An Assessment of Innovative Models of Peer Support Services in Behavioral Health to Reduce Preventable Acute Hospitalization and Readmissions. 3. Four Site Visit Case Studies


This section contains four site visit case study reports. These case studies are meant to provide a brief description of the four PSS programs reviewed in this study. The case studies highlight program-specific information corresponding with key study questions. They are intentionally uniform in their headings and sections; provide summary level information; and are not meant to exhaustively include the information gathered during the site visit.

Each of the case studies includes a table of a service framework that was developed for this study. The table lists three categories of PSS that are likely to impact preventable hospitalizations, readmissions, and ED utilization. The table also highlights the service programs offered by each of the organizations within the three categories. Additionally, each of the organizations participating in the site visits had the opportunity to review the case summaries and correct any inaccuracies.

Georgia Mental Health Consumer Network, Inc.

Program Background

The GMHCN is a non-profit corporation founded in 1991 by Georgia consumers of mental health, developmental disabilities, and addictive disease services. The GMHCN PSS program was initiated through consumer grass root efforts and collaboration with state leaders. The GMHCN's strong relationship with state leadership helped make Georgia the first state to authorize Medicaid reimbursement for PSS. GMHCN continues to work with the state to foster a recovery oriented framework for services, including collaboratively drafting of state service definitions. The PSS programs offered by GMHCN are embedded within the larger Georgia provider network in which peers are employed. There are over 1,200 certified peer specialists in Georgia, and training and certification of the workforce is coordinated through GMHCN.

"In our state, funding for PSS has been available for 16 years. The Georgia Consumer Network and the Certified Peer Specialist Program is the crowning achievement of the Georgia Mental Health System."

-- Georgia Department of Behavioral Health and Developmental Disabilities staff

PSS Categories GMHCN Programs
Crisis and Respite Services
  • PSWCs
Transition in Levels of Care
  • Peer Mentors Program
Community-Based to Promote Recovery and Resiliency
  • 24-hour Crisis Phone Lines
  • Daily Structured Education Programs

Service Catchment Area

Services are primarily focused in the cities of Decatur; Cleveland; Cartersville; Moultrie; and McDonough.

Peer Support Services Model

The GMHCN uses a hybrid model of services that draws from the Intentional Peer Support (IPS) model to guide PSS programs ( and other mutual support principles. They also use the WHAM program to support integrated health goals and services. The training manual for certifying Peer Support Specialists was developed by the ACG.

Service Recipients

Individuals must be at least 18 years of age and self-identify as a person in recovery from mental health challenges. All individuals are self-referred and are welcome, regardless of insurance status. No financial or insurance information is requested from service recipients.

"The only wrong place for a certified peer specialist is no place."

-- Sherry Jenkins Tucker, GMHCN Director

Training and Certification of Peers

GMHCN provides Certified Peer Specialist training for consumer peers within Georgia. The Certified Peer Specialist training curriculum was developed by the ACG. The training registration fee is $85 per-person, although it can be waived, as needed. The training is manualized. The GMHCN provides approximately five trainings per year. GMHCN reports great demand for the trainings, with 100-300 applicants for each training session. Training sessions can accommodate up to 45 consumers. The initial training lasts 9 days. Twelve hours of Continuing Education Credits are required annually to retain certification.

Advanced training for peers who have completed the Certified Peer Specialists Training are also offered through GMHCN and include WHAM, Mental Health First Aid, and peer services for working with prison/forensic populations, older adults, and homeless populations.

Financing Services

Many GMHCN peer programs are in partnership with, and funded through, service contracts with the Georgia Department of Behavioral Health and Developmental Disabilities. Unlike many other PSS providers within Georgia, GMHCN does not bill Medicaid directly. Instead, GMHCN submits monthly reports to the state that are used to monitor contract compliance. Reimbursement for services is paid by the state retrospectively, after processing the GMHCN monthly report. There are no per-person costs that are billed to any payer. Peer specialists do not contribute to medical records or bill for their activities or time with service recipients. Peer specialists do document their interaction with consumer clients, but these records are primarily used for supervision purposes and contribute to the GMHCN monthly report to the state. The monthly report to the state requires that certain deliverables are met. Example deliverables include: an average number of two respite beds are filled per day; an average of ten calls are received at the call center per day; and an average of five participants participate in daily programming. GMHCN follows compliance regulations (Health Insurance Portability and Accountability Act [HIPAA] and CFR-42) as part of their state contract.

Featured Programs

"People come through our doors and they stand a little taller, straighter. People are treated with dignity here."

