Peer Specialists in Federally Qualified Health Centers Enhance Access to Behavioral and Physical Health Support Services for Clients With Co-Occurring Medical and Mental Health Issues | AHRQ Innovations Exchange

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Peer Specialists in Federally Qualified Health Centers Enhance Access to Behavioral and Physical Health Support Services for Clients With Co-Occurring Medical and Mental Health Issues | AHRQ Innovations Exchange

Service Delivery Innovation Profile

Peer Specialists in Federally Qualified Health Centers Enhance Access to Behavioral and Physical Health Support Services for Clients With Co-Occurring Medical and Mental Health Issues

What They Did | Did It Work? | How They Did It | Adoption Considerations

Snapshot Summary The Michigan Department of Community Health placed certified peer support specialists in two federally qualified health centers; these staff members offer support services to individuals with co-occurring medical and mental health diagnoses, including substance abuse disorders. The centers care for many patients with mental health conditions deemed to be mild or moderate in nature.  These individuals have not had services provided by a certified peer support specialist and do not meet the criteria in the traditional behavioral health system for community mental health provider support. After receiving referrals from health center providers, the peer specialists meet with individuals to discuss medical and behavioral health needs, develop wellness plans, provide educational information as health coaches and links to community services, offer emotional support, and facilitate the provision of medical care. Peer specialists also run support groups and may accompany individuals to support group meetings and medical appointments. They document services provided in an electronic medical record accessible to all providers. The program has enhanced access to support services and generated high levels of satisfaction among both individuals and peer specialists; several stories suggest the program has helped to improve the physical and mental health of some individuals. Evidence Rating (What is this?) Suggestive: The evidence consists of post-implementation data on the number of individuals served by the certified peer support specialists and the number of visits these individuals attended, along with anecdotal reports from individuals and peer specialists about their satisfaction with the program and its impact on health. Developing Organizations Michigan Department of Community Health; Michigan Primary Care Association Date First Implemented 2012 The program began at one site, Hackley Community Care Center, in April 2012 and at a second site, MidMichigan Community Health Services, in July 2013. Patient Population Vulnerable Populations > Co-occuring disorders; Mentally ill; Substance abusers

Problem Addressed

Mental health conditions are a leading cause of disability, particularly for people of low socioeconomic status. Many low-income individuals with these conditions use federally qualified health centers (FQHCs) as a regular source of care for physical health issues, but those diagnosed with mild or moderate levels of disease are often unable to access behavioral health services offered by traditional community mental health centers provided by behavioral health systems. As a result, a crisis or emergency often manifests that leads to the need for expensive acute care. Trained peers can provide meaningful support to these individuals, but few FQHCs have them available. 

• A common diagnosis, especially among the poor: Roughly 20 percent of adults in the United States have a mental disorder, and approximately 5 percent have a serious mental illness.¹ Approximately one-fifth of individuals with mental illness also have a co-occurring substance dependence or abuse disorder.¹ People in poverty face a particularly high risk of both mental illness² and substance abuse disorders.³
• Lack of regular treatment and support: Less than half of individuals with mental disorders receive treatment for them,² and access to care is even more problematic for people with low socioeconomic status.⁴While roughly two-thirds (65 percent) of FQHCs integrate behavioral health care services with primary care,⁵often these services are not available to those with mental health diagnoses classified as mild or moderate in nature. For example, in Michigan, these individuals do not qualify for State-funded mental health services.
• Expensive, difficult-to-treat crises: Untreated mental illness and substance abuse disorders (including those that are mild or moderate) often lead to crises that subsequently require expensive hospitalizations, intervention by the police, and/or incarceration. Many sufferers feel isolated and become desperate, leading to additional crises and a repeat of the same destructive cycle.
• Unrealized potential of peer support in FQHCs: Individuals who are in recovery from mental illness and/or substance abuse can provide sensitive, practical support to peers because of their shared experience. Such mutual support complements and enhances the provision of health services. While some private and State-funded behavioral health programs include a peer support program focused on mental illness, relatively few FQHCs have such services available.

