Creating Replicable and Sustainable Peer Support Services

Peer Support Services Help Reduce Hospitalizations, Curb Costs

Mental Health Weekly  March 21, 2010

A peer support initiative in Wisconsin and Tennessee has been shown to be effective in helping consumers with serious and persistent mental illness (SPMI) decrease the number of days spent in inpatient hospitalization and help them transition into the community.

The aim of the program, called PeerLink, was to demonstrate that ‘peer bridger’ services decrease psychiatric inpatient days, Beth Epps, MEd, solutions development director for OptumHealth, told attendees during last week’s ACMHA: The College for Behavioral Health Leadership summit (see story, page 1).

The peer bridger model was implemented from Dec. 1, 2009 through August 31, 2010. The project was a collaborative effort, involving OptumHealth, Grassroots Empowerment Project, and the Tennessee Mental Health Consumer Association, all of whom worked to design and implement the project.

Epps told attendees that that certified peer specialists helped consumers who were hospitalized transition to the community. The consumers assisted with aftercare appointments. Someone leaving a psychiatric hospital may feel alone, said Epps. A certified peer specialist has lived through a similar experience, she said. The “I’ve been there” approach is key, she said.

Hospitalization data were analyzed for PeerLink members who had a history of at least one hospitalization from December 2008 through the month preceding enrollment in Peer Link. Prior to the PeerLink effort, the average number of hospitalization for 28 PeerLink members in Tennessee in the months prior to entering the PeerLink program was 7.42, according to preliminary outcome figures. After involvement in the program, the number of hospitalization days decreased to 1.9 or by 73.32 percent.

In Wisconsin, the average number of days per month of hospitalization for 28 PeerLink members was 0.86 or less than a day, according to the report. After involvement in the pilot program, the number of days dropped to 0.48 or by 44.19 percent.

The pilot was a very collaborative process, she said. “We wanted to serve individuals with serious and persistent mental illness who had at least two hospitalizations in the last two years,” she said. Chyrell Bellamy, Ph.D., and associates at Yale University’s Program for Recovery and Community Health conducted the independent evaluation of the data of the pilot program, Epps said.

The peers helped individuals in the program meet their personal health and wellness goals. The pilot sites in West Tennessee and three Wisconsin counties were chosen based on high utilization inpatient hospital rates, said Epps. “We want to expand the system so we can put it in place in other areas,” she said.

This initiative provides evidence that peer support can cut costs, said Epps. Peer support has to be part of an organization’s entire system, she said. “They need to become core to everything that happens.”

The analysis of the project included hospital authorization data, peer support specialist encounter data surveys from OptumHealth staff and peer specialist focus groups, and surveys from focus groups with pilot participants. OptumHealth has a number of consumer and recovery-oriented initiatives, said Epps. A full report of the Peer-Link project is expected in three to four weeks, said Epps.

Creating Replicable and Sustainable Peer Support Services

Beth Epps, Med, OptumHealth Public Sector; Chyrell Bellamy, PhD, MSW, Yale School of Medicine

Background
Centers for Medicare & Medicaid Services (CMS), Substance Abuse and Mental Health Services Administration (SAMHSA), and most national behavioral health experts promote peer support and indeed, the last decade has experienced a substantial increase in peer support services.[i] Unfortunately, the empirical evidence supporting peer-provided services lags behind their rapid proliferation. Studies that do exist rarely evaluate the unique aspects of the service.[ii] In an effort to proffer peer support for system-wide implementation, OptumHealth tasked a group with understanding and documenting the components necessary for implementation, replication, and sustainability of peer support services.  A pilot, with two sites, was designed and implemented as a way to determine those systems and processes.
An independent evaluator was chosen to document the empirical evidence gathered through the pilot and an internal OptumHealthSM team monitored the design and operational activities from pre-pilot to post-pilot.