-- Director of the Decatur Peer Support Wellness Center

Peer Support Wellness Centers

The GMHCN operates five Peer Support Wellness Centers across the State of Georgia. The role of these Centers is to provide support before a crisis occurs or as someone is adjusting after a mental health crisis. The GMHCN describes their services as "preventative" (of hospitalization or ED use). Individuals who participate in the Center programs are self- referred. Individuals are encouraged to engage in Center services when they feel as if they might be getting close to a crisis or feel they need a safe place that is an alternative to hospitalization. Individuals are welcome to walk out and leave whenever they want.

The Centers each have three beds -- two beds that are set aside for first time visitors and one bed that is set aside for "an old friend." An old friend is someone who has had a prior stay at the Center and would like to return for a short-term stay. Center staff report that there is a consistently high demand for the "old friend" beds, and there is often a waiting list. The center is staffed 24 hours per day by a peer specialist. Staff report that individuals rarely need to be transported form the Center to the hospital.

Funding for the Centers is provided by the state and requirements include that each crisis center fill a minimum of two respite rooms each night. As part of the contractual requirements with the state, centers provide encounter and consumer self-report information.

All of the wellness centers provide open access to computers, educational programing, and other resources to promote wellness and recovery.

"Other kinds of providers encourage consumers to move away from something. We support to move toward something, their recovery goals."

-- A GMHCN Peer Mentor

Wellness Activities

Wellness activities and classes are offered at each of the five Peer Support Wellness Centers. The scheduled activities and classes are offered daily and are open to individuals who are in residence at the Centers and mental health consumers living in the community. There are generally three Wellness Activities offered daily. Wellness activities cover topics such as WRAP, housing, financing and budget assistance, and vocational and educational help.

Warm Line

The GMHCN provides a 24/7 "warm line." The call center for this service is housed within each of the five Peer Support Wellness Centers, and staffed by on-site peer specialists. Peer specialists who are employed to provide this service receive additional training and use a training manual that guides the services provided by this program. Inbound calls generally last no more than 20 minutes. Crisis calls that are more acute than the warm line can accommodate are rerouted to a statewide crisis line that is staffed by traditional service providers. Callers to the warm line cannot request specific staff, but can request the availability of staff by gender.

Peer Mentor Program

GMHCN operates a Peer Mentor program that is designed to help transition individuals who are receiving care in state facilities to community living. The State of Georgia originally maintained seven state hospital facilities and there were two Peer Mentors assigned to each hospital. Currently there are now five hospitals and 14 Peer Mentors. Individuals are referred to the program by the state and GMHCN assigns a Peer Mentors for each individual assigned to the program. The peer specialists employed within this are required to complete 40 hours of training, in addition to their Georgia peer certification training. Many of the individuals who receive the Peer Mentor Program services have had multiple readmissions to the state hospitals and many have been in the hospital for more than 60 consecutive days. The Mentor meets with the individual at the hospital initially and follows their transition into the community. There is no time limit for how long someone can be engaged in this program.

"We are providing a continuum of care, an eco-system of care, to keep people from having to go to the hospital"

-- Sherry Jenkins Tucker, GMHCN Director

Data and Outcomes

The GMHCN collects information on utilization of services as part of their monthly reporting requirements with the state. The monthly reports have not been analyzed to measure impact on hospitalization rates and ED use. GMHC reports that they have results from an annual self-report consumer survey of their GMHCN Peer Mentor Program (2013-2014 survey). The latest survey shows that only 37 percent of the respondents said that they were re-hospitalized after being involved in the program, and 90 percent said peer mentor helped improve their quality of life. Unfortunately, the heterogeneity within the sample of program participants did not allow for the survey to assess whether meaningful engagement with program had any effect on re-hospitalization. Georgia state leaders report that in 2014 the Peer Support Wellness Centers and the Peer Mentor Program have successfully reduced hospitalizations below the state's baseline targets. Unfortunately, no further data is available since services are not racked on an encounter basis.

Georgia Mental Health Consumer Network
246 Sycamore Street
Decatur, Georgia 30030
Phone Number: (800) 297-6146


New York Association of Psychiatric Rehabilitation Services, Inc.

Program Background

The New York Association of Psychiatric Rehabilitation Service's (NYAPRS) Peer Bridger Program was established in 1994 through a contract with the State of New York. NYAPRS is recognized nationally as the initiators of the original Peer Bridger Program. There are a number of other organizations that offer similar services, but many are not affiliated with, nor follow, the NYAPRS model. Initially, NYAPRS was funded to provide PSS to individuals who had a history of lengthy stays at one of five New York State psychiatric hospitals. The peer specialists, known as "Peer Bridgers," work with individuals in the hospital and then continue to work with them in the community. Recent changes in the state's reimbursement mechanism have influenced NYAPRS to accommodate changes to their original model. For example, in 2009 NYAPRS partnered with the Optum Health managed care organization in a Chronic Illness Demonstration Project to serve Medicaid populations. Following that partnership, NYAPRS partnered with Optum Health in a long-term program to implement the Peer Bridger model throughout New York City and Long Island. The goal of this collaborative project is to find individuals who are high users of EDs and crisis centers and to provide them with Peer Bridger services. Unlike the traditional Peer Bridger Program, Peer Bridgers who work in the Optum program often have to find and engage individuals within the community, rather than starting in an inpatient setting. Similarly, in 2014, Health First, another Medicaid managed care payer, also contracted with NYAPRS for Peer Bridger services. The Health First service contract shares many of the features of the Optum Health program including engagement of individuals within the community. The Health First contract includes a telephonic case manager that works with peer specialist in the coordination of an individual's care.

