Since 1992, Pathways to Housing has provided individuals who experience homelessness and mental health conditions immediate access to permanent, independent housing and consumer-driven supports. As a Housing First agency, part of Pathways’ mission is to end homelessness; however, this is just the beginning. Once housed, consumers have a new sense of hope and possibility, but also face the challenges of maintaining housing and taking next steps. We saw an opportunity to enhance the services provided by Pathways’ existing clinical teams by adding a program that utilized the strengths and perspectives of peer providers. This program would be the first large-scale inclusion of a team of peer providers within the Housing First model.
In 2009, Pathways launched the Peer Wellness Program to provide consumers with recovery-oriented wellness services delivered by peer specialists who assist consumers to achieve goals of their own choosing. Funded by a 5-year SAMHSA Services in Supportive Housing grant, the core mission of the program is to deliver wellness services that foster hope and self-determination using a peer-to-peer, strengths-based approach. The Peer Wellness Program uses tools and interventions designed to address in-depth, long-term recovery goals that may not be a focus of clinical support teams who are often focused on responding to immediate needs. Any Pathways consumer is eligible to receive services from the Peer Wellness Program. Now in its third year, the program has served over 190 participants with a team of nine peers.
Peer Wellness Specialists: The Importance of Training
The Peer Wellness Specialists are individuals who have had their own experience with mental health issues, substance use, and/or homelessness and who have demonstrated their resilience. They assist consumers to reconnect with children, take better care of their physical health, enroll in college, find employment, or cope with mental health symptoms. In addition to lived experience, Peer Wellness Specialists have also received extensive training at Howie T. Harp Peer Advocacy and Training Center (HTH). They have completed 6 months of coursework and a 3-month internship to receive Peer Specialist Certification. This training and experience ensures that staff have already learned concepts of wellness, recovery, and engagement, and have been introduced to Evidence-Based Practices, as well as administrative responsibilities. Building on that base, our in-house training can then focus on orienting staff to the Peer Wellness program and covers specific topics such as intentional peer support, wellness tools, stages of change, motivational interviewing, and minimizing burnout. The Peer Wellness Specialists have emerged as a team of highly skilled and effective peer providers.
Program Start-up: How to Integrate with Integrity
The Peer Wellness program was created as an enhancement to Pathways’ services. Therefore, a service structure had to be created that would allow for the Peer Wellness Program to be integrated into existing operations while maintaining the integrity and specialized mission of the new program. The overall goal was to expand and enhance the quality of services provided by other Pathways staff, while not replacing or duplicating existing services. The goal was to maximize Peer Wellness Specialists’ ability to engage in deeper, long-term recovery-oriented activities (e.g., reuniting with family, improving management of mental health symptoms, and obtaining employment) and to minimize the degree to which they would be involved in more routine aspects of service delivery (e.g., obtaining entitlements, addressing housing repairs, managing medications). This was accomplished in two ways: 1) Peer Wellness Specialists were assigned to work with, but not for, Pathways’ existing service teams and 2) The Pathways Resource Center, which offered groups and classes for consumers, was converted to a center where all recovery services became peer-led by the specialists.
Peer Wellness Specialists based with Pathways support teams work alongside clinicians, attend team meetings, visit clients in the community, and facilitate groups. However, they act as consultants on the team – a role that signifies they work with the team but are there to provide a specialized service. This buffers them as much as possible from routine tasks assigned to other team members that might dilute a focus on Wellness services. It also allows the peer specialists to operate explicitly under the auspices of the Peer Wellness Program and to maintain a perspective and approach distinct from the team.
At the Center, Peer Wellness Specialists facilitate a wide range of classes and groups (e.g., Wellness Self-Management, Financial Wellness, Nutrition, Journaling, and Spirituality) and conduct individual counseling sessions. The Resource Center gives the Peer Wellness Program a “home base” and provides an environment that is completely separate from the support teams. Many of the Peer Wellness Specialists have also developed specific areas of expertise, or sub-specialties, including employment, education, financial literacy, nutrition/health, and parenting.
