Peer Support: Quick Guide to Supporting Evidence

Updated October 2016

Peer Supports as recognized by federal/national health entities: Substance Abuse and Mental Health Services Administration:

Peer supports “help people become and stay engaged in the recovery process and reduce the likelihood of relapse. Because they are designed and delivered by peers who have been successful in the recovery process, they embody a powerful message of hope, as well as a wealth of experiential knowledge. The services can effectively extend the reach of treatment beyond the clinical setting into the everyday environment of those seeking to achieve or sustain recovery.”

Acknowledgement of Consumer-Operated/Provided Services as an evidence-based practice through its toolkit: Consumer-Operated Services: How to Use the Evidence-Based Practices KITs. HHS Pub. No. SMA-11-4633, 2011.

Centers for Medicare and Medicaid Services: Dennis Smith, SMD Guidance #07-011: “Peer support services are an evidence-based mental health model of care which consists of a qualified peer support provider who assists individuals with their recovery from mental illness and substance use disorders. CMS recognizes that the experiences of peer support providers, as consumers of mental health and substance use services, can be an important component in a State’s delivery of effective treatment. CMS is reaffirming its commitment to State flexibility, increased innovation, consumer choice, self-direction, recovery, and consumer protection through approval of these services.”

John O’Brien, Senior Policy Advisor, Disabled and Elderly Health Programs Group, Center for Medicaid and CHIP Services, September 24, 2011: “Good News: Peer specialists are included in all health home proposals that include individuals with a significant MH condition.”

Cindy Mann/Pamela Hyde, Informational Bulletin, May 7, 2013: Family and youth peer support services “significantly enhanced the positive outcomes for children and youth.”

Health Resources and Services Administration: Specific to Maternal and Child Health, Behavioral Health: “Parent peer support has been important in providing education, support and advocacy services.”

Veteran’s Administration: Nationally, the VA recognizes only 5 Peer Training models for its behavioral health services, including the Recovery Innovations (d/b/a RI International) and Georgia Mental Health Consumer Network/DBHDD curriculums (ABHW, January 2013).

National Association of State Mental Health Policy Directors:

In its policy brief “Workforce and the Public Mental Health System” calls to “Increase the role of peer and family supports and recovery supports through systematic adoption of payment strategies

(Medicaid and other third party insurance) that provide meaningful employment for certified peer, family and recovery workers…The use of peer and family members in the workforce not only increases workforce capacity but also expands the use of a best practice and optimizes lower cost, community-based services.”

Annapolis Coalition’s (see note bottom) National Action Plan on Behavioral Health Workforce

Development calls to “GOAL 1: Significantly expand the role of individuals in recovery, and their families when appropriate, to participate in, ultimately direct, or accept responsibility for their own care; provide care and supports to others; and educate the workforce.” It further states that “Persons in recovery and their family members are explicitly recognized as pivotal members of the workforce, as they have critical roles in caring for themselves and each other, whether informally through self-help and family caregiving or more formally through organized peer- and family-support services. These individuals are the unsung heroes and heroines of the workforce and provide a unique perspective that enhances the overall relevance and value of the care provided.”

Association for Behavioral Health and Wellness (ABHW): This association which encompasses several managed behavioral health companies such as Aetna, Beacon, Cenpatico, and OptumHealth endorsed effectiveness of peers and peer support services. (ABHW, January 2013)

Peer Supports: Sampling of National Data

Center for Medicare and Medicaid Services, HCBS Clearinghouse, Thomson Reuters (Campbell, Eiken, 2008) reported several positive and neutral research findings. The positive findings include the following:

“In a randomized controlled trial, people with access to peer support had fewer hospital admissions and one-third the number of inpatient hospital days in a 10-month period, when compared to people who did not have access to peer support.”

“…people received one of three case management options: 1) a case manager and a peer specialist, 2) a case manager and a non-consumer assistant, or 3) a case manager working alone… people served by a peer specialist and case manager showed greater improvements in several quality of life measures than people in the other two groups.”

Optum Health and Yale University found a significant reduction in hospital days after enrollment in peer supports (Bergeson, Ronfield 2011).

