The PSS described within the site visit case studies (Chapter 3) demonstrate four very different types of program models that are actively engaged in fostering improved recovery status and behavioral health outcomes for those served. These programs help address and inform the three questions that frame this study of how peer support service models help reduce preventable psychiatric hospitalizations, re-hospitalizations, and ED utilization. Based on the review of existing peer support service programs across the United States and these case examples, it is evident that they have established an emerging role in the health care systems of many states.
As illustrated by the case examples in this study, there is a range of service models and roles that Peer Support Specialists are engaged in. To illustrate the spectrum of PSS approaches and models, a framework of the types of services that are applicable to the question has been developed. This includes programs that provide services for crisis and respite care; level of care transitions; and community-based recovery supports.
A summary of the range of programs evaluated is included in Table 6 below.
|TABLE 6. Site Visit Programs by Type|
|GMHCN||NYAPRS||Optum -- Pierce County||RI|
|Crisis Respite Programs||
|Level of Care Transition Programs||
|Community-Based Recovery Supports||
The outcomes measured for these services types are variable and have methodological challenges. All of the outcomes reported by these programs are generally derived from self-report or administrative data. There were no formal evaluations that used quasi-experimental or RCT approaches. Two of the programs (GMHCN and NYAPRS) do not have specific staff that are responsible for outcome evaluations, and they do not receive any funding or administrative support for these functions. One of the programs (RI) has a robust accreditation commitment and many of their outcomes evaluations are linked to these accountability standards. The Optum program has the greatest level of commitment to measuring outcomes and they have access to utilization and other administrative data, and both local and national staffing resources, to support these tasks.
Crisis Respite Programs
Crisis respite programs are designed to provide a safe and stable environment for someone experiencing a psychiatric emergency. PSS in these crisis settings foster a safe relationship that allows individuals to engage with others who have had similar experiences. In team-based crisis care such as evaluation centers and mobile outreach programs, peers work collaboratively with clinicians and are effective at engaging individuals and helping to develop person-centered plans.
Three of the four programs reviewed have some type of crisis respite programs. These include telephonic crisis and warm lines as provided by GMHCN and RI, both of which are staffed by peer specialists and collocated within crisis facilities. Various forms of crisis centers were also observed, including the GMHCN Wellness Center and the RI Recovery Response Center. In varying degrees these programs are focused on wellness and recovery in addition to specific crisis focused services. Optum contracts for a crisis center and an evaluation and treatment center. The crisis center programs are peer staffed, while the others are hybrids programs using both clinical and peer staff. Optum also supports a range of other crisis programs including mobile crisis outreach teams, which include peer staff, and high utilizer care management programs.
Across the crisis and respite services there is not a consistent model that is predominant. Each of the programs provides staff training and has employee guidelines. However, these are not specific protocol-based services and there appears to be considerable variability across programs. Staffing models, including peer-only as well as peers and professionals integrated in a service setting, are also variable across these programs.
As noted above, there are significant challenges and limitations in the evaluation of outcomes among many of the programs reviewed. The GMHCN program primarily uses self-report data on personal health information and program participation satisfaction. Their participants self-report a re-hospitalization rate of 37 percent at any time within the past year. They also have some state-reported outcome data that indicates that the number of hospitalizations has declined below anticipated trended rates. However, since they do not have specific encounter-based service utilization data, it is difficult to directly attribute these outcomes to specific crisis respite services. The results for RI are similar in that they are not specifically tracked to internal outcomes at the client level. However, the results of their reporting to their contract RBHA supports an overall reduction of hospitalizations in the target year of 14 percent, and 1,080 hospital diversions are noted for the population served. Additionally, based on currently trended measurements, they report that 75 percent of those receiving care in their crisis center self-reported that they did not require admission to a psychiatric facility. The best results for crisis respite services are provided by Optum. This is due in large part to their role as network administrator across multiple programs and state contractual requirements. Optum reports system-wide results of savings in both total dollars and per-case utilization. For example, they note that they have been able to reduce hospital admissions by 32.3 percent for an estimated cumulative savings of $7.3 million over a 3-year period. This is cost-trended data based on historical utilization patterns and service costs.
Level of Care Transition Program
Level of care transition programs are designed to help individuals who are hospitalized for mental health conditions successfully transition to outpatient care and return to the community. These programs provide a peer support specialist who can both assist the recipient of service and help advocate for their community needs. This is accomplished in part through a supportive peer relationship that promotes the linkage and connection to ongoing care and community support resources.