"We were the first Peer Bridgers in the world. We've been doing this work for over 20 years!"

-- Tanya Stevens, Director of the NYAPRS Peer Bridger Program

PSS Categories NYAPRS Programs
Crisis and Respite Services  
Transition in Levels of Care
  • Peer Bridger Program
Community-Based to Promote Recovery and Resiliency
  • Peer Bridger Program
  • Critical Time Intervention Housing

Service Catchment Area

Through contracts with the State of New York, NYAPRS delivers Peer Bridger services in the following counties: Albany, Broome, Queens, Suffolk, and Westchester. Through the managed care contracts, services are delivered in Long Island, and New York City.

Peer Support Services Model

The manualized components of the Peer Bridger program were developed by NYAPRS. Information on the components of the NYAPRS Peer Bridger Model are described in subsequent pages of this case study.

Service Recipients

Individuals who receive Peer Bridger services engage in the program voluntarily and have a history of mental health and/or substance use conditions. Through the New York OMH contract, Peer Bridgers meet with and work with clients in the state hospitals and then in the community.

Through the managed care contracts, individuals with frequent and recent hospitalizations are referred to the Peer Bridger program. In most cases, Peer Bridgers first engage the individual in the community. Much more time is spent on outreach and engagement of referred individuals.

"Peer Bridgers are part of our team. They are integrated into our workflow."

-- Bill Dixon, Executive Director of Albany State Hospital

Training and Certification of Peers

The State of New York is currently in the process of developing training, certification and reimbursement standards for PSS. However, as of July 2014, the State of New York has not implemented any requirements for training and certifications of peer specialist; peer specialist services are not Medicaid reimbursable in New York. NYAPRS has established their own training and supervision requirements for individuals who work as Peer Bridgers in their programs. Peer Bridgers are trained using an established manualized training curriculum that includes 40 hours of training and covers the core competencies for the NYAPRS' Peer Bridger Program. Once training is completed, Peer Bridgers are provided with weekly telephonic supervision and in-person meetings every 2-3 weeks with the Director of the NYAPRS' Peer Bridger Program. NYAPRS also offers Peer Bridgers additional training on housing, entitlements, working with individuals with substance use problems, and whole health peer support service models.

Financing Services

NYAPRS maintains contracts with the state and two managed care entities to provide Peer Bridger services. The managed care contracts include Optum Health and Health First, both serving Medicaid-covered lives. Each contract has different criteria for covered services. Clients are identified through referrals from the state or managed care companies. Historically, NYAPRS has received bundled payments for services to designated populations. NYAPRS leadership note that as the New York State Medicaid system evolves, it is likely that reimbursement for PSS will change. Changes may include billing for fee-for-service reimbursement and establishing electronic health record capabilities. Additionally, New York is expected to begin certifying and reimbursing peer specialists in late 2015.

Featured Programs

"Peers are great at engagement, activation, and outcomes. People are leading happier lives and getting less intrusive services."

-- Optum Managed Care representative for New York

Peer Bridger Model

Peer Bridger services are a time-limited model of care. The length of stay in the program varies by contract and service recipient needs. The model has four distinct, yet overlapping, phases. Peer Bridgers work with individuals to get through the phases, often starting the Peer Bridger relationship while the person is still in the hospital. The phases are:

Phase 1: Engagement. Ideally, the engagement process begins when an individual is still in the hospital. However, this is not always feasible and then engagement begins with outreach in the community. In this phase the Peer Bridger helps establish a relationship that is grounded in recovery principles and supports a transition to community living. The Peer Bridger does not rely on existing medical records or other clinical summaries to understand the individual that they are working with. Instead, the engagement is developed through a direct relationship with the individual, and not diagnosis or prior service based.

Phase 2: Crisis Intervention. Recognizing that the transition from the hospital to the community is difficult, the Peer Bridger Model defines it as a "crisis transition." Psychiatric hospitalizations can be a traumatizing experience, and can also exacerbate earlier life traumas. Regardless of whether the first contact is initiated within a hospital setting or in the community, during this phase the peer specialist works with the individual to determine their immediate needs and assess their immediate and short-term plans and goals. Helping to stabilize the person's life during this phase is the most important goal. Discretionary one-time use support funds are generally available to help during this phase.

