronic mental illnesses (CMIs), substance use disorders (SUDs), and comorbid CMI/SUD (Davidson & White, 2007; Gagne, White, & Anthony, 2007; Reif et al., 2014). This means that persons participating in P-BRS need not be segregated based on diagnosis. Persons with any of these behavioral health conditions can expect to benefit from P-BRS. For example, participation in P-BRS has been linked to decreases in symptoms of, and hospitalizations for, CMI (Bergeson, 2011; Campbell & Leaver, 2003; Chinman et al., 2006; Sledge et al., 2011) and reduced risk of relapse for those persons with SUDs (Boisvert, Martin, M., & Clarie, 2008; Sledge et al., 2011). We may anticipate, therefore, that entry into P-BRS at COSPs will benefit persons entering these services regardless of diagnostic category.
P-BRS are also an effective means for conducting outreach, especially with hard-to- reach populations (Solomon, 2004). This may be a demonstration of the experiential knowledge brought to outreach efforts by peer staff members who have frequented these obscure gathering places. Alternatively, it may reflect qualitative differences in the care provided by peer staff rather than clinicians. Davidson, Bellamy, Guy and Miller (2012) have identified three specific qualitative differences between clinical and peer-support services: Installation of hope through positive self-disclosure; application of role-modeling in day-to-day life, especially with non-illness related factors such as poverty, housing, stigma, discrimination and other trauma, all while negotiating the complex social and human service system, and; the very nature of the roles of peer specialist and member, defined by mutuality and shared meaning rather than clinical expertise and help-seeking.
The qualitative differences between P-BRS and traditional clinical treatment go beyond those listed above. For example, one set of researchers found addition of a peer-facilitated person-centered planning process increased the degree to which participants felt their care was responsive and inclusive of non-treatment issues, and increased their sense of control and ability to bring about changes in their lives (Mueser et al., 2002). The increased sense of control and self-efficacy among participants may have increased their dissatisfaction with their lives, as many came to view the symptoms of their illnesses as barriers to be overcome rather than limitations that must be accepted. Other authors have identified increased feelings of hope, well- being and willingness to engage in self-care as correlated with participation in peer-run support services (Sledge et al., 2011).
After an organization has successfully contacted potential service participants it is necessary to engage them in services. Again, peer organizations have proven effective at engagement, as researchers found that the role of peer staff in engagement included successfully facilitating the initiation of service delivery, enhancing service delivery and sustaining service delivery (Chinman et al., 2006).
Finally, P-BRS has been shown to reduce social isolation and increase ties to natural supports in the community (Bergeson, 2011; Chinman et al., 2006). These are crucial steps in moving behavioral health systems of care from the continued embrace of acute models of care and the adoption of a chronic care perspective. P-BRS, based on mutuality, supportive relationships, and the recognition that behavioral change is a process rather than an event, can assist systems of care to adopt this more accurate and effective approach to conceptualizing behavioral health services. (Gagne et al., 2007; W. White & Kleber, 2008; W. White, Scott, Dennis, & Boyle, 2005; W. L. White, 2008). Of course, traditional treatment organizations are likely to respond to findings like this by establishing their own peer staff and providing P-BRS themselves. This would not accomplish the same goal, in that the effectiveness of peer-based recovery support has been positively correlated with participant control over services, not typically a characteristic of traditional treatment organizations. In short, COSPs provide a more effective version of P-BRS than do traditional treatment organizations. (Alberta & Ploski, 2014; Campbell & Leaver, 2003; Chamberlin, 1977; Kaplan, 2008; Kemp & Henderson, 2012; Salzer, 2002).
The available evidence, then, indicates that COSPs have a significant role to play in
Over the past year, in response to changes in the regulations governing the Mediciad- funded system of care in Arizona, Transitional Living Center Recovery, a COSP providing
peer-based recovery support in southern Arizona, has demonstrated the possibilities available to peer-run organizations that choose to leverage the strengths of COSPs working within a system of care dominated, as most are, by traditionally organized treatment providers.
- Identifying persons who will benefit from participation in behavioral health services;
- Engaging these persons in services;
- Encouraging participants to remain in services;
- Advocating on behalf of participants, and, through these interactions, assisting participants to learn how to advocate for themselves within the system of care and increasing the effectiveness of care;
- Linking participation in the treatment system to natural supports outside of the treatment system, and;
- Bridging the transition between reliance on the system of care and reintegration into the community and into individualized systems of natural supports.
