Hello and welcome. I'm Shireen Khan, SMI's Advisor Social Work Expert and Senior Director of Workforce and Organizational Development at Thresholds, Illinois' oldest and largest provider of community mental health services. I am pleased that you are joining us today for SMI's Advisors webinar. Senior Respite Houses, a Safe and Welcoming Alternative to Crisis Care. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now, I'd like to introduce you to the panel for today's webinar. Guyton Colantwano. Guyton Colantwano became the Executive Director of Project Return Peer Support Network in 2014 and has been working in the field since 1995. Guyton is motivated by his unwavering belief that people are people first and that a label is not a destiny. His experiences as a survivor of homelessness, drug addiction, and mental illness has fueled his fire for a person-centered approach in all aspects of his career. Guyton has led a multitude of programs, including homeless outreach programs, dual recovery services, transitional aid youth program, adult and older adult services, along with employment programs and homeless shelters. During his 25 years in the mental health field, Guyton has developed curriculum and trained in a wide range of topics, including harm reduction, the role of a peer supporter, hiring people with lived experience, motivational interviewing, welcoming and hospitality, meeting people where they are, homeless outreach and engagement, boundaries and ethics, community integration, program leadership, supportive employment and education, supervising people with lived experience working in the public mental health system. These trainings have been delivered at community colleges, universities, conferences, and other nonprofit organizations. Guyton, thank you for leading today's webinar. We're really looking forward to it. Thank you so much. What a wonderful introduction. So once again, my name is Guyton Colantwano, and I am the executive director of a peer-run agency in Los Angeles County named Project Return Peer Support Network. I'm going to give you a little bit of a history about us and our services. We are completely peer-run, and what that means in the consumer or peer movement is that every position at our agency, including mine, requires that we self-identify as having lived experience with the mental health system. And we have over 51% of our board of directors that also self-identifies as having lived experience with the mental health system. And that's essential because there tends to be a threshold of 51% of staff and some administrators, but we try to stick real close to 100%. What we do at Project Return is we do have a peer respite, which is going to be part of the topic today. We have an after-hours warm line that operates from 5 to 10 p.m. During COVID, we've expanded it to 9 o'clock in the morning until 10 p.m. And they take calls from people all over the country and help provide resources and referrals and just peer-to-peer support. And then we have two Spanish-speaking programs in Huntington Park, California, again, peer support. One is based on de-stigmatizing mental health in our surrounding community, and the other is what we call a peer-run center where people walk in, participate in self-help groups, get housing assistance, employment assistance, community integration and resource. And again, just in basic terms, one-to-one or group-style peer support. We have a nationally-recognized training program where we have been training other people of lived experience to enter the workforce as a direct service provider, either in a peer-specific role or in any other role that they would like to compete for in the workforce. We provide online support groups. We have been doing that for about six years. And so when COVID hit, we were at a real advantage in that we'd already been using a technology and a platform through Support Group Central, which is based here in Los Angeles County also. Our core of our agency is peer support groups. And prior to COVID, we had about 150 peer support groups going on throughout all of LA County and a variety of agencies throughout the whole county. If you know anything about LA, it's a huge county. And we have been able to sustain that program through using our pre-existing technology and also outreaching to people that are now in much more of an isolation-type situation. And then we have, yeah, I think that's pretty much our agency. And then as was described, I've been working in the field now for 25 years. I'm a National Certified Peer Specialist. My lived experience is what got me hired in the field going back to 95. And I've been in treatment for years. I also like to share that I live with bipolar disorder. Okay. So the learning objectives today are that we hope is to describe the purpose of a peer respite house, summarize the types of services and supports provided by peer respites, and then contrast the cost-effectiveness of a peer respite stay compared to crisis services. And I want to say up front that oftentimes peer respites or emergency rooms are seen as working against each other. Like why have a peer respite if we have hospital beds or emergency beds or IMD beds or whatever that. And what I hope to also share is that I see peer respites as complementary to a system, to our system, and that if I truly believe from experience here that if we had peer respites in almost every community, that it's complementary because it creates another option for people because in a traditional system, it's agencies close down at five. And if someone's not doing well for whatever reason, they might have a mental health urgent care that they might be able to go to, or people end up in an