Pecoraro, et.al. (2012) found for individuals who had peer team intervention, insurance claims demonstrated a 33% ($35,938) decrease in inpatient medical admissions, a 38% ($4,248) decrease in emergency department visits, a 42% ($1,579) increase in behavioral health/substance abuse (BH/SA) inpatient admissions, and a 33% ($847) increase in outpatient BH/SA admissions.

Tsai, Rosenheck (2012): An intensive peer-support (GIPS) model of case management that was implemented in a supported-housing program for homeless veterans with a broad range of psychiatric, substance use, and general medical problems. Findings show a greater increase in social integration ratings, a greater number of case manager services, and faster acquisition of Section 8 housing vouchers

after program admission compared with outcomes at the same site before GIPS implementation and at the other sites before and after implementation.

Davidson, 2012: • “ENGAGE [peer support program] participants have a significantly greater increase in social

functioning from baseline to 9-months than Standard Care (est.= -.43, p =.01) and Skills Training (est.= -.31, p=.05).”

• “ENGAGE participants had a significantly greater increase in ratings of the importance of additional alcohol use treatment from baseline to 3-months than Skills Training (est.=-3.05, p<.001) and Standard Care (est.= -2.89, p<.001)”

• “ENGAGE participants demonstrated a significantly greater reduction in problems with alcohol use in the past 30 days from baseline to 3 months than Standard Care (est.= 8.84, p<.001) and Skills Training (est.= 7.89, p<.001)”

• Citizens Project [peer support program] findings: Level of service engagement much higher when Peer Support is provided

• Addition of peers reduced: o readmissions by 42% and o days in hospital by 48%

• Addition of peers: o Decreased substance use o Decreased depression o Increased hopefulness o Increased self-care o Increased well-being

Significant Differences between Conditions over Time for Intervening Variables

Condition Drug Use Hope Depressed Poor Self-Care Well-Being

Base- line 9 Mos. Base-line 9 Mos. Base-line 9 Mos. Base-line 9 Mos. Base-line 9 Mos.

Usual Care .54 (1.23) .53 (1.17)

39.03 (11.45)

38.63 (7.75)

4.21 (2.06)

3.20 (1.91)

2.04 (1.40)

2.80 (1.36)

43.56 (28.20)

53.65 (19.76)

Peer Support .85 (1.52) .05

(.21) 43.467 (12.52)

45.68 (10.59)

4.03 (2.28)

2.64 (1.99)

2.09 (1.69)

1.68 (1.04)

44.70 (29.41)

61.40 (28.41)

Statistical Significance p = .004 p = .04 p = .002 p = .02 p = .016

Solomon (2010): Outcomes of team-based case management services improve when peer specialists are included on the teams, and vocational outcomes also are improved through peer-provided services.

Magellan Behavioral Health (2013): Montgomery County, Pennsylvania study on Peer Support Whole Health found that pre- and post-program results from surveys completed by participants show an improvement within the 10 health domains of the PSWH&R training. For the 8 week program, baseline versus post-training measurement showed participants increased their average to excellent responses by 20% on the Stress Management domain and 13% on the Healthy Eating domain.

Kamon and Turner (2013): Peer supported participants had more primary care visits, fewer hospital/ER/ detoxification admissions, and significant increases on domains of recovery capital, (services, housing, health, family, alcohol & other drugs, mental health, legal, and social).

Ja et al. (2009): Peer-supported participants’ housing stability increased from 21% at baseline to 63% at 12 months; residential treatment decreased from 24% to 7%; and probation/parole status decreased from 82% to 32%.

Mangrum (2008). Peer Support clients were significantly more likely to be abstinent 30 days before discharge compared to non-peer supported criminal justice clients and non-criminal justice clients. Also, peer-supported clients were more likely to complete treatment (60%) than those in non-ATR treatment and had better outcomes if drug court or probation was involved.

Rowe, et.al. (2007): There were significantly lower levels of alcohol use in the experimental group at 6 and 12 months. The experimental group decreased alcohol use over time while control group increased alcohol use over time. Drug use decreased significantly in both groups to the same extent.

Min, et.al. (2007): Significantly fewer people in a peer-supported group were re-hospitalized over a 3-year period than the comparison group.