Methods
Peer Bridger was chosen as the specific peer support model to be implemented and measured in the pilot.
Peer Bridger services, originally developed in 1994 by the New York Association of Psychiatric Rehabilitation (NYAPRS), are provided by individuals in mental health and/or addiction recovery who are trained in peer support and often certified as peer specialists or peer wellness coaches.  They offer engaging hope and recovery focused mutually accountable relationships that help individuals meet their personal health, wellness and life goals. Peer bridgers provide transition assistance and linkages to services and natural supports in the community by offering individualized support for effective wellness management, independent living, social skills, and coping skills.  Peer Bridger services are most often provided for individuals leaving inpatient treatment or other segregated environments such as residential treatment, adult (board and care) homes, prisons and jails.  www.nyaprs.org/peer-services/peer-bridger

Services – called PeerLink due to potential confusion with an existing Tennessee consumer program named Bridges – were developed for pilot sites in southeast Wisconsin and West Tennessee along with Grassroots Empowerment Project (GEP) and the Tennessee Mental Health Consumer Association (TMHCA) as provider partners.  OptumHealth, GEP and TMHCA worked collaboratively to design the pilot and to implement services.   The pilot began in December 2009 and ended August 31, 2010.
The most impactful method of ensuring that peer support is implemented and sustained system-wide is to show its cost effectiveness.  The objective of this project was to demonstrate that Peer Bridger services decrease psychiatric inpatient bed days.
Dr. Chyrell Bellamy and her associates at Yale University’s Program for Recovery and Community Health conducted the independent evaluation that included an analysis of the following:  1) hospital authorization data, 2) Peer Support Specialist encounter data, 3) surveys from OptumHealth staff, 4) Peer Specialist focus groups and 5) surveys from and focus groups with pilot participants.
Additionally, an internal team conducted a process evaluation and lessons learned were observed and documented throughout the project.  The programs were not static; each site matured and changed as new information became available.  Services continued at both sites following the pilot.

Results
Empirical Data
Hospitalization data was analyzed for PeerLink members who had a history of at least one hospitalization from December 2008 through the month preceding enrollment in PeerLink. This subsample included 28 PeerLink members in Tennessee and 65 PeerLink members in Wisconsin.

In Tennessee, PeerLink participants spent an average of 7.42 days per month (sd = 7.52) in the hospital prior to receiving PeerLink services and experienced a 73.32% decrease in average number of hospital days after enrollment in PeerLink, F = 12.08 (1, 27), p = .002.
In Wisconsin, the PeerLink participants spent an average of .86 days per month (sd = .83) in the hospital prior to enrollment in PeerLink and an average of .48 days per month (sd = .93) in the hospital after enrollment in PeerLink, F = 4.75 (1, 64), p = .004, a 44.19% reduction in hospital days after enrollment in PeerLink….

Reason(s) Research Can Be Considered a Disruptive Innovation
The independent evaluation of the PeerLINK pilot adds to the body of knowledge verifying that peer support is effective and increases community tenure for its recipients.
The process evaluation provides a checklist for future implementations of peer support services and begins to offer guidelines for program sustainability.  As a result of the project, OptumHealth is developing Level of Care Guidelines for seven distinct levels of peer or family support services, is developing credentialing criteria for both peer and family provider organizations, and is clarifying the claims process from point of service to provider payment to ensure that providers are not financially at risk.

Implications for Behavioral Health Practice
Widespread peer support services will change the face of behavioral health –  practice, policy and research. Full integration of peer support services facilitates recovery and a cadre of recovering consumers will truly create disruptive innovation.

Background
Centers for Medicare & Medicaid Services (CMS), Substance Abuse and Mental Health Services Administration (SAMHSA), and most national behavioral health experts promote peer support and indeed, the last decade has experienced a substantial increase in peer support services.[i] Unfortunately, the empirical evidence supporting peer-provided services lags behind their rapid proliferation. Studies that do exist rarely evaluate the unique aspects of the service.[ii] In an effort to proffer peer support for system-wide implementation, OptumHealth tasked a group with understanding and documenting the components necessary for implementation, replication, and sustainability of peer support services.  A pilot, with two sites, was designed and implemented as a way to determine those systems and processes.
An independent evaluator was chosen to document the empirical evidence gathered through the pilot and an internal OptumHealthSM team monitored the design and operational activities from pre-pilot to post-pilot.

