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How Peer Support Complements Clinical Practices
Presentation Q&A
Presentation Q&A
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Video Transcription
We are going to take a few questions, and we welcome your questions submitted through the GoToWebinar portal. So, Patrick, our first question I have really focuses on some of the nitty-gritty of the logistics of having peers in the clinic. And so it reads very simply, how are peers paid for? I'm sorry, Tristan, I got cut off for a minute. Could you repeat the question? Sure. It's a pretty simple question. How are peers paid for? I guess what are some of the models through which clinics have supported the incorporation of peers into their clinics? One of the things that's happened over the last 10 to 15 years is that most states are going to or have already gone to managed care for Medicaid. Managed care has been a champion for peer support, and so it's increased peer support tremendously. So the majority of peer support is now being paid for through the Medicaid system through a managed care contract. In some states where there is not the ability to bill Medicaid for managed care, and that's about eight states, I think, maybe seven states now, that have not approved peer support as Medicaid reimbursable. The peer support that does exist are paid for through state general revenue. Now, the exciting thing that's happening right now is that virtually every commercial health insurance plan is looking at including peer support in their menu of services. And so I know we are about to begin a pilot with one of the larger commercial plans to introduce peer support with the idea we'll do a pilot in two states. And if it's successful, they'll roll it out across all of the states where they provide their services. So it's paid for in a number of different ways. There are some also people who hire peer support on a private basis, but that's very small. And there's very few peer support agencies that stand out by themselves. There are peer-run organizations that provide peer support. But generally, it's through somebody who has the ability to bill state government or Medicaid. Great, thank you. Our next question reads, how do you handle ex-clients who may want to become a peer support person in the agency they were a part of as a client? And that is a very frequent occurrence. Like I said, many small towns. For instance, I live in a town of about 100,000 people, and we have one community mental health center. It's quite large, but it's one center. So the peer support people are going to have been receiving their services at the same community mental health center that they are working in. And so what you have to do, as much as possible, you try not to align the individual with somebody that they've had a close relationship with. But because the way peer support is introduced, it's often when a community mental health center wants to start off with peer support frequently, they only hire two people. So they bring in two peer support staff. There are going to be times when you're actually working with someone that you've known on a regular basis. And so it's really important that supervision be involved in those type of relationships. Great. Our next question focuses on the issue of liability. And it basically reads, can Patrick comment on supervision as it relates to liability issues? Well, yeah, definitely having professional, you know, for instance, if somebody's working in a clinical environment, there must be clinical supervision. And that's where the liability exists in that situation. But working in other types of situations, I've run organizations that contracted out peer support services. I do that now in my current job. And we've had to insure the people that are working for us. But strangely enough, the liability insurance for peer support is very low because you're not making medical decisions. So just as a follow up question, are peer specialists ever do they ever seek malpractice policies specifically or because they're not quote unquote clinicians in this setting? That's not really a requirement. Well, when we've gone into, we've done some pilot programs with HMOs, the largest hospital corporation in the United States, commercial insurance, one of the seven largest health organizations in the country. In each case, when they got involved in it to look at their liability and all that, they did not have to provide malpractice insurance for peer support. As a specific thing, it was covered just in a general way. Great, thank you. I'm wondering if you could comment on training and licensing differences state to state and the role of national standards. How much heterogeneity is there in a peer who might be working in these settings in different parts of the United States? That's a major issue because we have 45 states that currently have certification. Strangely enough, California, the largest state, employs over 6,000 peer specialists, does not have certification. But the level of standards across the states is very erratic. So you may have one state where you may require 35 hours of training and 50 hours of volunteer experience. And then you may have another state that may require over 100 hours of training and 1,000 hours of experience. So we know that this has worked okay in working in the Medicaid system and working in, you know, through community mental health. Because particularly with the Medicaid managed care where they've provided the peer specialists, they may be certified in their state. But the managed care companies have made sure to give them additional training. But it is an issue. And so consequently, there's one mental health national certification at this time. That's Mental Health Americas. But it's not meant to replace state certification. It's an advanced certification that is kind of like an advanced degree. And so we actually require that if you're in a state with certification, you have to hold that state certification in order to get hours. The value of hours is that it allows these other organizations, like Medicare, for instance, or like commercial insurance plans, where they're going to be providing service across the country. So that they want to know when they hire somebody in Washington State and in Florida, they're getting the same level of experience and expertise. So this is a reason why we have to move these standards to a uniform standard. And we have to have, because there's very little reciprocity also between states at this point. I think there's only three or four states that offer reciprocity. So we really have to make sure that we increase the level of training. But the national certification really, to a large degree, covers that for people. Even though it's not required by the state, an employer can require it at any