In fiscal year 2018, beginning October 1, 2017, Transitional Living Center Recovery (TLCR) began an effort to demonstrate the effectiveness of COSPs in Arizona’s system of care. The effort emphasized implementing Arizona’s new regulations allowing COSPs to arrange for individual behavioral health professionals to provide assessments for use by COSPs, and, through this mechanism, 1) moving people from the initial request for services to enrollment in the system as quickly as possible; 2) securing employment for members seeking
employment, and; 3) enhancing outreach activities to enroll a greater percentage of the persons contacted in services at TLCR.
In FY2017, 25% of all persons contacted during outreach by TLCR staff members enrolled in services with TLCR. In FY2018, the percentage of persons contacted by TLCR outreach staff who then enrolled in services has been 68%, including 100% of potential service participants who contacted TLCR in the third quarter of FY2018. Similarly, the days from initial contact to completed enrollment decreased from a mean of 73.46 days in FY2017 to 21.56 days in FY2018. A closer look at these statistics reveals the obstacles faced by COSPs when seeking assessment and service plans from traditional treatment providers, as the range of the intake to enrollment data for FY2017 was 281 days, with a standard deviation of 101 days. In FY2018, working with an individual behavioral health professional to conduct the assessments and reducing the number of treatment organizations we refer new members to for assessments, the mean days from intake to enrollment decreased to 21 days, including a mean of 6.4 days in the third quarter of 2018. The range of the intake data was reduced from 281 days in the last quarter of FY2017 to 44 days in the third quarter of FY2018, and the standard deviation was reduced from 100.23 days to 10.45 days. These reductions in the time it takes to enroll people into care contributed significantly to the 100% outreach-to-intake for new participants documented in the third quarter of FY2018.
The benefits of P-BRRS provided through COSPs have been increasingly well documented. Rather than continuing to look to treatment organizations to support our efforts we must insert ourselves into the service delivery environment in a manner that capitalizes on our strengths and maximizes the benefits of participation in peer-based recovery support for our participants and the communities in which we live. It is clear that the most effective role for COSPs in a system of care is not merely to serve as ancillary service providers, but rather as the primary portals through which persons enter and exit the system. During each member’s episode of care, COSPs should play lead roles in outreach and initial engagement, maintenance of engagement through the provision of advocacy and support, evaluation of how well services are meeting each participants’ needs and encouraging the development of a system of natural supports outside of the behavioral health system. COSPs in Arizona are regularly proving this: conducting outreach, engaging people in services, conducting assessments, creating service plans, and working with treatment providers to ensure that every individual enters the healthcare system in a timely fashion and has access to the entire range of services necessary to address their particular set of needs.
In Arizona at least, this means that the key to expanding the role of COSPs as portals into, and out of, the system of care lies within the COSPs themselves. As noted above, COSPs in Arizona are working within a regulatory framework that allows us to assume a more central role in the system of care. Unfortunately, many COSPs may be reluctant to step into this role. Something similar happens when participants in behavioral health systems of care are encouraged by those systems to “adopt the role of ‘mental patients,” (Mead et al., 2001).
COSPs in Arizona that continue to look to treatment organizations for referrals to peer services are not taking advantage of systemic opportunities for empowerment. We would even suggest that this passivity, in turn, creates a parallel, internal culture that promotes dependence among persons receiving services at these organizations. We base this assertion on the extremely low numbers of service recipients who secure employment while participating in services at many of these organizations in Arizona- essentially zero. The numbers suggest that the persons receiving services at these organizations are not moving through the service delivery system, but instead are remaining there for long periods of time. And so, these COSPs seem to be perpetuating the very condition which COSPs were specifically created to ameliorate – the creation and perpetuation of ‘mental patients’ rather than engaging in mutually transformative relationships in which people who are often identified primarily by their diagnoses create self- identified, satisfying roles for themselves in their communities.
If COSPs are to move beyond our current position on the periphery of the system of care, it is up to our leaders and members to address this situation. COSPs must step forward and recognize that our role is to encourage the behavioral and lifestyle changes our members have defined for themselves, and especially those changes that will allow our members to develop their own skills and live their lives outside of the limitations they may have experienced as a result of their illnesses and/or circumstances. Similarly, we cannot wait for traditional treatment organizations, many of which have been, and continue to be, reluctant to refer persons to COSPs for reasons both real and imagined. Rather than seeking some sort of administrative remedy that will require the treatment providers to refer people to COSPs, a remedy often promoted by the leadership of COSPs in Arizona, we must create our own pathway to a key role in the system of care. Again, the literature is clear on this: treatment providers often doubt the ability of COSPs and peer providers. Insisting that these organizations must refer persons to COSPs will not change this. Conducting effective outreach and assessment, and subsequently referring members to the treatment organizations, will demonstrate the value and effectiveness of COSPs and allow us to more fully contribute to the provision of health care in our communities.
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