The future is here. 2014 is the year of the peer. In economics, the cycle of poverty is the “set of factors or events by which poverty, once started, is likely to continue unless there is outside intervention.” (Wikipedia, 2014) People with mental health, substance abuse and physical health challenges represent a large portion of individuals living in chronic poverty. The implementation of the Affordable Care Act (ACA) and the health activated social movement provide the integrated health community an exceptional opportunity to provide outside intervention.
Background and Problems: People living with serious mental illness in the United States die, on average, twenty-five years earlier than those without a serious mental illness, largely due to preventable medical conditions and suboptimal medical care (Brekke, J., Siantz, E., Pahwa, R., Kelly, E., Tallen, L. and Fulginiti, A., 2013). Studies are finding higher incidences of certain physical disorders and addictions, among people with serious mental illnesses including: diabetes, obesity, high cholesterol or dyslipidemia, metabolic syndromes, cardiovascular problems and cancer.
When combined with a serious mental illness, physical illness can lead to other health conditions and to a quality of life lower than that of both the general population and individuals with mental illnesses alone. These negative health consequences affect other recovery goals such as housing, vocational training, and education (Brekke, J., Siantz, E., Pahwa, R., Kelly, E., Tallen, L. and Fulginiti, A., 2013)
Peer providers bring their own experiences of living with mental illnesses, addictions and/or community health problems to light the path to recovery for others. Creating a recovery-based peer driven and delivered workforce creates training and employment opportunities providing peers with a stronger role and voice in integrated care plus the opportunity to break the cycle of poverty with employment in this emerging new healthcare field.
The Affordable Care Act and its implementing regulations, building on the Mental Health Parity and Addiction Equity Act of 2008, expands coverage of mental health and substance use disorder benefits and federal parity protections in three distinct ways:
- By including mental health and substance use disorder benefits in the Essential Health Benefits;
- By applying federal parity protections to mental health and substance use disorder benefits in the individual and small group markets; and
- By providing more Americans with access to quality health care that includes coverage for mental health and substance use disorder services (Stateline, C., 2013).
CMS is developing new programs and tools as a result of the Affordable Care Act. The ACA is based on a wellness model rather than a fee for service model, changing the landscape of health care.
This new landscape is paving roads for peer provided services. 2014 is being coined as the Year of the Peer; the timing is right and integrated innovation and emergent solutions are expected.
A US Peer Workforce Development Plan: Creating a national Lived Experience Workforce Development plan can establish and legitimize the lived experienced service provider as a healthcare occupation and should be recognized by the United States Department of Labor (DOL) as a billable healthcare provider category through the Centers for Medicare and Medicaid Services (CMS) and managed care organizations (MCO).
OptumHealth, an innovative MCO, implemented a Peer Services project in New York and Wisconsin both of which are producing remarkable outcomes. The Peer Services preliminary program evaluation results (July 2013) show members who received Peer Services:
- Have a Significant Decrease in the number of behavioral health hospital admissions
- Have a Significant Decrease in the number of behavioral health inpatient days
- Have a Significant Increase in outpatient behavioral health visits
- Have Significantly Decreased total behavioral health care costs.
An integrated study with funding and support from both the National Institute for Mental Health (NIMH) and the National Institute for Health (NIH) is needed. Health outcome measures should reflect the whole person. Physical and mental health are equally important components contributing to an individual’s quality of life.
We need research funded to study the outcomes for both the individual serviced and the peer providing services to legitimize the impact of including and developing this emerging workforce. We need quantifiable evidence from studies examining to what degree implementing a peer workforce career ladder: Increases access to care, Reduces cost, Improves participant outcomes, and Improves provider outcomes.
Certified Peer Specialist, Recovery Coach, Community Health Worker Promotora: Certified Peer Specialists (CPSs), Recovery Coaches (RCs) and Community Health Workers (CHWs) are all essential components for implementing ACA driven physical and behavioral integrated systems of care. Increasingly, peer services are being embedded in healthcare delivery, helping to inform and transform those systems through an emphasis on whole health, wellness, social inclusion, cultural competency and the professionalizing of a peer-led and peer driven workforce. A key goal of the peer workforce is to prevent co-optation and the diminution of critical peer support values and practices.
The entry level paid position on the recovery career ladder starts with a health activated CPS, RC and/or CHW who wants to share their recovery message with others. Health activated people represent a new approach to healthcare focusing on prevention and wellbeing instead of the medical model of disease treatment. These people are able to implement their own recovery and wellness so effectively that they learn and hone specific skills that increase their subsequent resiliency (Manderscheid, 2014). This proposal focuses on leadership development for the future of a truly integrated approach to recovery and rebirth for millions of Americans trapped in this cycle of poverty. Evidence based practices with CPS, RC and CHW all demonstrate improved health outcomes when interventions are delivered by individuals with shared life experience.