What They Did Back to Top Description of the Innovative Activity Certified peer support specialists (CPSSs) in two FQHCs offer support to individuals with co-occurring medical and mental health/substance abuse diagnoses, with a particular focus on those with mental health conditions deemed to be mild or moderate in nature. After receiving referrals from health center providers, the peer specialists meet with individuals to discuss medical and behavioral health needs, serve as wellness coaches, develop wellness plans, provide educational information and links to community services, offer emotional support, and facilitate the provision of medical care (e.g., by scheduling appointments). Peer specialists also run support groups and may accompany individuals to group support meetings and doctor appointments. They document all services provided in an electronic medical record accessible to all providers. Key components of the program include the following: Placement in FQHCs catering to patients with mild/moderate mental health issues: Two peer specialists are placed in each of two FQHCs in Michigan: Hackley Community Care Center, a 31-provider center in urban Muskegon, and MidMichigan Community Health Services, a rural center in Houghton Lake with seven primary care providers. These centers tend to care for many patients with mental health conditions deemed to be mild or moderate in nature, and hence do not qualify for State-funded behavioral health services within community mental health centers. To be eligible for State certification, the peer specialists must be at least 18 years of age, hold a high school diploma or equivalent, have a mental health diagnosis and/or a co-occurring substance use disorder, have had the mental health diagnosis for at least a year, be clean and free of substance use for at least a year, and currently receive or have previously received services from an FQHC.6 Those hired in the centers spend a few weeks getting used to the environment and the job duties before undergoing formal training and certification, as described below. Formal training and certification: After several weeks getting familiar with the FQHC, the peer specialists complete a 56-hour training program designed and run by the Michigan Department of Community Health. An amalgamation of existing training courses, the curriculum covers Whole Health Action Management (WHAM, a self-management training program and peer support group model developed by the National Council for Behavioral Health); Wellness Recovery Action Planning (WRAP, a tool that aids in the development of a customized care and self-management plan); disease-specific training on topics such as diabetes, trauma-informed care, and smoking cessation; group facilitation; housing outreach; and other topics that allow the peer specialists to address a variety of mental health and medical needs. The training culminates with a 4-hour exam; those who pass receive three community college credits and State certification as a peer support specialist. Referral of eligible individuals: CPSSs receive client referrals from physicians, psychologists, nurses, and medical assistants in the FQHC, either in person or via e-mail within the FQHC’s electronic medical record system. To be eligible for CPSS services, individuals must have at least two diagnosed chronic conditions—one medical condition and one behavioral health (mental illness and/or substance abuse) disorder. After receiving a referral, the CPSS reviews the individual’s medical record and invites him or her to schedule a face-to-face visit. In some cases, providers make the referral in real time by asking the CPSS to join an ongoing medical visit. Support services based on trust and rapport: Each CPSS works between 16 and 40 hours a week, providing approved peer support services as defined by the State’s Medicaid program.6 CPSSs seek to quickly build trusting relationships with individuals, using their own life experiences and recovery journeys to relate to them in ways that other providers cannot. Offered in individual and group settings, CPSS services supplement and complement the care offered by medical providers, as outlined below: One-on-one support: The CPSS provides one-on-one support to individuals related to recovery and self-management of chronic medical conditions. Health navigation: The CPSS helps individuals schedule appointments for medical care and other needed services. The CPSS may also accompany individuals to doctor appointments, the pharmacy, social worker visits, and support group meetings (e.g., Alcoholics Anonymous, Narcotics Anonymous). The CPSS also identifies and helps connect individuals to needed community-based resources and benefit programs. Care plan development and monitoring: The CPSS as part of the team addresses specific goals in the medical record and writes progress notes on the services provided. In working with the person individually, WRAP is used as a wellness tool and self-management plan. Over time, the CPSS discusses the individual’s progress towards the WRAP plan to identify ways to prevent and overcome challenges related to achieving physical and mental health goals. Support groups: The CPSS facilitates weekly support groups on a variety of topics, including WHAM, WRAP, smoking cessation, diabetes care, and physical activity and fitness. Documentation and communication with providers: CPSSs document services provided to individuals in the electronic medical record, thus allowing other providers to remain aware of what services the individual has received. CPSSs and providers also communicate about the individual's needs and progress during informal personal discussions and through e-mail. Context of the Innovation The Michigan Department of Community Health is responsible for health policy and management of Michigan’s health, mental health, and substance use care systems, with a special focus on addressing the needs of vulnerable and underserved populations. The Michigan Primary Care Association promotes, supports, and develops community-based primary care for Michigan residents. The Michigan Primary Care Association is composed of 39 health center organizations that provide quality, affordable, comprehensive primary and preventive health care for more than 600,000 Michigan residents at more than 230 sites located in both rural and urban communities across the State. Michigan was one of the first States to approve Medicaid reimbursement for peer specialist services. Since 2005, the Michigan Department of Community Health has sponsored a training and certification program for peer specialists; to date, 1,234 individuals have been certified. The impetus for this program came from Michigan Department of Community Health leaders, who recognized that people receiving primary care at FQHCs often had unmet needs related to mental health and substance abuse, with the problem being particularly acute for those with conditions deemed to be mild or moderate in nature. To offer services that are currently not Medicaid reimbursable in Michigan, a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Association of State Mental Health Program Directors was written.