Phase 3: Activation of Wellness Tools. The individual has completed Phase 1 and 2. They are living in a stable environment within their community. In this phase, the development of wellness and self-management skills are the key tasks. The Peer Bridger works with the individual to promote the principles of recovery using structured programs like the WRAP. Self-directed goals and ongoing plans are developed. Peer Bridgers are trained in the Stages of Change model, and they use Motivational interviewing skills.

Phase 4: Disengagement. In the final phase of the Peer Bridger Model, the focus is on completing the process of community integration and comfortably disengaging from Peer Bridger services. As the individual successfully transitions to their life in the community and natural supports are established, then the evolution from the hospital back to daily life is complete.

Adapted Peer Bridger Model

In recent years, NYAPRS has adapted their original model to accommodate the changing health care environment. Unlike the original Peer Bridger Model where a Peer Bridger initially engages with the person in a hospital setting, recent adaptations include client referrals that require Peer Bridgers to first engage with an individual within the community. More often the individuals they are asked to work with are identified by Medicaid managed care companies as high utilizers of EDs and have a history of repeated psychiatric hospitalizations. These individuals often have complex needs, including co-occurring substance abuse and homelessness. Peer Bridgers working within these programs are trained as "recovery coaches" to address substance use issues, as well as mental health conditions; they are also educated as housing specialists. All program participants are voluntary, but referred by the state, Optum Healthy, or Health First.

In the Health First program there is a telephonic case manager who alerts the Bridger program of a new enrollee in the program. Peer Bridgers and the Health First case managers have biweekly meetings where they discuss specific "members" (consumers) that they share, and reach out to one another while working with the consumer.

Housing has been a growing challenge for the individuals that NYAPRS Peer Bridgers work with. To address this challenge, NYAPRS has recently implemented the Critical Time Intervention (CTI) Housing Program. CTI is a well-researched practice designed to prevent homelessness among people suffering from severe mental illness. CTI is a time-limited intervention, lasting nine months. The phases of CTI, Transition to Community, Try-Out, and Transfer of Care, are each roughly three months. CTI targets repeat and high-cost users of inpatient services.

"When I was sick, 'hope' wasn't a word in my vocabulary. I wish I had a Peer Bridger who helped me."

-- Peer Bridger working in NYC

Data and Outcomes

The NYAPRS Peer Bridger program does reduce the rate of re-hospitalization. The Optum Health's behavioral health sciences group reports that after including NYAPRS Peer Bridgers into their managed care program, there was a 47.9 percent decrease in the use of inpatient services; the average number of inpatient days decreased by 62.5 percent, from 11.2 days before NYAPRS involvement to 4.2 days after NYAPRS Peer Bridger involvement; and outpatient visits increased by 28 percent among individuals served by Peer Bridgers. The overall behavioral health cost decreased by 47.1 percent (report from July 2013). In a previous study of the NYAPRS Peer Bridger program, a cohort of 176 individuals who participated in the NYAPRS Peer Bridger Program to transition from the New York State hospital into the community were assessed 1 year after leaving the hospital setting (from 2008-2009). These data show that approximately 71 percent of the individuals were able to maintain their tenure in the community and were not re-hospitalized.

"As a Bridger, sometime I say to people, 'Been there and done that. I just don't have the t-shirt.'"

-- Peer Bridger working in Albany

New York Association of Psychiatric Rehabilitation Services, Inc.
Peer Bridger Program
194 Washington Avenue, Suite 400
Albany, New York 12210
Phone Number: (518) 436-0008


Optum, Pierce County Regional Support Network

Program Background

Since 2009, Optum has served as the RSN (Optum Pierce RSN) for Pierce County, Washington. As the RSN, Optum coordinates mental health care for Medicaid beneficiaries (an eligible monthly population of approximately 135,500) through a network of inpatient, outpatient and residential treatment providers. In this role they are responsible for developing the health care system that serves the most severely ill behavioral health consumers in region. In the past 6 years, Optum Pierce RSN has made a commitment to integrating PSS into their service provider networks. Through direct contracting with providers, Optum Pierce RSN has changed their county mental health system to be recovery oriented and staffed by a growing portion of Certified Peer Counselors (a.k.a., peer specialists) who work alongside traditional mental health providers and within systems of care. Within the Optum Pierce RSN, peer specialists work in ED settings, in crisis centers, and in outpatient provider settings. Peer specialists work with adults, youths, and families. Optum has worked with the state to establish certification guidelines for peer specialists and helped to train this workforce in Pierce County and in other parts of the state.

