Thank you so much for that interesting presentation, Patrick. You covered quite a bit of ground to help us transform care. So let me, Patrick, a few questions have come up and actually a few comments that I wanted to share with you. So one of our attendees pointed out early on that they really think that peer specialist act as a catalyst for building the link to recovery and resilience. So I think you pointed out, but I thought it was really nice that this person felt that that sort of catalyst word just really sort of struck me. Yeah. That really resonates. I agree. Yeah. And then we also heard from someone and they said, you know, peer specialists have been integrated into psychiatric inpatient wards in Pennsylvania. And this person did actually a pilot program there a few years ago. Yes. And actually, peers are working in inpatient roles all over the country, not in every location, but for, you know, in almost every state there's some degree of inpatient peer support. And there's specialized programs that have come out of it that really began in the inpatient stay and then follow the person into the community. So, you know, we're finding peers in almost every type of role you can think of in jails and prisons and, you know, emergency rooms and inpatient stays, working with primary care. I mean, just about any place you can imagine, peers are beginning to make inroads. So one person asked, what do you see as the largest or greatest barriers to implementation of peer support services? And then as you think about those biggest barriers, and you mentioned a lot of, a few things on the thing, but where do you see the biggest places? And have you, do you have ideas about how to overcome those? Well, you know, the biggest barrier to the full expansion of peer support, which means, you know, right now peer support has got a pretty good hold. It's not totally there, but a pretty good hold in community mental health. So it's growing and the barrier it faces there frequently, part of it's the culture, but also part of it's the payment structure. And right now the majority of peer support in the country is being paid for with Medicaid dollars through, primarily through managed care contracts. So managed care has actually been in many, many states a champion of peer support. But what we face for expanding it beyond, like into the private sector, for instance, is that we don't have commercial health plans paying for peer support yet. And they're all thinking about it. And right now, my organization, No Health America, is in direct discussions with a number of them to try pilot programs. So we're seeing inroads there. And then one other place, you know, if peer support is paid for by Medicaid, and that's the primary payment method, where's Medicare in all of this? Medicare being a federal program, so the standards have to be uniform across the country. That's our barrier. Because right now we have 46 states with certification, and each certification is slightly different from one another. So, and some of them are dramatically different. The range of experience and the degree of training and all the processes that have to go through for certification can range dramatically across the country. And that makes it difficult for a commercial plan to pay, but even more difficult for something like Medicare that needs one standard, whether you receive peer support in Washington State or Florida, it's got to be the same. So as we begin to standardize more, we will open up new doors for payment methods, which will allow many people, for instance, you know, somebody who is on disability, but they're on SSDI, so they get Medicare, but Medicare is not going to pay for their peer support. And it can be very difficult then for them to find it. So there's a lot of barriers. I think payment is the biggest one. The other thing too, I mean, just even with the existing systems, some states are really valuing peer support and they're paying really livable wages, but we've got some places in the country paying minimum wage for peer support, and you can't live on minimum wage. Everyone knows that, I think, and, you know, people take multiple jobs. What we see happening is people who are really good at peer support and come in and do it for a while and prove to be excellent, as they move forward in their own recovery, they leave peer support and go on to find something that offers them the possibility of a career and a livable wage. Well, on that note, Patrick, someone wrote in that they are developing a position description or a job description for peer support specialists at their integrated healthcare clinic. And this is a question that I've also gotten a lot, which is, do you have any templated job descriptions that someone like this person could borrow from when developing their own? Is there a place that he could go, he or she could go to access position descriptions? There's not one place. I mean, if somebody wants to contact me, I have a couple that I've collected from different organizations. There's not a single, you know, kind of generic job description because peers can play such a vast variety of roles. The job descriptions are usually written specifically about the role they're wishing to hire the person in. So if it's for like inpatient, it's going to have a different job description than if it's for running support groups or, you know, all this variety. If somebody is going to work with inside jails and prison, you know, their background's going to have to be different and their skill sets are going to have to be different. So there's not a generic job description, but you can, you know, if you just do a search on peer support job descriptions, there's a number of them that'll pop up. I think Magellan Health, the managed care company, has publicly put out their job descriptions that they use, and I believe they have several different versions. Great. So, yeah, we have a lot of little questions coming in. So someone wrote in, I have concerns about the integrity of peer services, maintaining mutuality, peer support providers not simply representing interests of their agencies or the system. Can you comment on that? Yes, and that's probably the biggest topic of discussion in the peer support world. And it's this idea that, you know, it's very, you know, you have a group of people who have been relatively powerless, and then they begin to move into recovery of their own, and a lot of people decide that they really want to give back, and that's how they move into peer support initially. So frequently it starts off as a volunteer position, but people, many people want to eventually, you know, expand their life back into a work phase and to be paid for their efforts. There's a temptation to always want to satisfy the person who's writing your paycheck, obviously, and you can be asked sometimes to go outside the bounds of your role as peer support. We need, you know, certification is a good thing because it sets up a standard of ethical responsibilities and procedures that clarify that you should never go outside your scope of practice, which means you should never be pushed into a clinical-type role. You should never try to just get by. Your job is to focus on the person you're serving, and sometimes that may put you at odds, but you have a very strong case to make that what you're doing is the proper way to do it, and you may be being asked to do something that's easier to do or, you know, fits into the culture, the clinical culture that you're coming into. It's a tough road. The best thing is when people working in peer support roles have other people as their supporters, and so we found that peer support frequently is really best maintained when people are able to join, like, many states, for instance, have an organization for peer specialists, and they may have online or telephone or even face-to-face support groups regularly. The pilot programs that I've set up around the country where we put peers into, like, inpatient settings and emergency room settings, we have made sure that every week they had their own support groups and discussed issues and that their supervisors had their back and made sure that if they were being asked to do something or being pushed into this, you know, cooptation, that the supervisor would stand up for them and the rest of the staff would, too. It is a real problem, and people have to be constantly aware of it. So, Patrick, I want, unfortunately, there are still a few more questions, but we're going to have to wrap up. One thing I would say to individuals, there's someone, for example, who's asking about statistics for the number of peers who are out there who are certified, et cetera. I would point that individual to, Patrick, you've done previous webinars for us, for SMI Advisor, where you've done a lot about the statistics and where certification is and what certification is like, and so I would point people to the smiadvisor.org page and look for previous webinars where you can, and you can search under Patrick's name. There's some very good webinars that he's already done talking a little bit about the statistics of how many peer certification programs there are in peers across the country. So, on that note... And I just want to add one very quick thing about our website is that I spoke about how language matters. We're very aware of that, and we're going back and reevaluating some of the language in our own website to make it reflect the values that we stand for. So, that's my final comment. Yes, thank you so much. I know that you are working with representatives from NAMI to make sure that the language is improved, and it's a work in progress. Yes.

peer specialists

recovery and resilience

psychiatric inpatient wards

Medicaid payment structure

standardized certification