Peer roles in mental health, substance abuse and community health are evolving, as people with lived experience offer a potent resource to help other peers who are facing these health concerns through education, support, and coaching. Peer roles are evolving within the context of emerging “recovery-oriented” integrated health systems (Tucker, S. J., Tiegreen, W., Toole, J., Banathy, J., Mulloy, D., & Swarbrick, M., 2013).
The International Association of Peer Supporters, Inc. is currently developing national practice guidelines focusing on competencies, ethics, and implementation for peer workforce roles (INAPS National Practice Standards, 2014). Faces and Voices of Recovery is developing a credentialing process for organizations that deliver peer services (de Miranda, 2014). This work is supported financially by SAMHSA and will create the cornerstone for the emerging peer workforce. The International Certification & Reciprocity Consortium (IC&RC) has developed and is currently piloting a Peer Recovery Credential after having a thorough job analysis conducted by Schroeder Measurement Technologies, Inc., in order to identify essential job functions for peer services.
We are introducing the development of a workforce of professionals whose shared life experience opens the door to end the cycle of poverty by creating a recovery-based workforce who have empowered themselves using the principles of Recovery Based Practices. A great deal of important work has been done toward integrating mental health and substance abuse peer support services. The next phase of integration is to include physical health concerns including preventative services and wellness planning; thus the need for the Licensed Integrated Care Professional (LICP).
Other factors also compel further development of the peer workforce. The ACA requires Medicaid and all other health plans to cover behavioral health care on par with health care for physical services. It also will add an estimated 8 million people to the Medicaid rolls in the first year, many of whom will have untreated mental illnesses. Another 7 million people are expected to get federal tax subsidies to purchase health insurance, many for the first time. This surge in demand, combined with an already severe shortage of mental and community health workers not only supports but demands the need to expand the peer workforce and create a career ladder including Licensed Integrated Care Professionals and a certification process for licensed medical professionals to add Lived Experience Professional credential as a specialty.
Licensed Integrated Care Professional: We propose using national/international mental health and substance abuse standards developed in conjunction with SAMSHA and cross walking those standards with national CHW standards to filter for cross program required competencies. We are not trying to compete with current plans for CPS, RC or CHW certification programs. Our goal is to build upon existing work and establish an infrastructure which values and supports multidisciplinary teams with specialized training to lead/manage a recovery-based peer workforce and provide integrated care services to populations served.
A LICP position adds a step to the new career ladder. LICPs are trained across disciplines; they are the third leg of a stool helping people become health activated and strive for wellness. LICPs are cross trained in mental health, substance abuse and physical/community health recovery and resiliency issues. They will mentor, support and manage the peer provider workforce lending value-added supports by integrating the strengths of the CPS, RC and CHW career paths and a step up and out of poverty for a large group of disenfranchised people.
Lived Experience Professionals (LEP): Establishing a Lived Experience Professional (LEP) certification for licensed healthcare professionals who embrace recovery practices, promote self-directed care models and are open to identifying as a person with lived experience is an additional board certification a medical professional could receive. Empowering licensed professionals to earn a LEP certification demonstrates they are recovery and self-directed care experts in their field of licensure. Healthcare customers will benefit by having additional information to use when selecting a licensed professional. Society as a whole benefits when lived experience and taking personal responsibility for health and wellness are respected instead of stigmatized.
Currently, there is limited coordination between roles and responsibilities for the three different types of peer providers. Essential competency requirements are different between types of peer providers although many competencies are the same for all types of peer providers. A structured approach is needed to integrate the strengths of each type of peer provider. Standardization of peer provider certification is out of scope for this proposal; however, we seek to gather the data necessary to discover the overlapping competencies among peer providers and to define and develop the occupational category of Licensed Integrated Care Provider.
Jennifer M. Padron, M.Ed, ACPS, CHW is a Candidate for her Doctor of Public Health Degree. She is a member of the ACMHA College for Behavioral Health National Board of Directors and Mental Health America’s National Diversity and Cultural and Linguistic Competency Committee. Padron is also a National Leadership Committee Member of the National Institute on Disability and Rehabilitation Research’s Rehabilitation Research Training Centers Program with Temple University. Currently, she resides in North Georgia working in Mobile Crisis Intervention services with Benchmark Human Services and consults with Vanguard Communications on national wellness and social inclusion initiatives.
Pam Hardin is a mental health advocate who also happens to be a peer with lived experience as both a consumer of mental health services and as a family member of mental health and substance abuse recovery. She has many years of project management experience implementing major governmental agency innovative project initiatives with proven skills in planning, development, implementation and evaluation. She is a talented forward-thinking instructional designer, with 17 years of experience in public service, transforming how and where training is developed and delivered. In her “day job,” Pam is an Instructional Designer with the Texas Health and Human Services Commission. Ms. Hardin is collaborating with Jennifer Padron and Ron Manderscheid preparing for a major change in the delivery of integrated healthcare services. They propose creating a career ladder for peer providers by establishing an Integrated Care Professional (ICP) credential for Certified Peer Specialists, Recovery Coaches and Community Health Workers focusing on the recovery model.