Dummont and Jones (2002): At baseline all study participants had experienced substantial hospital stays with a majority having had four or more admissions and a median ‘longest stay’ of over one month. The median annual income of the group was only $8,400. At 12 months, the experimental group had better healing outcomes, greater levels of empowerment, shorter hospital stays and less hospital admissions (which resulted in lower costs than control group).

Clarke, GN, Herincks, HA, et.al. (2000): Participants receiving Peer-based Case Management had fewer hospitalizations and longer community tenure than those who were receiving “usual” care or “standard case management.”

Trainor, J., Shepherd, M., Boydell, K,. Leff, A. & Crawford, E. (2002): members receiving peer support used fewer mental health services, noted an increase in community involvement and contacts, found consumer/survivor organizations to be more helpful than traditional mental health services, and found other consumer/survivors as individuals to be more helpful professionals with mental health issues.

Rowe, M, Bellamy, C, et.al. (2007): Peer Support significantly reduced alcohol, drug use, and criminal justice involvement in individuals with dual diagnosis over traditional treatment.

Tondora, et.al., National Institute of Mental Health, (2010): 290 adults with a Serious Mental Illness randomly assigned to three groups: 1) Usual Care plus Illness Management & Recovery supports (IMR); 2) Usual care plus IMR plus a peer-facilitated person-centered planning process; and 3) usual care plus IMR and person-centered planning with peer-run community connector program. Findings:

• Peer-facilitated care planning increased the sense that treatment was responsive and inclusive of outcomes that mattered to the person

• The peer-run community connector program increase hope, belongingness, treatment engagement and decreased psychotic symptoms. (Summary from Ahmed, 2013)

Sledge, et.al., National Institute of Mental Health, (2011): 74 participants who had been hospitalized at least twice in the last 18 months randomly assigned to usual care versus usual care plus peer recovery mentor. Findings include that the inclusion of Peer Mentorship decreased the number of hospitalizations, decreased the duration of hospitalization, and decreased substance use and depression (Summary from Ahmed, 2013)

Corrigan (2006): Participation in peer support was associated with increased levels of empowerment as measured by an empowerment scale (from Repper and Carter, 2011, Literature Review) Forchuk, et.al. (2005) Peer Support used as part of discharge planning reduces readmission rates and increases discharge rates. Nelson, et.al.: (2006) At 9 months of participating in consumer initiatives, significant reduction in use of emergency room services compared to those who were not active in this initiative; and (2007) at 36 month follow-up participants scored significantly higher on community integration, quality of life, and instrumental role involvement and significantly lower levels of symptoms distress (from Repper and Carter, 2011, Literature Review) Grantham, Dennis, Published 2/14/13, Accessed 2/15/13, Behavioral Healthcare magazine, “Peer supports show women the way to addiction recovery”: As shown below, women in the New Pathways for Women project which uses peer outreach workers demonstrate significant behavior changes over time, including a reduction in high-risk behaviors and an increase in self-help behaviors. After six months of involvement with the NPW project, 40 percent of women have elected to enter drug or alcohol treatment.

Intake and six-month follow-up data, New Pathways for Women project (Philadelphia)

Notes:

1 The Annapolis Coalition is a not-for-profit organization focused on improving workforce development in the mental health and addiction sectors of the behavioral health field. Since 2000, the Coalition has functioned as a neutral convener of diverse individuals, groups, and organizations that recruit, train, employ, license, and receive services from the workforce. The Coalition conducts strategic planning, identifies innovation, and has provided technical assistance in workforce issues to federal and state agencies, private organizations, and commissions, including the New Freedom Commission on Mental Health (2003) and the Institute of Medicine (IOM, 2006).

Substance use in past 30 days At intake At six months Change Crack/cocaine 165 (87%) 42 (22%) -75% Heroin 20 (11%) 3 (2%) -85% Drinking to intoxication 95 (50%) 67 (35%) -29% Binge drinking 78 (41%) 53 (28%) -32% Marijuana 81 (43%) 38 (20%) -53% Attended self-help group in past 30 days 30% 62% 206%

Involved in substance use treatment program

40%

2 CSU and other community-based services utilization for the study group receiving Peer Support was higher leading analysts to be interested in whether a randomized study group/control group was actually the best sampling technique. Funds were not available to explore an additional phase of research.