Nearly one-quarter of adults diagnosed with a mental illness report they did not receive necessary treatment in 2021. This may be caused by barriers within the health care system, such as inadequate coverage of services, shortages of providers, lack of available treatment options, or a disconnect between primary care and behavioral health services, or by barriers such as stigma, distrust and previous poor experiences.
When integrated into health care teams alongside treatment for mental illness or substance misuse, peer support specialists expand access to care by extending the reach and capacity of existing providers; complement the role of other health professionals; and offer acceptance, understanding and validation necessary to support the recovery and wellness journey. Research has found that patients receiving peer support services are less likely to be readmitted into a hospital, spend less time in inpatient care and have lower overall costs of services than those receiving standard care.
Peer Support Specialist Services
As health care extenders, peer support specialists are nonclinical health professionals who work in behavioral health settings with people diagnosed with mental health or substance use disorders. Also known as peer support workers or peer mentors, peer support specialists use their lived experience of recovery from mental illness or substance use disorders, along with formal training, to promote mind-body recovery and resiliency.
Peer support specialist roles often include:
- Advocating for people in recovery.
- Sharing resources and building skills.
- Building community and relationships.
- Leading recovery groups.
- Mentoring and setting goals.
Roles may also include providing training, supervising other peer workers, developing resources, administering programs or agencies, and educating the public and policymakers.
Training and Certification
To protect patients, states regulate aspects of training and certification for health professionals, including peer support specialists. Training and certification programs vary widely across states in terms of curriculum, requirements and continuing education standards. In addition to state-run programs, third-party organizations also offer peer support specialist certification or guidelines for states.
As of June 2020, 48 states and Washington, D.C., had established training and certification programs for peer support specialists, through state-run programs or third-party organizations. A 2019 report from the University of Michigan Behavioral Health Workforce Research Center found that certification for peer support specialists requires an average of about 50 hours of specialized training and 550 hours of volunteer experience. Florida requires certified recovery peer specialists to complete 3,000 hours of supervised work or volunteer experience and 40 hours of training, or a certificate of completion from a program approved by Mental Health America. Oregon requires peer wellness specialists to complete 80 hours of training and peer support specialists to complete 40 hours of training.
Reimbursement and Financing
The growth of peer support services has largely been facilitated by reimbursement through Medicaid, which is the largest payer of mental health services in the United States. The Centers for Medicare and Medicaid Services released guidance in 2007 authorizing Medicaid reimbursement for peer services based on research identifying peer support as an evidence-based model of care.
As of 2019, at least 39 states require Medicaid reimbursement for mental health peer services. These services can be provided through several mechanisms, such as rehabilitative services under Section 1905(a)(13) of the Social Security Act, home health state plan options under Section 2703 of the Affordable Care Act, a state plan amendment or a Medicaid waiver. Wisconsin enacted legislation to provide reimbursement for peer recovery coach services under Medicaid as long as peer coaches are supervised by competent mental health professionals and services are coordinated with Medicaid recipients’ individual treatment plans, among other conditions.
Outside of Medicaid, states also use general funds, grant funding or dedicated funds from governors’ commissions or task forces to implement and sustain peer support programs. Minnesota appropriated $2 million in fiscal years 2022 and 2023 for Recovery Community Organization Grants to pay for community-based peer recovery support services otherwise not eligible for reimbursement.
Removing Barriers to Health Care Access
In addition to barriers within the health care system—workforce shortages, lack of insurance coverage for services—individuals seeking care may face barriers including stigma associated with diagnosis, distrust of health care systems and previous poor experiences.
To facilitate access to behavioral health services and expand the reach of existing health care providers, several states are utilizing peer support specialists in a variety of ways. In addition to updating training and certification processes and increasing reimbursement opportunities for peer services, states are exploring how peer support specialists with lived experience may facilitate health care access for other populations, including those living with HIV or experiencing housing instability or homelessness.
Research shows that peer support with routine medical care promotes better health outcomes than routine clinical follow-up for individuals living with HIV. Several states, including Florida, New York and Wisconsin, use peer support specialists to facilitate connections to care and encourage the maintenance of treatment among patients living with HIV. Peer support specialists who have lived experience with HIV are uniquely positioned to understand the stigma and foster dialogue with others living with HIV.
Peer-staffed or peer-led interventions are also shown to have a positive impact on health outcomes for individuals experiencing housing insecurity and homelessness. Washington has appropriated funding since 2014 to establish Housing and Recovery Through Peer Services teams including a managed care health professional, a supervisor or clinical oversight professional and two certified peer counselors. Approximately 1,500 individuals, including 219 experiencing a substance use disorder, remained housed between July 2019 and June 2020.
Supporting emerging health professionals such as peer support specialists is just one of several strategies states can use to address behavioral health workforce issues. Legislators continue to look for ways that health care professionals can remove barriers and enhance access to health care, especially in rural and underserved communities.
Kelsie George is a policy analyst in NCSL’s Health Program.
This project is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services as part of a financial assistance award totaling $200,000 with 100% funded by the CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, the CDC/HHS or the U.S. government.