Did It Work? Back to Top Results The program has enhanced access to mental health support services and generated high levels of satisfaction among both individuals served and peer specialists; several stories suggest the program has helped to improve the physical and mental health of some individuals. Enhanced access to support services: As of December 2013, 154 individuals have been served by the CPSSs within one of the FQHCs, Hackley Community Care Center. Collectively, these individuals had 813 visits with the peer specialists, including attending support groups and one-on-one meetings. Without the program, the vast majority of these individuals would not have had access to this CPSS's services because most were considered to have mild or moderate mental health diagnoses and hence did not previously qualify for State-funded behavioral health services at community mental health centers. Data from the other FQHC are not yet available. High levels of individual and CPSS satisfaction: CPSSs and individuals both report high levels of satisfaction with the program. Anecdotal reports of improved health: Anecdotal reports about several individuals suggest the program has helped improve their mental and physical health. More information can be found in the Back Story section.) Evidence Rating (What is this?) Suggestive: The evidence consists of post-implementation data on the number of individuals served by the certified peer support specialists and the number of visits these individuals attended, along with anecdotal reports from individuals and peer specialists about their satisfaction with the program and its impact on health.

How They Did It Back to Top Planning and Development Process Selected steps included the following: Securing grant funding: The Michigan Department of Community Health’s Behavioral Health and Developmental Disabilities Administration applied for and obtained a Transformation Transfer Initiative grant from the National Association of State Mental Health Program Directors. The grant supported the placement of peers in two FQHCs. Selecting FQHCs: Research conducted by the Michigan Department of Community Health identified nine Michigan FQHCs serving large populations of people with mental illness, including two where a large percentage of patients did not qualify for State-funded community mental health care (because their mental health diagnoses were classified as mild or moderate), and where leadership appeared willing to fund the CPSS positions once grant funding ended. Hiring individuals to serve as specialists: The Michigan Department of Community Health hired four individuals to work in the two sites; providers within these sites referred these candidates to the department. Introductory meeting between providers and CPSSs: The newly hired individuals met with providers at the two sites to discuss their own experiences and describe how they could be helpful in enhancing the care of patients. Resources Used and Skills Needed Staffing: The four CPSSs work between 16 and 40 hours per week. The average caseload for each CPSS varies based on individual needs. As noted, each CPSS must complete a 56-hour training program and then pass an examination to become certified. Costs: The primary expenses consist of salaries and benefits for the four CPSSs. Approximate program costs total $51,000 per site for two CPSSs at 60 hours per week (one part-time and one full-time with benefits). Funding Sources Substance Abuse and Mental Health Services Administration (U.S.); National Association of State Mental Health Program Directors As alluded to earlier, States have the option of reimbursing for CPSS services at the FQHC. The Substance Abuse and Mental Health Services Administration and the National Association of State Mental Health Program Directors provided funding to cover salaries and benefits for the four CPSSs through a 2-year, $221,000 Transformation Transfer Initiative grant. As specified in the grant award, funding is channeled through the Michigan Disability Rights Coalition, a nonprofit organization that helps individuals with disabilities live in their communities. Tools and Other Resources A white paper titled Ethical Guidelines for the Delivery of Peer-based Recovery Support Services, prepared for the Philadelphia Department of Behavioral Health and Mental Retardation Services and the Pennsylvania Recovery Organization—Achieving Community Together (PRO-ACT), is available at:http://www.bhrm.org/recoverysupport/EthicsPaperFinal6-8-07.pdf (If you don't have the software to open this PDF,download free Adobe Acrobat Reader® software .). Information about WHAM is available at: http://www.integration.samhsa.gov/health-wellness/wham. Information about WRAP is available at: http://copelandcenter.com/wellness-recovery-action-plan-wrap. The Michigan Department of Community Health Medicaid Provider Manual for peer services is available at:http://www.michigan.gov/mdch/0,1607,7-132-2945_5100-87572--,00.html.