Methods
Peer Bridger was chosen as the specific peer support model to be implemented and measured in the pilot.
Peer Bridger services, originally developed in 1994 by the New York Association of Psychiatric Rehabilitation (NYAPRS), are provided by individuals in mental health and/or addiction recovery who are trained in peer support and often certified as peer specialists or peer wellness coaches.  They offer engaging hope and recovery focused mutually accountable relationships that help individuals meet their personal health, wellness and life goals. Peer bridgers provide transition assistance and linkages to services and natural supports in the community by offering individualized support for effective wellness management, independent living, social skills, and coping skills.  Peer Bridger services are most often provided for individuals leaving inpatient treatment or other segregated environments such as residential treatment, adult (board and care) homes, prisons and jails.  www.nyaprs.org/peer-services/peer-bridger

Services – called PeerLink due to potential confusion with an existing Tennessee consumer program named Bridges – were developed for pilot sites in southeast Wisconsin and West Tennessee along with Grassroots Empowerment Project (GEP) and the Tennessee Mental Health Consumer Association (TMHCA) as provider partners.  OptumHealth, GEP and TMHCA worked collaboratively to design the pilot and to implement services.   The pilot began in December 2009 and ended August 31, 2010.
The most impactful method of ensuring that peer support is implemented and sustained system-wide is to show its cost effectiveness.  The objective of this project was to demonstrate that Peer Bridger services decrease psychiatric inpatient bed days.
Dr. Chyrell Bellamy and her associates at Yale University’s Program for Recovery and Community Health conducted the independent evaluation that included an analysis of the following:  1) hospital authorization data, 2) Peer Support Specialist encounter data, 3) surveys from OptumHealth staff, 4) Peer Specialist focus groups and 5) surveys from and focus groups with pilot participants.
Additionally, an internal team conducted a process evaluation and lessons learned were observed and documented throughout the project.  The programs were not static; each site matured and changed as new information became available.  Services continued at both sites following the pilot.

Results
Empirical Data
Hospitalization data was analyzed for PeerLink members who had a history of at least one hospitalization from December 2008 through the month preceding enrollment in PeerLink. This subsample included 28 PeerLink members in Tennessee and 65 PeerLink members in Wisconsin.
In Tennessee, PeerLink participants spent an average of 7.42 days per month (sd = 7.52) in the hospital prior to receiving PeerLink services and experienced a 73.32% decrease in average number of hospital days after enrollment in PeerLink, F = 12.08 (1, 27), p = .002.
In Wisconsin, the PeerLink participants spent an average of .86 days per month (sd = .83) in the hospital prior to enrollment in PeerLink and an average of .48 days per month (sd = .93) in the hospital after enrollment in PeerLink, F = 4.75 (1, 64), p = .004, a 44.19% reduction in hospital days after enrollment in PeerLink….

Reason(s) Research Can Be Considered a Disruptive Innovation
The independent evaluation of the PeerLINK pilot adds to the body of knowledge verifying that peer support is effective and increases community tenure for its recipients.
The process evaluation provides a checklist for future implementations of peer support services and begins to offer guidelines for program sustainability.  As a result of the project, OptumHealth is developing Level of Care Guidelines for seven distinct levels of peer or family support services, is developing credentialing criteria for both peer and family provider organizations, and is clarifying the claims process from point of service to provider payment to ensure that providers are not financially at risk.

Implications for Behavioral Health Practice
Widespread peer support services will change the face of behavioral health –  practice, policy and research. Full integration of peer support services facilitates recovery and a cadre of recovering consumers will truly create disruptive innovation.

[i]  The Pillars of Peer Support Services Summit.  Pillars of Peer Support: Transforming Mental Health Systems of Care through Peer Support Services.  (Atlanta, Georgia.  The Carter Center Nov 17–18, 2009) 1.

[ii]  Davidson, L., Chinman, M., Sells, D., Rowe, M. (2006). Peer Support among Adult with Serious Mental Illness: A Report from the Field. Schizophrenia Bulletin, Feb 3, 2006.