emergency room. And so we're not looking to replace any traditional services. We're looking at this from the perspective of adding additional options for people living with mental health struggles. So I also hope to define what peer support is and what are peer respites, and as described, the type of services a guest can expect to receive. And we do call for the vast majority of peer respites. We call the people that stay at our houses guests. At my agency, for everyone else that receives services, we use the term member, that they're a member of our program. In the peer movement, we're not big on patient and client terminology. So we tend to find other ways to describe the people we serve. And then how do people access peer respites? And how do peer respites help a person in crisis? So we really hope to expand a lot on all these different components of peer respites. And again, I'm hoping to be successful in conveying that peer respites can truly be seen as an amazing addition to a traditional system, because it gives people living with mental health additional choices, so they don't have to end up in such a severe crisis for many people and end up in a hospital. So what is peer support? This definition comes from Mental Health America National. I think it's a wonderful definition and really captures what peer support is. So in behavioral health, a peer is usually used to refer to someone who shares the experience of living with a psychiatric disorder and or addiction. In that narrow context, two people living with those conditions are peers. But in reality, most people are far more specific about whom they would rely on for peer support. Trust and compatibility are extremely important factors. So I want to just expand on that a little bit in that in behavioral health, the term for peer supporters has become peer supporters, peer specialists, peer advocates. And peer has been a more recent term used to describe those of us that live with mental health or drugs and alcohol. In the past, it had been terminology like psychiatric survivor, ex-patient. There's been a lot of different terms used to describe us. And the second part I want to expand on is this trust and compatibility. In the years that I've been working in the field and looking at the literature and doing trainings for our staff and other agencies, one thing that I've consistently found is that the relationship is the most, if not the most, one of the most important things that we do in our field. That if the person we're helping doesn't trust us, we're probably not going to get much done. And I stress that point because as a person that receives services and as a person that provides services, I have found quite a bit where we forget that front end piece, that engagement, that relationship building. We tend to move past that into other areas many times too quickly. And that could be as a result of the system or our agency or the demands. There's a lot of reasons, but I think it's critical to remind ourselves that the relationship is essential because if the person we're helping doesn't trust us, we're probably not going to get the most honest answers or information. So then peer supporters support others in recovery using our lived experience, formal skills, and knowledge of systems. So if I pull that all together, as a peer supporter, we do self-disclose consistently. And I know self-disclosure has and continues to be a taboo topic for many, but the critical part about having a peer supporter title is implicit in that is that I have some experience on the, say, the client end of things with going through this system. And so that's where we use our self-disclosure skills and techniques into being able to as simply sometimes as saying with someone that we're working with, yeah, you know, I've been through something similar before, you know, and here's kind of what I've done about it, but I also want to make it clear that it's your choice on what you do because not everyone's the same. So we use our lived experience to interact with the people we serve, and we then hopefully gain formal skills through a combination of trainings. In our country, I'm in California, so we're now state 49 that is slated to have a statewide peer certification. California, we like to believe that we lead the way in many things, but in peer support, we're in last place pretty much. We just recently, Governor Newsom had signed a statewide peer certification, some version of it, and that's where many peer supporters in the country get their formal skills is through what people would call a CPS, certified peer specialist training, plus internship and set for a test and things of that nature, but many people also get formal skills through webinars and conferences and staff trainings. The knowledge of systems in this is, to me, really, really powerful in that many times as a provider, I have some decent ideas about where to go or where to maybe send people for specific type of help that they're looking for, but what I have found is the people that actually are on the side of accessing the services have more information or can share more specifically about how to access that specific resource. So, early on, when I was a provider, many times I would work with the people we serve, and I would ask them, how do you get access to that services? What do you need to say? What kind of, how do you need to present? Who do we ask for? And then as the provider, I would then try to reach out to the individuals that they were saying are the gatekeeper, basically, to the service to build that relationship, but as many times, it's the people that we serve have a greater understanding of how to access services, and so as a peer