For the caregiver of a Medicaid-eligible child who has a behavioral diagnosis, or demonstrated loss of a physical health diagnosis, Children & Family Support & Services (CFTSS) provide unprecedented support, advocacy and resources. On July 1, 2019, the fourth CFTSS component, Family Peer Support Services (FPSS) will become reimbursable under Medicaid Managed Care. Many young people stand to meet eligibility and with the emphasis on family support, it is a service that the whole family can benefit from.
This service differs from other CFTSS and Home & Community Based (HCBS) services in that it stabilizes and supports caregivers through a unique model of peer support. FPSS providers must demonstrate that they have “lived experience” navigating multiple systems of care for their child/ren. Among other benefits, a mounting body of research demonstrates that family peer support provides caregivers with a better understanding of their child/ren’s behaviors, increases their engagement in community and health resources, and reduces the rates of missed medical and behavioral health appointments. In addition, it validates the lived, personal experience of FPSS Providers and empowers them to help others. It further increases the pool of qualified service providers for clients, and provides a pathway to meaningful employment for individuals without a formal education in child development or social services. Currently, more than 35 agencies serving New York City have been designated to provide FPSS. However, there are considerable obstacles to the recruitment, onboarding, supervision of potential FPSS providers, as well as fiscal viability issues for the agencies employing them.
In various shapes and forms, JCCA has provided peer advocacy and support to families for quite some time, and can offer instrumental insight into the challenges of building and maintaining the FPSS workforce. JCCA, a child & family services agency in the New York metropolitan area, has provided home & community based services, foster care, preventive, mental health, and residential treatment for almost 200 years. The staffing pipeline is clear: almost every JCCA program works with motivated, resilient parents/caregivers who successfully navigate child welfare and/or behavioral health systems and emerge “on the other side” with newly developed strengths, skills, and knowledge. They are prime candidates to become advocates. However, their experience can leave parents and caregivers feeling exhausted and drained. Even the most resilient can harbor feelings of anger and resentment and need time to process, heal, and recover.
Credentialing FPSS providers poses another obstacle. Once employed, FPSS provider must be Credentialed Family Peer Advocates. To obtain a provisional credentialing, one must complete a multi-day online Level I training as well as an application with an attestation and two letters of reference. While providers do not need a formal education, this process can be challenging for prospective advocates who may not have recent work experience. For others, a written attestation recounting personal experiences is a deterrent. For Level II, the FPSS worker must obtain 1000 hours of experience before completing the training and submitting a new application; recertification is required as well. These same credentialing qualifications do not exist for other CFTS services.
Once they begin work, the Family Peer Advocate is expected to share their own experience, yet maintain boundaries. This is a difficult balance. The FPSS provider needs to have ongoing training, regular supervision, and an ability to process therapeutically the impact of vicarious trauma. Yudelca De La Cruz, the director of JCCA’s Family Resource Center and Parent Advocate program, encourages staff to seek outside therapy but finds that individuals, who are often parents with limited spare time, rely on their supervisor to manage both their work performance and their emotions.
Lastly, for employers who maintain a per-diem workforce structure, the multi-day training can make onboarding costly. The credentialing is at no charge, but providers must be compensated for their time even before they provide a billable service. Additionally, the rates for new Family Peer Support & Services are inadequate to sustain full-time staff. State-negotiated FPSS rates are nearly $10 less than the rates for Psychosocial Rehabilitation, a service that can be provided by a high-school educated worker without personal experience, credentialing, or additional training. JCCA and other agencies provide this service using a per-diem workforce, paying workers for the hours they work at a maximum of 20 hours per week—without benefits or vacation time. Turnover is high, as providers leave for opportunities with better wages, more hours, or benefits.
As JCCA embarks on providing this service, some suggestions are offered:
Recruitment: Not every service recipient is prepared to become a Family Peer Advocate, and especially not right away. Onicka Miller and Veronica Worley, Parent Advocate (PA) Coordinators in JCCA’s PA program, provide insight on theirs and others’ experiences transitioning from recipient to provider. The experience was draining, and individuals may need some distance before becoming advocates. Others feel unqualified and need repeated encouragement to gain confidence with their developed skills. When Ms. Miller and Ms. Worley first attempted to recruit participants at JCCA’s Family Resource Center parenting and anger management group graduations, they were not always successful. Instead, the Coordinators began simply collecting names and contact information at graduation, finding better results when they reached out six weeks to three months after the end of services, giving potential providers time to feel less overwhelmed and more confident in their abilities. Therefore, maintaining long-term contact with an established roster of clients, who demonstrate advocacy skills and interest, can improve the recruitment of viable candidates for the future.
Onboarding: The onboarding process, as noted previously, can be laborious. It is essential to identify candidates early on who appear capable of completing the requirements for the provisional credentialing. Through their experience, the Parent Advocate Coordinators have found that past work experience, especially in advocacy, can predict a peer’s ability to follow through with and complete the lengthy onboarding training and credentialing process.
Supervision: The Family Peer model must take into consideration training and opportunities for ongoing therapeutic processing. JCCA has found that staff relate positively to supervisors with lived experience. Supervision needs to be on a regular, ongoing basis with opportunity to debrief when needed as soon as possible and regular training on vicarious trauma. Staff new to work may require more intensive managing. It is also vital to instruct staff on boundaries as they leverage their lived experience without over-sharing. It is notable that longevity, in comparison with other staff of the same level, is much higher, even among the per-diem staff. Intensive supervision can be noted as a factor.
Fiscal Viability: Research has shown that, in order to be a sustainable career option, peer advocates would need to be increased at least $16 per hour. At New York State’s current rate, it is difficult to create many positions or a true career trajectory for FPSS providers. On-going government advocacy work aims to address the differential in wages.
A strong, committed workforce is waiting to be recruited, trained and put to work. With so much potential to strengthen and benefit caregivers confronting challenging medical and behavioral diagnoses, the innovative FPSS model requires an innovative approach to workforce development. JCCA’s “lived experience” demonstrates how to leverage this exciting opportunity for clients, agencies, and the providers they employ.
Marleen Litt, LCSW Assistant Vice President at JCCA with oversight of the CFTSS, HCBS, Parent Advocate & Family Resource Center programs. Contributions by Yudelca De la Cruz, MS.Ed Director of the Family Resource Center & the Parent Advocate program, and Onicka Miller & Veronica Worley, Parent Advocate Coordinators in the Parent Advocate program.