"Before Optum began working in Pierce Country, peer support services were not valued. Now, for every intervention someone is asking, 'How can we involve peer partners in this?'"

-- Pierce County Behavioral Health Provider

PSS Categories Optum Pierce RSN Programs
Crisis and Respite Services
  • Crisis Triage Centers
  • Evaluation and Treatment Centers
  • Top 55 ED Utilizers
  • ED Diversion Program
  • Mobile Outreach Crisis Teams
Transition in Levels of Care
  • Peer Coaches for Community Transition
  • Residential Facility Community Re-entry
  • Jail Community Re-entry
  • Juvenile Detention Services
Community-Based to Promote Recovery and Resiliency
  • Mobile Integrated Health Care
  • Recovery Centered Housing (PORCH)

Service Catchment Area

Optum Pierce RSN coordinates mental health care for Medicaid beneficiaries in Pierce County, Washington, through contracts with a network of inpatient, outpatient, and residential treatment providers in the region. Optum also operates a national program for behavioral health management that promotes the role of PSS in other markets.

Peer Support Services Model

Optum Pierce RSN has implemented their own curriculum for training peer support specialists based on their national Optum Health service model. Most of the peer specialists employed within the Optum Pierce RSN are trained by Optum and they receive additional training from the provider organization that they are employed within.

Service Recipients

Optum Pierce RSN serves Medicaid beneficiaries with mental health conditions. They are in the process of expanding beyond a focus on behavioral health conditions and promoting a whole health approach that addresses the physical health needs of persons with mental health and/or substance use conditions. In some cases, peer specialists work with individuals without Medicaid benefits to complete paperwork for their entitlements.

"I've worked in other states and in other counties within Washington. I can tell you that Pierce County is unique. Here, peer specialists are integrated into our work. Optum has promoted in Pierce County the value of peers."

-- Director of a Community Behavioral Health Center in Tacoma, Washington

Training and Certification of Peers

Optum Pierce RSN conducts its own training of peer specialists within the network. Optum leadership describes the training as manualized but dynamic enough to cover new topics as the health care system evolves. The training meets Washington State certification standards for peer providers. Optum is one of three training sites within the state. Forty hours of training is required, as well as continuing education credits.

Approximately 200 peers are employed within their Pierce County provider network. As of July 2015, Optum Pierce RSN has trained nearly 500 peer specialists and continues to conduct training sessions approximately 2-3 times a year. All graduating peers are welcome to receive ongoing Optum Pierce RSN newsletters that list relevant changes in the field and employment opportunities for graduates.

Financing Services

Optum Pierce RSN is contracted by the State of Washington. Most PSS are paid for through contracts with network provider organizations using a modified fee-for-service model. Provider organizations are prospectively paid and encounters are tracked and adjudicated against these payments. Optum Pierce RSN contracts with providers in Pierce County and develops detailed description of the peer services that are being contracted for. Optum also uses some of their administrative dollars to promote the role of peer services across their network and the community. In order to support the role of peers in provider organizations, Optum has made the administrative decision to pay peers at the same rate as Masters-level clinicians. It is up to the providers who employ peer specialists to determine salary.

Featured Programs

"We see that putting peers into situations where they have no lived-experience is not helpful. For example, when we put peers without criminal justice experience into the criminal justice system it didn't work. So then we decided to staff the peer support services with peers who had been arrested, been in jail or prison. Ta da! It was amazingly effective!"

-- Director of a community behavioral health agency within the Optum Pierce County RSN

Crisis Triage Center

As a part of their network of care, Optum Pierce RSN contracts with RI (an Arizona-based provider organization) for the Recovery Response Center in Pierce County. This was the first Triage Center in Washington State to be staffed with 50 percent peer specialists. Individuals are mostly referred by first responders and EDs. Of the 2,500 average guests per year, only 2 percent are hospitalized.

"Hospitalization is traumatizing! We needed an alternative. If it weren't for peer support services, so many people in our community would be lost within the maze of the health care system." -- Pierce County Peer Specialist

Evaluation and Treatment Centers

Optum Pierce RSN has supported the opening of four16 bed Evaluation and Treatment Centers. This resource serves as a crisis evaluation and management facility. Peer specialists work side-by- side with other providers on the treatment team.

Top 55 Emergency Department Utilizers

This program was developed to serve the most frequent utilizers of emergency psychiatric services. Peer specialists play a key role in this program. The program is designed to serve children and adults, and a team is available 24 hours/7 days a week to provide outreach and services for this population.

Emergency Department Diversions

In this program, peer specialists work with mental health professionals in local EDs to rapidly assess and divert as indicated, individuals who are seeking ED care. Within this program, of the 1,040 individuals seen (during a 14-month period), only 6.2 percent were hospitalized.