Each of the sites reviewed operates one or more programs to support level of care transitions. Generally these are services that are focused on helping individuals transition from psychiatric hospitals to lower levels of care and community living. Three of the programs are based in states (Georgia, New York, and Arizona) that continue to use state psychiatric hospital care for longer term stays. However, these transition services are deployed in both state and community psychiatric hospitals.
These level of care transition programs are variously described as "peer bridger" (NYAPRS), "peer mentor" (GMHCN), and "peer coaches" (Optum). Several organizations also used the term "peer bridger" to describe level of care transition services. Across the programs reviewed, the NYAPRS Peer Bridger program has the most structured model of services. This model describes four phases of service that guide the work of the peer specialist. The other programs do not have as clearly structured an intervention model and their work is more open-ended.
The outcomes of the level of care transition programs are monitored and reported in various ways by the different organizations. Again, there are challenges and limitations in the way outcomes are measured and reported. NYAPRS reports outcomes based upon an early study from 2008-2009 that was conducted internally and not repeated. In this study, they report that 71 percent of the individuals served were able to maintain community tenure without readmission throughout the study period, but they do not have baseline data for comparison. More recent data have been reported by one of their managed care payers (Optum), and the results indicate a 62.5 percent reduction in hospital length of stay, and a 47.9 percent reduction in inpatient services among participants. This is based on comparison with the plan and state's historical data. Additionally, supporting the successful transition to lower levels of care, Optum also reports increased outpatient utilization by 28 percent among those receiving peer bridger services. Based on self-report data, GMHCN reports that there is a 90 percent satisfaction rate with their peer mentor services, and within the year 37 percent of service recipients reported re-hospitalization. Without longitudinal or comparison data it is difficult to interpret the Georgia statistics. Optum Pierce County reports that over a 3-year period of time their readmission rate has declined 26.5 percent from baseline, and they have realized one-half million dollars in savings as a result of these reductions in hospital utilization.
Community-Based Recovery Supports
Community-based recovery supports are those services that foster ongoing resiliency and well-being. These can take many forms, including ongoing PSS as well as the development of other peer and community supports. These activities also promote engagement, activation, and ongoing self-management for behavioral and physical health conditions. Over time, these services are less formal as individuals assume more community-based recovery activities.
All of the programs reviewed for this study provided some forms of community-based recovery supports. One of the more frequently described challenges by the organizations that provide these services is the need for stable housing. NYAPRS, Optum Pierce County, and RI all provide some sort of housing resources as part of their programs. RI provides temporary housing resources in a designated apartment complex to help foster stability for those in transition and crisis. These are short-term supportive housing resources that are linked to the continuum of their services. NYAPRS also has designated peer specialists who can assist in housing transitions. Pierce County Optum's provider network offers community housing support programs that are linked to their provider organizations and local social service agencies.
Community-based resources are also a fundamental component of recovery supports. GMHCN provides recovery education programs within their wellness centers. These are daily structured programs that provide both direction and support to foster community tenure and recovery self-management. RI provides a campus-like setting for ongoing recovery support activities and describes the participants in their programs as "citizens."
Measuring the outcomes of ongoing community-based recovery supports is particularly challenging. In Pierce County, Washington, based on the addition of peer services, Optum is able to measure community engagement through improved rates of clinical provider follow-up after discharge (50 percent increase), and reduced hospital readmissions (32.1 percent over 3 years) when compared with baseline trends. Other programs also report reduced re-hospitalization rates, but it is difficult to assess how much this is attributed to specific community recovery programs.
Measuring and determining the outcomes of specific PSS is difficult. While programs and systems are able to report reduced admissions, declining readmission rates, decreased ED utilization, and lower rates of necessary admissions from those seen in crisis and community settings, it is challenging to identify specific interventions that account for these results. A detailed review of these challenges is reported in the discussion below.
Results from Site Visits
The findings of this study suggest that there are a range of PSS programs currently operational across different states. The programs reviewed in this study demonstrate promising, although not always well documented results in these areas. Many PSS programs describe their mission and role as the promotion of recovery and the improvement of resiliency and well-being of those served. Four key challenges were observed from the review of these programs.
Key areas of findings from this study that merit further evaluation and discussion include:
- Service models for PSS;
- Funding and reimbursement models for PSS;
- Health system integration of PSS; and
- Measurement and reporting of the outcomes of PSS.
