Using Peers to Improve Mental Health Treatment

By Emily Heller | Vol . 24, No. 10 / March 2016

NCSL NewsDid you know?

  • Approximately 4,000 mental health professional shortage areas exist in the United States.
  • Medicaid is the largest funding source for mental health peer support services.
  • Fewer than half of those with a mental illness in the United States received treatment in 2014.

State budgets feel the strain caused by costs associated with untreated mental illness and substance abuse, including those related to overcrowded emergency rooms and jails. Fewer than half of the estimated 43.6 million people with a mental illness received treatment in 2014, according to a Substance Abuse and Mental Health Services Administration (SAMHSA) survey. Similarly, in 2013, only 11 percent of the estimated 22.7 million Americans who needed help for substance abuse received treatment at a specialty facility.

The shortage and maldistribution of behavioral health workers contribute to treatment access challenges. More than half—55 percent—of U.S. counties lack any practicing behavioral health workers, according to SAMHSA, and 77 percent of counties report unmet behavioral health needs.

Using peer support specialists to improve access to treatment has gained attention as a promising strategy across the country. SAMHSA defines a peer support specialist as “a person who uses his or her lived experience of recovery from mental illness and/or addiction, plus skills learned in formal training, to deliver services in behavioral health settings to promote mindbody recovery and resiliency.” Also called peer providers, recovery coaches and peer recovery specialists, they draw upon their personal knowledge and experience to provide clients with education, support and connections to other services. Depending upon their training and certification, they may provide either mental health or substance abuse services.

Proponents of peer support specialists believe they have the potential to expand access to care, prevent hospitalizations and lower health care costs. As part of health care teams, they may help extend the reach and capacity of existing providers. In addition, due to their shared experiences, people in recovery may find peer providers especially approachable and trustworthy. Critics cite potential challenges in incorporating these providers into more traditional care models, and the need for more research to assess their efficacy.

State Action

Many states have taken steps recently to fund peer support services and create training and certification standards.

Funding and Reimbursement. Medicaid has become the largest funding source for mental health peer support services, according to a 2015 report from the University of California, San Francisco Health Workforce Research Center on Long-Term Care. A ruling in 2007 by the Centers for Medicare and Medicaid Services (CMS) authorized Medicaid billing for such services, based on research that identified peer support as an evidence-based model of care. To receive reimbursement, organizations that employ peer support specialists must meet standards for supervision, care coordination, and training and certification. At least 36 states offer providers the opportunity to bill Medicaid for mental health peer support services. They can do so through mechanisms such as a state plan amendment, the rehabilitation services option or a Medicaid waiver, according to a 2014 report from the Texas Institute for Excellence in Mental Health and the 2015 University of California report. Peer support services for substance abuse may be billed to Medicaid in at least 11 states, according to the reports. States also may cover peer support services through Medicaid managed care or other arrangements.

In addition, states may support peer services through alternative funding streams. For example, in 2013, the Wisconsin Legislature passed Assembly Bill 455, which provides grants to establish peer-run respite centers for people in recovery from mental illness or substance abuse. In 2015, the Oklahoma Legislature passed Senate Bill 713, requiring the Department of Mental Health and Substance Abuse

Services to develop seven peer-supported veteran drop-in centers.

Training and Certification. At least 38 states and the District of Columbia have established training and certification programs for mental health peer specialists, according to the Texas Institute and University of California reports, and at least 13 have established them for substance abuse peer specialists. For example, in 2007, the Minnesota Legislature passed House File 1078, directing the commissioner of the Department of Human Services to establish a peer specialist training and certification process.

Certification typically requires previous personal experience with recovery from mental illness or substance abuse. Beyond this prerequisite, training and certification requirements vary widely among states. The number of hours of training required ranges between 30 to more than 100, and work or volunteer experience required ranges from none to more than 500 hours. Many states also require continuing education for peer support specialists.

Several organizations offer training and certification programs or guidelines for states. The 2009 Pillars of Peer Support Services Summit convened 23 states with peer provider programs to create 25 guidelines for mental health peer support training and certification. For substance abuse services, International Credentialing and Reciprocity Consortium boards in 11 states adopted standardized credentialing, which ensures reciprocity for substance abuse peer support certification between states. In addition, the Association for Addiction Professionals provides a national certification for peer support specialists. To promote peer behavioral health services, SAMHSA also convened stakeholders to create core competencies for peer support providers.

Federal Action

The Affordable Care Act’s emphasis on integrating behavioral and primary care provides opportunities for states to use peer support specialists. Georgia became the first state in 2012 to reimburse peer support specialists who provide whole health (physical and behavioral) services through Medicaid.

The U.S. Department of Veteran’s Affairs also employs veterans as peer providers at each VA medical center. They support fellow veterans who are dealing with mental health issues and help them navigate the VA health system. In addition, SAMHSA and the Health Resources and Services Administration launched the Behavioral Health Education and Training program in 2014, which supports training for 2,750 behavioral health paraprofessionals, including peer providers.

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