Peer Coaches for Community Transition

This program helps support individuals who are in the hospital to transition to the community. The program assigns a peer specialist who works with the individual both within the hospital setting and then in the community following hospital discharge.

Mobile Outreach Crisis Teams

As part of this program, a mobile van travels to community locations to address the needs of individuals who are experiencing psychiatric crisis. Teams of clinicians and peer specialists work together. Optum Pierce RSN reports that this program has helped reduce involuntary detention by 31.1 percent.

"We are the hope. For the people we work with, we are the model for recovery."

-- Pierce County Youth Peer Specialist

Residential Facility Community Re-entry

This is a PACT Team model in which 70 percent of the staff are peer specialists. Since the program began 5 years ago, Optum Pierce RSN reports that they have doubled their original investment, resulting in over $3 million in savings.

Jail Community Re-entry

This program is designed to help incarcerated individuals successfully transition from jail settings back to the community. Peer specialists engage individuals while they are still involved in the criminal justice system and support them once they are back in the community. This program relies on peer specialists with a history of mental health conditions and who have been criminal justice system-involved. Optum Pierce RSN reports that one year after starting the program they saw a 72 percent reduction in re-arrests.

Optum Pierce RSN also supports a similar program in which daily jail bookings are reviewed for individuals with a past history of mental health treatment. Peer specialists contact individuals while they are still in jail and help them transition back into the community, enroll for Medicaid benefits and access needed health and community-based services.

Juvenile Detention Services

In this program, certified peer youth mentors engage with detainees who are struggling with mental health issues. Peer specialists help reunite families and address safety planning with the youth.

Mobile Integrated Health Care

Optum Pierce RSN has partnered with a local hospital to develop a mobile outreach van that provides on-site primary care services at local behavioral health centers. This van is staffed by nurse practitioners and peer specialists. The van offers routine primary care services. As of June 2015, this program has served 1,174 individuals, and of these individuals: 49.5 percent have reduced their body mass index; 50.0 percent show decline in their Hemoglobin A1c; and 56.3 percent show reduction in their lipid counts.

Recovery Centered Housing (PORCH)

Fifty percent of the staff working within this housing program are peer specialists. The program helps individuals with mental health conditions find and maintain stable housing. Optum Pierce RSN reports that 88 percent of individuals who have enrolled in this program now have stable housing.

Data and Outcomes

Optum Pierce RSN's integrated provider network has allowed them to collect data on service utilization including hospitalization, ED use, and health care costs. Their data shows that after introducing PSS into their repertoire of services, they have achieved an estimated $21,600,000 savings in excess service utilization costs.

An analysis of Pierce County services in 2013 shows that following the inclusion of PSS across provider contracts, among individuals served by Optum there was a 31.9 percent reduction in hospitalizations (estimated $12.1 million saving in 5 years). Additionally, follow-up by a provider after discharge from a hospitalization rose from 20 percent to 70 percent. There was a 32.6 percent reduction in involuntary admissions with an estimated savings of $8.4 million over 5 years. There was a 32.1 percent reduction in 30-day readmission rate (estimated $1.1 million savings in 3 years).

Additional data and outcomes are provided for the specific programs described in the Featured Programs section of this case study. (Statistics provided by G. Dolezal and F. Motz. Data dated August 1, 2013.)

  Prior Year FY 2009 Optum FY 2010 Optum FY 2011 Optum FY 2012
Individuals Served
  • 32.0% increase in individuals served annually
12,121 15,262 15,410 16,005
Total covered county population   1,399,846 1,492,221 1,535,745
Reduction in Hospitalization Admissions
  • 32.3% reduction in hospitalizations
  • $7.3 million est. cumulative 3-year savings
123 monthly 99 monthly 79.25 monthly 71.6 monthly
Involuntary Treatment Act (ITA) Reduction
  • 31.1% reduction in ITA
  • $5.0 million est. cumulative 3-year savings
83.6 monthly 56.8 monthly 55.8 monthly 57.58 monthly
Re-admission Rate/30 Days
  • 26.5% reduction in re-admission rate
  • $0.5 million est. cumulative 3-year savings
12.6% 8.6% 10.75% 8.45%
Inpatient Bed Days/1,000
  • 35.0% below state average
  • $12.0 million est. cumulative 3-year savings
19.60 12.13 12.37 13.73
Cumulative reduction percentages in column 1 are calculated as the average reduction over the 3-year Optum period compared to the prior year. Bed days/1,000 is based on the total covered county population. Cost savings calculations use average length of stay and/or daily unit costs based upon the prior year experience.