Adoption Considerations Back to Top Getting Started with This Innovation Identify sites with significant need: Place CPSSs at FQHCs that care for many individuals with mild or moderate mental illness or substance abuse disorders who could benefit from peer support. Educate FQHC providers about CPSS services: FQHC providers need to understand the unique role CPSSs can play in complementing their services and fostering recovery. Once providers see that individuals benefit from the unique assistance and perspective CPSSs offer, they will become more enthusiastic about the program and begin to refer more patients to it. Hire motivated peer specialists: Hire individuals who want to help their peers and who understand their role and have a strong desire to work as health coaches and navigators, sharing their similar experiences in this unique setting. Offer fair compensation, full- and part-time employment: To attract and retain CPSSs, pay a fair level of compensation and offer the option of working either full- or part-time. Identify enthusiastic CPSS supervisors: Find supervisors at the FQHC who understand the role and value of peer specialists and are committed to supporting the project. Support continuing education: Ongoing education helps CPSSs refresh their knowledge and keep up with new treatments, services, and educational techniques. Sustaining This Innovation Seek sustainable sources of funding: As noted, Michigan Medicaid does not currently reimburse FQHCs for CPSS services. As a result, organizations must seek grant funding. Ideally, program adopters should secure a commitment for ongoing support of the program from FQHCs or other sources once grant funding ends. Monitor and share data on program benefits: Quantitative and qualitative data (including anecdotes) that document the important benefits of CPSS services may encourage potential funders to support this program on an ongoing basis.

More Information Back to Top Contact the Innovator Pamela Werner Michigan Department of Community Health Office of Recovery Oriented Systems of Care Bureau of Community Based Services 320 South Walnut Street Lansing, MI 48913 Phone: (517) 335-4078 Fax: (517) 335-1233 E-mail: wernerp@michigan.gov Innovator Disclosures Ms. Werner reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section. Footnotes 1 Substance Abuse and Mental Health Services Administration. Results from the 2010 NSDUH: mental health findings and detailed tables. Available at: http://www.samhsa.gov/data/NSDUH/2k10MH_Findings/. 2 Hudson CG. Socioeconomic status and mental illness: tests of the social causation and selection hypotheses. Am J Orthopsychiatry. 2005;75(1):3-18. [PubMed] Available at: http://www.apa.org/pubs/journals/releases/ort-7513.pdf. 3 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Prevalence of substance use among racial and ethnic subgroups in the U.S. May 19, 2008. Available at: http://oas.samhsa.gov/nhsda/ethnic/ethn1006.htm. 4 Bazelon Center for Mental Health Law. Mental illness and the need for health care access reform. Fact sheet. Available at: http://www.bazelon.org/LinkClick.aspx?fileticket=Tgq0Qq-w6_c%3d&tabid=220. 5 Lardiere M, Jones E, Perez M. National Association of Community Health Centers. NACHC 2010 assessment of behavioral health services provided in Federally Qualified Health Centers. January 2011. Available at:http://www.nachc.com/client/NACHC%202010%20Assessment%20of%20Behavioral%20Health %20Services%20in%20FQHCs_1_14_11_FINAL.pdf. 6 Michigan Department of Community Health. Medical Services Administration Bulletin 07-52. Michigan PIHP/CMHSP provider qualifications per Medicaid Service & HCPCS/CPT codes. September 1, 2007. Available at:http://www.michigan.gov/documents/mdch/MSA-07-52-PIHP_Bulletin_207606_7.pdf.