time. Great. We have another question from one of our attendees. It reads, it seems like peer staff are themselves early in recovery, which may hinder their ability to support individuals who desire support, but need someone who can relate to them at a more advanced level. What qualities do you suggest employers look for in peer staff? Well, you know, people working in peer support are in recovery. You know, recovery in our concept in mental health is very similar to in substance use in that it's an ongoing process. You don't recover, you're in recovery. And you have to work at it. I mean, I've gone almost 20 years now without a hospitalization. But prior to that, I was hospitalized many times, even involuntarily. When I first started working in peer support, they looked at whether I had been out of the hospital a minimum of a year. Now, that may or may not be a good indicator. It probably is a good idea that persons have maintained their recovery status for a substantial amount of time before they go into the training. And then people are also weeded out in the training because the trainings, for the most part, are pretty rigorous. And they involve a lot of role plays and the people being put into positions of making difficult decisions on a quick basis. So if a person can handle this, the other thing is that it's very important that a person understand their own well-being, what it takes for them to stay well. And so that they see early warning signs and they take action, that they have recovery plans in place. And that's a question I ask when I hire peer support workers is, do you have a pre-crisis recovery plan in place? So what are you going to do when you first start noticing early warning signs? What are you going to do if you get into crisis? Are you going to admit yourself and get some help that maybe you can't provide or your other peers can't provide for you? And then what do you do when you get out? And so those are some of the things that you need to look for in hiring a peer where you know that if they're that self-aware, they're going to be a good person on your staff. Great. Let's take another question from the audience. Do peer specialists ever co-facilitate psychotherapy groups and or any other types of groups within a treatment setting? They do. Particularly in a treatment setting, in an inpatient facility, they may co-facilitate a group where you have a clinical staff on one side, peer support person. Mostly what peer support does, though, is they hold, they run peer-run support groups. And again, it's interesting because, you know, there's this dynamic of having to build trust in a support group. You know, many people are reluctant to open up in support groups because they don't necessarily have the trust in the people or they fear reprisal. That if they say the wrong thing, for instance, their status may change within the facility or in the treatment team. And so they don't have those same kind of fears in talking to a peer support person. Now, as a peer support professional, you have some of the same requirements as anybody else. For instance, if you are told by an individual that they are planning to either harm themselves or somebody else, you have the duty to warn, just like any other professional. But other than that, basically peers feel when they're talking to a peer support specialist that this can be a much more open conversation because the person will understand more of what I'm saying than a clinician who might tend to put those kinds of answers or statements into boxes that require certain types of changes in treatment or status. I hope that answers your question. All right. Seems quite helpful. Let's take one last question here, which says, in the case of mental health providers, a breach of ethical boundaries would be reviewed and addressed by the licensing board. How would this type of issue be addressed for peer specialists? All of the certifying bodies across the country have ethical and professional standards for peer support specialists that they must adhere to. If they receive a complaint, for instance, I worked to set up the peer support system in Florida, and I worked with the Florida Certification Board, and they have their ethical statement and professional responsibilities. And when they would receive a complaint, I was one of the members of the team that looked at ethics violations, and so we would investigate it. And it's required in order to take the certification that you agree to cooperate with any investigation. If you don't cooperate, you can actually be stripped of your certification. So the cases are investigated. There's a finding made. It may be that nothing changes. It may be that a person is censured but not stripped of their credential. They may have a temporary suspension of their certification, or they may have a full suspension of their certification. So it's very similar to any other kind of professional law. Okay, thank you so much, Patrick, for a really informative question to answer as well as an informative presentation.
Video Summary
In this video summary, Patrick addresses various questions about the logistics and implementation of peers in clinics. Regarding payment, he explains that most peer support is now being paid for through the Medicaid system via managed care contracts. In states where Medicaid reimbursement is not possible, peer support is funded through state general revenue. He also mentions that commercial health insurance plans are starting to include peer support in their services. When it comes to ex-clients becoming peer support personnel, Patrick emphasizes the need for supervision when working with someone with whom there was a previous close relationship. In terms of liability, he states that liability insurance for peer support is typically low since they are not making medical decisions. Patrick then delves into the differences in training and licensing requirements across states, highlighting the need for a uniform standard to ensure consistency and reciprocity. He mentions Mental Health America's national certification as an advanced certification. Patrick also discusses what employers should look for in peer staff, including maintaining recovery status and having a pre-crisis recovery plan. He addresses co-facilitation of therapy groups, stating that while peer specialists can co-facilitate psychotherapy groups in treatment settings, their main role is to run peer-run support groups. Finally, he explains that ethical violations by peer specialists are reviewed and addressed by the certifying bodies, which have their own ethical and professional standards.
Keywords
peer support
Medicaid reimbursement
commercial health insurance
supervision
training requirements
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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