supporter, we use that experience also. So, what is a peer respite? This is our peer respite house. As you can see, it's a pretty decent size house. It's 10 bedrooms. It has a multitude of bathrooms. It's co-ed. Our peer respite house is located in a community of exclusively social service agencies in Long Beach, California. So, our peer respite is, as I was saying, 10 beds, co-ed. We have 13 staff, 13, 14 staff. We're 24-7, so we always have at least two staff on site. Many peer respites have a variety of staffing patterns and also house size. We're probably on the much larger end of the size of a peer respite, and we're completely staffed by people with lived experience. We do not hire any clinicians. We do not prescribe medications. We do not monitor medications. We practice what is called harm reduction. We don't require people to be clean and sober. We don't require people to be medicated. We leave all that up to the person, and this is pretty common as we expand later in peer respites. Right now, during COVID, we have kept our beds down to six beds from 10 to provide additional space for all of our guests, and we've stayed open during COVID, much like other crisis residentials. So, a peer respite is a community-based house staffed by peers that is 24-7, and there's some variations in terms of what peer respites provide. We provide one-to-one support and group support via support groups. We help people access resources in the community. We require people to have a place to live. If they are homeless, we will accept people as long as they have a very clear plan of housing in less than a month. They've signed a lease. They're just waiting for the apartment to open or something like that. So, peer respites don't typically take people that are homeless. It's more someone living in the community that is experiencing a crisis that could benefit from coming in here, and I like to describe it as it's a bed and breakfast for people experiencing psychiatric distress. Much like when many of us get burned out or we need to get out of town, we go to a bed and breakfast, a hotel, Airbnb. So, I like to describe peer respites as that. So, staffing of peer respites. Staffing of peer respites, as I was describing, is completely staffed by peers, and there are some peer respites that are a peer respite that's part of a more traditional agency that is not peer-run. So some peer respites, it's a peer arm of a traditional mental health agency, and I oftentimes get asked what my thoughts are about that, and my thoughts are, great, because peer respites are wonderful and powerful and important, but the key part of a peer respite is ensuring that it's staffed by peers. So what are the typical trainings that peer respite staff get? I'm going to expand on some of these, not all of them. Intentional peer support is a 40-hour curriculum. It's a really great curriculum, and it's to train people with lived experience to provide services in a specific way. Peer specialist, like I was describing earlier, is in almost every other state in our country. There's a statewide version of that. On average, it ranges about 40 hours of training plus internships. Wellness recovery action planning, WRAP, is an evidence-based practice started by Mary Ellen Copeland. It is designed to help people develop their action plan, to take a look at how they are when they're well, to take a look at what happens if they hit a crisis, and there's many other components to it, but it starts with someone being in a decent state to really take a look at their whole life and who they are and what they do to stay well, and it's a real empowering tool for those of us that live with mental health. I have a WRAP plan, and in my WRAP plan, I have under no circumstance put me in a hospital unless of course there's no other option. I have in my WRAP plan to have me go to a peer respite if there was any type of need. That would be an example of a WRAP plan. Then mental health first aid, which a lot of people are familiar with, we train our staff and we train other community agencies on mental health first aid. We require our staff to be trained on wellness recovery action plan. The peer specialist training, we provide our own training, which is 84 hours. It's double the average of the states, and plus we have 126 internship hours that we require, so we require that of our staff. Obviously, first aid, CPR, suicide related, we use an approach called QPR, peer zone boundaries and ethics, motivational interviewing, we train all of our staff on that. I think it's a wonderful tool, communication skills, whole health action management, WAM. WAM is another approach that teaches people skills to self-manage their illness, so to speak, from a person-centered perspective. Cultural competency, I prefer to use the term cultural sensitivity or cultural awareness, trauma-informed care, hearing voices network, and harm reduction. For me, harm reduction is critical because the vast majority of people that we provide services to, and in my 25 years in mental health, have a co-occurring drugs, alcohol, mental health, and other things, but I have found that harm reduction fits perfectly within this person-centered, recovery-oriented mental health models. These training, these lists of trainings, they actually came from surveys that were done at peer respites by liveandlearninc.net, by Lyasha Ostro, PhD. So peer respites, we consider them, we consider our peer respites to be a crisis diversion model. And again, I want to stress the importance, some people do end up in a hospital, and hospital is important for some people. The problem with our system that peer respites are attempting to fill is there's no, generally there's no