The Importance of Flexibility and Consumer Feedback
Fundamentally, it is the Peer Wellness Program’s flexibility that truly accounts for its success. Peer specialists deliver services in locations of the consumer’s choosing–in the person’s apartment, at the Resource Center, or anywhere in the community. Staff can also meet with consumers singly or in groups, as the consumers prefer. While peer specialists have an assigned caseload, they can refer consumers to other Peer Wellness staff for specialty services (e.g., employment, education, financial) and thus also serve consumers as a team. In this manner, staff members are able to deliver services both as a team and as individual providers.
Consumer feedback plays a large role in shaping the program, both formally and informally. Formal evaluation activities document participant needs, goals, and outcomes and feed this information back into the program. For example, social isolation and parenting emerged as two priority areas from the baseline evaluation; in response, the program started a parenting initiative and a host of activities aimed at expanding social connectedness. Consumers also provide feedback informally, requesting new groups or modifications to existing services. For example, the program incorporated an informal “warm line” after consumers began calling Peer Wellness Specialists outside of their regular hours. A consensus emerged among the peer specialists that the ability to reach a caring peer after hours was a need that they could readily identify with, and therefore wanted to provide for.
Wellness Tools and Curricula
The program uses a combination of evidence-based practices and program-specific tools and curricula. The Wellness Self-Management (WSM) workbook, a curriculum consisting of 57 individual lessons that allows consumers to flexibly proceed in addressing a range of wellness topics, is a core component of the program. New and original curricula have also been developed for the program based on the literature, but customized with the input of consumers. This has included manuals such as: spirituality (“Healing from Within”) developing meaningful activity (“Leading a More Enjoyable Life”), and men’s trauma (“Becoming a Better Man.”) These standardized guides help groups remain on-topic, sustain groups through staff turnover and allow for replication across sites.
Monitoring Fidelity: Supervision and Support
Fidelity to core principles is monitored through on-going supervision and support. Since many services are delivered outside the office, it is critical to support peer specialists “in the field.” Field supervision targets two areas: 1) how Peer Wellness Specialists are interacting with consumers including engagement and intervention strategies, 2) how they interact with other Pathways staff – is their voice heard in team meetings, are they able to advocate for consumers and appropriate tasks. Office-based group and individual supervision are also conducted and include routine discussion of caseloads, engagement issues, and documentation. However, more unique to the program, is time set aside to discuss how interactions with other clinical staff are going, to clarify responsibilities and mitigate role strain, and to provide support around job expectations. In addition to allowing Peer Wellness Specialists to brainstorm challenges as a team, these meetings also afford an opportunity to celebrate successes to sustain positive energy. Finally, progress notes written by Peer Wellness Specialists are reviewed on a daily basis to provide feedback on practice, suggest edits, and ensure that the peer perspective is maintained.
Challenges and Establishing Buy-in
As any new initiative, the Peer Wellness Program faced skepticism from some staff regarding the value of a new program. Further, even in agencies where there is a history of employing peer specialists, peer staff may encounter negative reactions or pose challenges to existing operations. To counteract these negative responses, we have used in-vivo supervision to target the dynamic developing early on between the Peer Wellness Specialists and the clinical teams with which they work. Another effective strategy has been encouraging the peer to identify a staff member on their team who is most supportive of their role and to use that team member to help broker other staff relationships. We also educated team members around the role of the peer wellness specialist, reiterating how those specialized services are different from “business as usual.” Finally, since several Pathways consumers were hired as Peer Wellness Specialists, procedures had to be established that would support the individual in their role both as staff and consumer.
Skepticism regarding the peer specialists can also extend to consumers, who sometimes discount the peer specialist’s role by dismissing them as individuals who lack clinical credentials. Time, persistence, creativity, and accomplishments have paved the way for greater acceptance of peers.
Thus far, two areas where consumers have made the greatest gains are social connectedness and functioning in everyday life. However, progress is highly relative and very individualized. For one individual, progress is measured by getting a job; for another, it may be more subtle – dressing professionally, leaving the house regularly, and seeing the identity shift that this process creates. The Peer Wellness Specialists have been particularly successful working with a few subgroups: 1) consumers who are new to Pathways, 2) those have disengaged from their clinical team, 3) those preparing to graduate to less intense services, and 4) those who have identified a recovery goal but needed extra support in moving forward to achieve it. As one Peer Wellness Specialist stated, beyond ending homelessness, “what we do is…allow a person to see the possibilities, the things they can achieve. Through sharing, mentoring, encouraging, and inspiring hope…what we do most of is getting people to re-discover themselves.”