Each of these four factors is linked and impacts each other. Therefore, there is a cumulative effect such that variability in service models is influenced by the types and sources of funding for these services and the extent to which they are integrated into larger health systems. Finally, the result of these factors also cascades to a range of significant challenges in the measurement and reporting of outcomes. A review of each of these areas illustrates the challenges that face the continuing evolution of PSS in the United States health care system.
Service Models for Peer Support Programs
For this study, a framework of peer services including crisis/respite programs; level of care transition programs; and community-based recovery supports has been developed. Many of the organizations reviewed in this study had service programs in each of these different categories. However, variations in service models were observed, and these programs were generally not protocol-based interventions. It is also important to note that some organizations described the necessary requirements for the flexible design of PSS and programs to be consumer-recipient defined and geared to their goals and needs. And, while this is entirely consistent with person/patient-centered goals, some peer programs differentiate between PSS from the medical or clinical model. Therefore, they propose that PSS inherently require a degree of flexibility not always seen across traditional health care services and clinical/medical intervention models.
This study has illustrated that there are a range of service models for PSS. These are in part determined by the organizations that provide them and how they fit within their mission and the spectrum of existing health care systems. Most of the organizations observed provide a majority of their services through Medicaid and other state-funded programs. Two of the program models evaluated (GMHCN and NYAPRS) can be described as consumer-run organizations. Both GMHCN and NYAPRS operate statewide services. RI is a peer-focused organization; it also incorporates traditional clinical staff in team-based care services and has both national and international training and service programs. Optum Pierce County is a part of a larger national health insurance organization, and their programs are managed care payer based. While Optum employs some peer specialists, they largely contract for the provision of services from either consumer-run organizations or clinical provider organizations.
Across the PSS programs reviewed there are a range of program models that are deployed. These also vary in the rigor of their design and the extent to which they emphasize fidelity to specific program models. In some cases the PSS programs are organized around a set of core principles that guide the service models. In other programs there are structured interventions that are based on established models of service. Across the field of PSS there are few strictly defined service models. This finding is in line with what the Institute of Medicine (IOM) has observed for many psycho-social interventions (IOM, 2015b).
As an example, NYAPRS developed and was the first to implement the peer bridger program to support individuals as they transition from hospital-based care to community-based care. This model is based on four phases of care that begin with engagement; helping individuals deal with aspects of crisis as they leave the hospital and begin to re-integrate in the community; activation of recovery and wellness tools; and disengagement when the individual can successfully maintain community tenure. NYAPRS trains their staff in this model, and they have also provided training for other programs in different states.
Each of the programs reviewed indicates that they provide some type of level of care transition services. GMHCN calls the providers of these services "peer mentors" and the others variously describe them as "peer bridgers" and "peer coaches." Across the organizations reviewed, none of their level of care transition programs has a defined a set of stages or a defined program model, except for NYAPRS' four-stage model. In some cases, there are service requirements for the frequency and duration of contacts. In the Optum Pierce County program, these level of care transition services are linked to services provided across their network providers.
The RI crisis programs were observed in both their Arizona-based organization and also as a contracted service in the Optum Pierce County program. However, there are variations even within a single organization. For example, the RI program's state requirements for locked access to the crisis services required different service approaches in different states, as observed between Arizona and Washington.
Without clearly defined service models, it is difficult to differentiate the programs provided by the organizations included in this study. The three-level service framework proposed for this study can help differentiate the types of programs but not fidelity within services. Additionally, among the organizations reviewed in this study, there is no consistent agreement for where they fit within the continuum of health care services. This is seen in the extent to which programs operate as stand-alone PSS (e.g., GMHCN and NYAPRS), or in the extent to which they have some degree of operational integration of peer support specialists with clinicians (RI) or autonomy in the design and development of networks of services that include the full spectrum of clinical providers and facilities and PSS (Optum Pierce County). Some programs are well integrated in the systems of care and routinely share service information, while others are careful to operate outside of the traditional health systems and intentionally avoid the sharing of records and diagnostic information. As the role of PSS evolves within health care, an important challenge will be to determine the extent to which these programs are integrated as part of larger health care systems. In part, this may be resolved by the emerging funding models for these services. The extent to which PSS programs are reimbursed as health care services may require that they achieve greater integration with the overall eco-system of health care.