in-between. You're living in the community, things are going okay, then things are not going okay, so people go to emergency room, and then from there they might get put on a hold. And what peer respites are trying to do in many cases are trying to fill that in-between and divert people from needing the emergency psychiatric services, which are A, much more expensive, B, can be traumatizing for those of us with mental health. Not saying that they don't help, but for many people, our experience in a psychiatric hospital doesn't, when we're discharged, it's not seen as a positive experience. And again, they're helpful, but I think it's important to consider that many people have an adverse reaction to the hospitalization. So what is the crisis diversion model? So anyone living with a mental health problem, self-identified, because we do not verify records, we don't ask for, you know, psychiatrist notes or anything like that. So someone living with mental health experiencing any psychological stressors, which then puts them into a crisis, and that's where peer respite comes, excuse me, comes into play. And we have found when we started our peer respite that we were using a traditional waiting list because we stay pretty full, and while using that waiting list, people would begin to drop off, obviously, and as we were able to circle back with them, we started asking people, well, where did you go since you weren't able to come to our peer respite? And many of them said, oh, I ended up in jail, I ended up homeless, I ended up in the hospital. And so what we did to try to counteract that, and we continue to practice that today, is we invite people to come and participate in our services even if a bed is not open. And the reason we do that, again, is to try to help them come up with alternatives to the hospitalization and, again, more costly parts of our system. All right. So the mission of peer respites, as I keep describing, hospital diversion, you know, we hope to provide that in-between place where many people that might otherwise go to the hospital are able to work through it in a supportive environment and prevent that hospitalization. Turning crisis into learning, you know, what does that mean? For us, that simply means that when people come into our house, they are obviously in a crisis, they're struggling for a multitude of reasons, and we do not tell people what to do at our house. So we're looking at every step along the way, how can we work side-by-side collaboratively with the individual so they can learn from this crisis? And so they can maybe, and it might actually be being introduced to a wellness recovery action plan for the first time, where we can say, yeah, let's take a look at this crisis and if you were in this crisis, again, what are things that you can do to help address it and work and live more independently? Gel diversion, as I described in a previous slide, we found that many times if people aren't able to get the resources they need, you know, they might have a breaking point. And so coming to a peer respite, at least in our experience, has helped prevent people from going to jail, not 100%, but a decent amount. Homelessness diversion and community connection. So these are all things that we're trying to address within our system in a non-clinical and non-traditional way. I lost my mouse. There we go. Okay, characteristics of peer respites. Emphasis is placed on personal responsibility and empowerment, not risk assessment. That is critical. We put the responsibility for the person's recovery on them while we provide side-by-side peer support. We are not assessing in a traditional way for risk, but obviously there are times when a risk assessment does come up, such as a suicide assessment that we might provide, and then, you know, there have been some times where we've had to reach out and someone has had to been hospitalized, but that's, for us, it's been super rare because we're trying to help maximize the person's empowerment and responsibility. Mutuality and self-determination. We try to take this approach that we're not better than anyone else. We're actually not smarter than anyone else receiving services. That's where mutuality comes in, and shared power and shared decision-making is critical. Most people, most human beings don't like being told what to do, and so we really avoid trying to tell people what to do, and we try to level the playing field, and, in fact, we were—an interview was done recently on our peer respite, and one of the quotes from our associate director is, if you walked into our agency at any given point, you would be hard-pressed to know who's actually receiving services and who's not, and that's not because of what you might think. It's because even our dress code, we don't wear badges, and, you know, we don't create situations where we are imposing a lot of separation. We use the same bathrooms as the people we serve. We dress casual, depends on what we're doing that day, and so we try to avoid creating all those artificial divisions, so healing from trauma, and in here is including from our mental health system. As I was mentioning earlier that myself and many people, you know, I've benefited from our mental health system, there's no doubt, but for many people, there's also been trauma that has been perpetuated from our mental health system where someone walks in, and they're treated as less than human, and they're held against their will, and everything they're describing is being summarized from an illness perspective, and so this can reopen up old wounds, and so we try to be mindful of that. We use non-clinical language. If we can't describe it with the person we're serving, we try to