Table is an excerpt from:

Optum, Pierce County Regional Support Network
3315 South 23rd Street, Suite 310
Tacoma, Washington 98405
Phone Number: (253-761-3084)


Recovery Innovations

Program Background

RI was founded in 1990. This case study focuses primarily on RI programs in Maricopa County, centralized in Phoenix, Arizona. In many of RI's programs, peer specialists (PS) work in integrated teams with nurses, psychiatrists, psychologists and social workers; some RI programs are entirely peer-run. They maintain one of the largest peer specialist workforces in the world. Peer specialist constitute 65 percent of the workforce at RI (approximately 500 peer specialist employed). The RI service model was initially developed to address the needs of persons experiencing psychiatric crisis. RI's Recovery Opportunity Center maintains a robust training program that supports the education and certification of their peer specialist workforce.

RI contracts with organizations and systems outside of Arizona and has developed programs and services in six states and in New Zealand; and the Recovery Opportunity Center has provided training and consultation in 27 states and five other countries. Impressively, the RI Crisis and Respite Centers "Recovery Response Centers" are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JACO) as a level 1 sub-acute health care facility.

"For over a decade Recovery Innovations has been the employer of the largest peer specialist workforce in the world. The Veterans Administration has recently taken that title from us, but we are involved in training their workforce too!"

-- Lisa St. George, Director of Recovery Practices, Recovery Innovations of Phoenix

PSS Categories RI Maricopa County Programs
Crisis and Respite Services
  • Recovery Response Centers
  • Peer Recovery Teams
  • Recovery Connections Phone Line
Transition in Levels of Care
  • Peer Advocacy -- Hospital Transition Services
Community-Based to Promote Recovery and Resiliency
  • Wellness City
  • Recovery Education
  • Supportive Housing

Service Catchment Area

Programs are run throughout Maricopa County, Arizona. Many are based in Phoenix. Through contracts, RI provides peer specialists in six states and New Zealand.

Peer Support Services Model

RI describes their services as being based on their Recovery Opportunity Center's Peer Employment Training for Certified Peer Specialists and a Whole Health Model, both developed by Recovery Opportunity Center.

Service Recipients

In the State of Arizona, RI provides services to over 10,000 adults with serious mental health and substance use conditions each year. Recipients are Medicaid eligible or qualify for other publicly funded mental health services. Most of the RI programs focus on adults, but some programs serve family members and transitional-aged youth.

"Our Peer Services focus on recovery. This is a shift in perspective. It shifts the perspective of all the other providers we work with."

-- Peer Specialist in the Housing program

Training and Certification of Peers

As of June 1, 2015, RI's Recovery Opportunity Center has trained over 7,000 Peer Specialists worldwide. Their training curriculum includes 80 hours of training over 2 weeks. All staff (including non-peers) must complete 40 hours of recovery oriented new employee training as a requirement of RI employment. The Recovery Opportunity Center Peer Employment Training program costs $1,295 per-person. However, in Arizona, any individuals who receive a referral from the Department of Vocational Rehabilitation are eligible to have their training paid for, if it is part of their service plan. The RI Peer Employment Training curriculum is a proprietary manualized program. RI has cross-walked the training requirements with their Arizona certification requirements, as well as those of many other states that certify PSWs, to ensure that certification requirements are fully met. RI has contracts to conduct peer specialist training in the states of Louisiana, Pennsylvania, Minnesota, Tennessee, California, Delaware, North Carolina, and is the primary trainer for the VA.

Financing Services

RI reports annual revenues of over $63 million across the company. Funding sources within Maricopa County include the State of Arizona Department of Health Services through a contract with the Mercy-Maricopa Integrated Care/AETNA Regional Behavioral Health Authority (RBHA), the Arizona Rehabilitation Services Administration, and the U.S. Department of Housing and Urban Development. The RBHA is a Medicaid-funded program, and RI serves as a crisis and recovery-based services provider. As a requirement of Medicaid funding, all services must be compliant with HIPAA. The RI programs have been able to sustain contracts with the RBHAs despite changes to the RBHAs entity. According to RI leadership, this is due in large part to RI's reputation and ability to effectively manage community-based recovery services. In other states, RI contracts with various funding authorities to provide a range of programs including crisis services, peer specialist training, housing, respite, and resource development. RI does not bill third-party private health insurance plans.

Featured Programs

"There is great consistency across Recovery Innovations' sites within and outside of Arizona. We find an 85-90% fidelity to our model across sites. All our materials across sites have the same look and feel. Our staff go through the same core training regardless of which state they are in."

-- Lisa St. George, Director of Recovery Practices, Recovery Innovations Phoenix

Recovery Response Centers

The Recovery Response Centers is a three-facility program with the following components: Front Room (walk-in crisis center); Retreat (a 23-hour observation center); and the Living Room (licensed as a crisis stabilization facility). Peer specialists work alongside other health care professional within the Centers.