Funding Models for Peer Support Services
The peer support service organizations reviewed for this study operate across different funding models. As example, the GMHCN program is reimbursed on a flat service rate that is similar to a grant or a prospective payment. The volume of services is tracked and reported monthly to the state, and reimbursements are generated. NYAPRS currently operates on a similar basis, and they are currently reimbursed across multiple contracts on a global budget that covers the totality of services provided. Under this model, the time spent in outreach and engagement of program participants is covered within the overall reimbursement formula. However, as reimbursement models shift in the state they anticipate moving into a fee-for-service model whereby only direct service encounters will be reimbursed. There will be a state-established rate based on 15-minute increments of service. In another model, the Optum Pierce County program reimburses providers on an encounter basis that is fee-for-service. To support peer services, they have an established rate that mirrors that of their Masters-level providers in their network. RI receives a range of funding through several different contractual arrangements. These include service reimbursement in Arizona through the local Medicaid vendor, through agreements with the Rehabilitation Services Administration, and also the U.S. Department of Housing and Urban Development.
As health care reimbursement increasingly moves toward value-based reimbursement, there is likely to be greater emphasis on accountability for consumer outcomes and utilization of high-cost health care services. These changes are likely to impose greater accountability and reporting requirements on PSS providers. However, there is also an emerging trend in the reimbursement of PSS that is contrary to this evolving approach. As Medicaid and other payers are increasingly responsible for the payment of PSS, they are shifting existing contracts away from prospective payments to fee-for-service approaches. This is likely being done as a way to increase the level of accountability of PSS, if only in terms of units of service provided. More systematic work may well be required before accurate assessment of the value contributed by PSS can be reliably measured and serve as a basis for reimbursement.
As the current trend for funding PSS programs evolves and shifts into fee-for-service reimbursement, there is an increasing threat that these services may not fit well within these traditional frameworks. With the advent of Medicaid-based funding for peer services, more states are moving away from prospective (grant-based) payment to fee-for-service, encounter-based reimbursement models for PSS. Some of the organizations reviewed in this study are concerned that their services are not well suited for this model of payment. When the PSS programs are community-based and involve a high component of indirect services for outreach and engagement, it will become difficult to account for the time spent in these activities unless the service definitions explicitly account for such activities. NYAPRS reports that when they begin their bridger services with individuals who have already been discharged from the hospital, there can be several hours of indirect service required to track and engage them. An important question will be the extent to which fee-for-service definitions recognize and address these requirements.
This trend toward fee-for-service reimbursement for PSS may only be transitional. As health care becomes more value and accountability based, it is likely that at least some PSS programs will become better integrated with larger delivery systems. Since PSS programs are demonstrating promising value-based results through decreasing utilization of high-cost services, systems are likely going to be drawn to including them in the continuum of health services.
Health Systems Integration
One of the principal challenges for many PSS organizations is how they fit within the existing health care systems. As seen in the examples from this study, some PSS programs are stand-alone and outside of the overall health system, some are integrated programs with peer specialists and clinicians working side by side in integrated team-based programs, and others are based in service networks. A differentiation is made by some programs that PSS should not be considered to be clinical services, and this creates an ambiguity as to how they fit within the continuum of health care systems and organizations. Some of the organizations reviewed (NYAPRS and GMHCN) specifically avoid direct identification of a recipient's diagnosis and formal interaction with medical records documentation outside of their services. Yet, at the same time, these programs do work collaboratively with health care systems to receive referrals, specifically in the case of crisis respite and level of care transition programs. In some cases, PSS programs also support care coordination with the payer systems they are contracted with.
If PSS programs are to assume an expanding and greater role in the health services continuum, there needs to be greater clarity of how these programs fit within the overall clinical landscape. It is evident that they are an increasingly widespread component of the public behavioral health care eco-system that serves those with the most serious behavioral health conditions. Some PSS programs are also working on improving the overall health of the recipients of their services through whole health, wellness, and other integrated approaches. Yet, what is not as clear is how these services fully integrate with primary, specialty, and other health care services, nor what role they will play outside Medicaid-funded and other public behavioral health systems for people with the most serious behavioral disorders.
There is a caution among some PSS programs to preserve their services as independent from the traditional clinical/medical model. Remaining independent from the traditional clinical system has been an important historical distinction for these peer-delivered services. However, as more care is delivered within clinical teams, it will be necessary to better define their role as members of the extended care team and the care continuum. It was not clear from the programs we observed how best to integrate these services with the overall systems of care, and this may be due in part to the lack of formally developed and tested peer support service interventions and protocols. Additionally, it is also important to note that some peer specialists believe that keeping peer services distinct from the formal clinical system is a key component of what makes PSS programs effective.