avoid using it is the key. There is almost no emphasis on diagnosis or symptoms in peer respites in many cases. If someone expresses a desire to discuss their symptoms or their diagnosis, we have no problem with that, but we are not sitting down there with the individual talking to them about how they need to address their symptoms and their diagnosis, and they need to take medication. We stay away from that and only engage in the conversation as far as the guest would like to go per them. People can come and go at any time. Peer respites are not locked. They are, you know, we ask people to come in the evening. We also, you know, we share meals with each other at the peer respites, and so we do ask people to come in and check in with staff, but they're not held to having to stay at the house all day or for three days. Goals are self-directed, pretty self-explanatory. We don't think it's beneficial to try to work on a goal that someone doesn't have, and so our conversations are, you know, how would you like to improve your life? What would you like to work on? Are there resources that you would like us to help you with? It's basically what would you like us to do that would help maximize your empowerment and self-reliance, and as I described earlier, medication and sobriety are not required. We do have people that will leave during the day and come back intoxicated. We will not kick someone out for that, and we hold people accountable to behaviors, meaning we expect people to respect the general community. Okay. So, how do people get access to peer respites? Most importantly is self-referral. If someone is referred to our peer respite from an agency or a family member, basically anyone other than the individual, we will meet with the family member, the clinician, the case manager, and the individual, but we will also, as we give the individual a tour of the house, we will ask them, is this what you would like? Again, if you can see the pattern, we try to avoid staying away from someone being referred to us and they don't want to be at the peer respite. If they're ambivalent at best, we still, we leave it up to the person, and we try to inform all agencies and all other referrals that at the end of the day, it's going to be their decision, but by all means, let's meet. So we get many times people being referred from family or agencies, and so, like I said, we will meet with everyone, give people a tour, and see if it's a fit for them. What type of services are provided? So one-to-one, we do morning check-ins, we do evening check-ins. We, people provide support groups. It could be anything from a walking group, which is great for a little bit of exercise and getting outdoors and, you know, all the obvious things. Wellness recovery action plan. We do hearing voices network. It's a group facilitated by people that hear voices, for people that hear voices, and any multitude of other topics, whether it be community integration-based, skill-based, and all the groups are provided by peers. Self-help, resources, and one of the key features, ironically, is the respite part, just providing a space for someone to relax, and I can't overemphasize this. If someone wants to just stay in their room for a day, we'll keep checking on them, but not like the check-in that would happen at a hospital. I always felt bad when I was in nursing school because I had to wake people up quite a bit, but it's for people just to get a respite, a break from their situation, and then skill development. What do guests say about their stays at peer respite? Many people say that had I not been to a peer respite, I would have ended up in a hospital. Again, there's not, there's, in very few communities are there in-between or even stepped option, and so my fundamental question is what would it look like in every system if we had a multitude of options that people could utilize and still reserve the hospitalization for maybe people that just needed that hospitalization? Many guests say that had I not been in a peer respite, I would have been hospitalized. There was an early on study from Second Story, which is in California up north, and it was reported that there was a 70% reduction in hospitalization for the individuals, so that's wonderful. What do they also say? They say that the fact that we're all peers, that we're relatable, that they can connect and relate with the people providing services, and again, many of that's because our services are informed by this idea that we have been there, we've done that, and we always like to say we have several t-shirts, and so if someone is struggling with medication and they want to have a conversation about that, most of us with mental health can say, yeah, I've struggled with medication too. Here's some things I've thought about, here's some things other people have thought about, but at the end of the day, it's your choice, and in what way would you like me to help you with that? Many people say that peer respites are comfortable. Part of it is because our peer respites are in a house. So, you know, in a house, we have a, you know, a couch and a den, a kitchen, people have a bedroom, you know, a shower, and again, there's no buzzers, there's no security guards. It's literally a home-like environment where people have free reign to, to roam around and use a computer or meet with staff or you know, go for a walk. And so, comfortable, supportive, open. Again, the open isn't just that people can come and go. The openness is a mindset that we were, we believe, like motivational interviewing, that the person we're helping is their own expert. We just, we have some expertise that we can offer. But not much, it's very difficult to get people