In the Front Room the initial behavioral health assessment is completed. A peer specialist is the first person the individual meets when they enter the Front Room. Individuals who are seen in the Front Room and need additional time to plan next steps are invited to stay in the 23-hour Retreat. Those who need longer stays are registered in the Living Room, where they can stay several days.

The Living Room Concept was created by RI as an alternative to traditional crisis services. The Living Room provides a space where individuals who are having a difficult time can become a guest. They receive comfort and hope from a team of peer support specialists.

The Centers emphasize a strength-based approach to all services. For example, the rooms in the Center where participants stay are labeled with a recovery-based name such as hope, strength, and resiliency. Staff in these programs are based in open areas, and engagement with the participants is encouraged at all times. These Centers are accredited by JACO.

"We show people that there is life after hospitalization." -- Peer Specialist within one of the Recovery Response Centers

Community Response Team

This mobile crisis service responds to people in their home or other community locations. The Crisis Response Team is staffed with peer specialist and traditionally trained psychiatric staff. Peer specialist offer up to three follow-up visits to fully resolve the situation. The Community Response Team (CRT) can also respond to hospital EDs and police requests.

Recovery Connections Phone Line

This 24 hours/day, 7 days/week telephonic crisis services is staffed by Peer Specialists who address calls from consumers and are able to dispatch a CRT or make a warm hand-off with other crisis professionals as needed.

Peer Advocacy Services

These services are hospital-based PSS. Their goal is to work with individuals who are currently in the hospital and help in the development of recovery-oriented discharge plans and ongoing recovery plans to support re-integration into the community. These services are intended to reduce the need and likelihood of hospital readmissions. The Peer Advocacy services work with the Peer Recovery Teams to coordinate and provide PSS in the community to foster resiliency and promote recovery. On average, Peer Specialists on the Recovery Team will maintain a caseload of about 30 participants. The hospital tracked outcomes the first year that Peer Support came into the hospital through RI. Those outcomes included a 56 percent reduction in recidivism, a 47 percent reduction in restraint use, and a 36 percent reduction in seclusions.

"We focus on what is strong; not what is wrong. Unlike traditional providers, when we write in the electronic medical records we describe how the person is doing rather than about their problems."

-- Peer Specialist in Peer Advocacy Services program

Wellness City

The RI Wellness City programs are open to individuals who have RI services built into their treatment plan. Participants in these services (referred to as "citizens") have a wide array of programs and activities that support recovery including: educational life skills classes, city hall meetings, employment support, career workshops, linkage to community resources, housing support, personal wellness coaching, computers access and social events. Fitness rooms, exercise equipment, and health-related programs are also available.

Recovery Education Center

The Wellness City also includes the Recovery Education Center. The Center offers a variety of educational classes and workshops. Participants can earn Vocational Educational Certificates by enrolling in specific programs. The Center is classified as an Arizona Licensed Private Postsecondary Vocational School. The Center meets GED testing requirements and supports participants' educational advancement.

Housing Services

This program is designed for persons on Medicaid with mental health problems. Every person in this program has a peer specialist assigned to them. Individuals meet with their peer specialistweekly at first for 1-1.5 hours a week, reducing duration and frequency of meetings over time. Individuals may graduate after 1-2 years from the program. This program has fidelity to SAMHSA Supportive Housing model. Use of peer specialist is what makes it unique. RI has replicated this program with peer specialist in other states.

Data and Outcomes

While RI maintains medical records for the consumers they serve, they do not specifically track data on ED use and hospitalization. The data directly tracked by RI are related to contract requirements and JACO accreditation standards. However, they note that sometimes the agencies that contract with RI will provide data. For example, in Maricopa County, the RBHA reports that following implementation of a recovery mission and Recovery Response Center in 2002, hospitalizations decreased from a high of 24 percent to 10 percent within a year (diversion of 1,080 hospital admissions), representing an estimated savings in hospitalization costs of $10,000,000. Of those individuals who are served at one of RI's Crisis Respite Centers, less than 25 percent are hospitalized. Between 2003 and 2004, RI was able to reduce hospitalization rates by 25 percent within 6 months in two other locations where they implemented Recovery Response Center crisis services.

Outside of Arizona, RI reports that for one of their contract sites in Ellendale, Delaware (Beebe General Hospital), reported that after the RI Recovery Response Center began to do business in their community, ED dropped by 50 percent for persons with behavioral health conditions. Likewise, in July 2010, RI was contracted by Wenatchee, Washington. In the first 6 months of RI operations, the number of persons enrolled in Medicaid increased by 40 percent and the number of hospitalizations decreased by a third of its previous level.

Recovery Innovations
2701 N. 16>th Street, Suite 316
Phoenix, Arizona 85006
Phone Number: (602) 525-3003

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