The measurement and assessment of peer-delivered services is difficult and challenging. This is due in part to a combination of factors that include the lack of established service models, variable outcome goals, and ineffective measurement tools. The IOM (IOM, 2015a) has cited the need for a set of outcome vital signs for all health care. While it is essential that PSS programs evaluate outcomes that include elements like recovery and resilience, well-being, and quality of life, they are not specifically included in the IOM's framework for this set of vital signs or outcomes. Another recent IOM report (IOM, 2015b) more directly examines the current state of psycho-social interventions including PSS, and has also noted the need for better defined interventions, and more consistently measured outcomes for these services. Again, the outcomes of PSS and the accountability of these programs must fit within the continuum of health services and other psycho-social interventions.
As noted above, there is a lack of a consistent service model across each of the three levels of programs examined in this study. For crisis and respite services this range includes mobile intervention teams, wellness and recovery environments offering a safe harbor for the crisis, and telephonic response services. Within each of these there are also service model variations that make the consistent assessment of outcomes difficult. This is particularly true in the level of care transition programs variously described as peer bridger, mentor, and coaching services. Recovery-based community support programs also encompass diverse forms of programs and services. Across all three of these levels of PSS, there is a clear need for better measurement and monitoring of outcomes within each of the programs. There is also a significant need for better comparative and controlled research studies that evaluate the different service models and the determining factors of successful outcomes.
Among the PSS programs observed in this study, most of the outcomes that were provided were generated from contractual reporting made to or by payers and funders. Some of the programs reported that they do not have sufficiently qualified staff to support detailed outcome monitoring or evaluation. Additionally, three of the programs reviewed (GMHCN, NYAPRS, and RI) note that the funding for their programs is limited and there has not been a commitment from funders to support these roles. The RI program has built in some accountability evaluation to meet the requirements of their accreditors.
In reviewing the measurement and reporting of outcomes, one individual at a program site commented: "The outcomes that many people outside of peer services are looking for are not consistent with what we are trying to accomplish. Peer services are trying to help people regain mastery of their life in whatever way best fits their needs." While this is a sentiment of some peer programs, the focus on supporting recovery, resilience, activation, community tenure, and improved quality of life is also consistent with reducing hospital utilization and will in turn reduce costs. Therefore, improving recovery, resilience, and activation are proximal outcomes that may in turn increase community tenure and could be instrumental in achieving the more distal outcome of reduced hospital utilization and costs. If PSS programs are provided the necessary resources and technical assistance to develop better outcome evaluations, it is likely that this can be accomplished.
A future challenge for the PSS field will be the establishment of common outcome goals and consistent measurement processes. This may be particularly challenging since there is a range of service types and intervention models. The field is further challenged by a lack of funding to support the systematic study and evaluation of performance measures and outcomes as well as staffing and programmatic models in these organizations.
This study has examined the role of PSS and their potential for reducing unnecessary psychiatric hospital admissions, readmissions, and avoidable ED utilization. A framework for the types of peer services that might impact these outcomes has been developed. These include crisis respite programs, level of care transition programs, and community-based recovery supports. Four peer-delivered service organizations have been examined to address the focus of this study.
The findings suggest that a principal goal of many of the PSS programs reviewed is to support recovery, rather than to specifically reduce utilization of high-cost health care services. However, all of the programs reviewed do see improved health outcomes and lower costs of services as fundamentally important. While the outcomes reported are based on limited and variable rigor and sophistication, they do yield some evidence that suggests that these PSS programs likely have significant impact toward reducing utilization of hospital and ED services.
Significant challenges to the measurement of outcomes among the PSS programs reviewed are noted. These include the lack of structured service models, funding models that do not support staffing and administrative resources to effectively measure outcomes, and limitations in the integration of peer services within overall health systems that complicate the evaluation of the effectiveness of these services. More rigorous and systematic evaluation research of PSS is needed and can help document the promising findings reported in this study.
There is promise for the continued expansion of PSS and their integration across the full spectrum of health care. Recipients of these services report favorable experiences, and PSS providers and managed behavioral health care organizations report very promising results. Additional systematic evaluation research is needed to verify these findings and shed light on other issues related to the role of peer services in health care service delivery.