to do stuff that they don't want to do. And so again, we avoid that power struggle. And compassionate. I will say that having gone through, for many of us, a variety of situations, whether it be hospitalization, homelessness, drugs, alcohol, having five different diagnoses, taking 15 different meds to varying success and sometimes bad side effects. When people talk to me about those issues or talk to a peer respite staff, it really does come down to, yeah, I may not know what it's like for you. But I have a decent idea of what it's like for many people, including myself. So that's where that extra little compassion comes in. So let's get to the breaking down a summary of peer respites. Unfortunately, or maybe positively, there's roughly 34 peer respites in the US and there's five in California. And again, my argument would be is we should have, hopefully one, wherever there's a hospital, we ought to have a peer respite. Again, even if we just looked at it as we're adding a step into our system. Respite guests were, as I described earlier, 70% less likely to use inpatient or emergency services. So the cost effectiveness of that, I'm going to use our house as a model, is we stay pretty full. So out of that 10 beds, we'll on average have eight to nine people per day. And it costs us roughly $260 per person per day to have them stay at our house. As compared to an emergency room, for the same amount of hours, that cost is a lot higher. Or in a psychiatric hospital, that cost is a lot higher than say $260, $250 a day per person. So that's where the cost savings on the more expensive end of things comes into play. The study shows reductions of readmissions when assigned to a peer mentor, and a review that assesses the level of evidence and effectiveness of peer support service. So the last two bullet points is there's a great body of work around peer supporters. And what I'd like to add to it is that even in agencies that have a traditional system, that have brought on a peer supporter, the evidence has been pretty great in terms of showing that hospital admissions go down, incarceration goes down, homelessness goes down. And if you look at conversely, community integration, socialization and connection go up. Now, and that's not obviously that's not an absolute, but there tends to be a great body of evidence that says even a traditional program, hiring a peer and understanding what the peer role is, is essential, but hiring a peer, allowing a peer to do that peer role with the people shows a lot of promise and evidence behind it. Peer respite, a research and practice agenda. I'm quoting Laisha Ostrow again from 2015. That many times, for good reasons, we're looking at what the evidence like evidence based practices and, and I do think that's important to be able to prove the efficacy of things. But I also think that sometimes, we forget that a lot of what we do isn't necessarily considered evidence based practice, but it's still helpful nonetheless. So, but Laisha, what she says is control or comparison groups are critical for understanding the effectiveness or efficacy. Observational methods such as asking guests to predict where they would have gone otherwise could be helpful in some of that research. In our peer respite, we were researched by LA County Department of Mental Health for the first three years of existence. And we were studied and researched and those were the type of questions that I was describing earlier and surveys and things that people were sharing with us that had I not been here, this is where I would have went. And then adopting participatory research methods may help accomplish the design. And so, really, I think what Laisha is attempting to describe here is that it is important to understand or to be able to describe the efficacy of what we're doing with peer respite. And I would agree. But again, I would I would counter just mildly with, there's a lot of stuff we do in mental health that isn't necessarily an evidence based practice, but could be helpful or is helpful to people. And so, sometimes practice based evidence is really critical to understand too, as we're developing these. So, in summary, because this is our gaps in research, in summary, as I get ready to turn it over to question and answers. Peer respites are staffed by peers. Most are from a peer run agency such as mine that's completely peer run. Some are part of a more traditional system. Two, we believe that adding more peer respites in communities provides people with more options. And I would like to believe that in our whole mental health system, that if people were able, that we would want to live in communities where people are able to live in a community and not necessarily require or have to access hospitalization as their only crisis opportunity. We are not looking to replace hospitals, emergency rooms, psychiatric beds, not looking to replace it, looking at adding to the system. I am going to turn it back over for questions. And thank you, everyone. Thank you, Guyton, for such an interesting presentation. Before we shift into the Q&A, I want to just take a moment and let you know that SMI Advisor is accessible from your mobile device. So, you can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating skills, and even submit questions directly to our team of SMI experts. You can download the app now at smiadvisor.org. So, we'll move into the Q&A. We had a lot of questions around funding. So, Guyton, if you could give us some information around how your peer respite house is funded or generally how they're funded, that would be really helpful. Yeah. So, the vast majority of peer respites are funded through their county mental health or behavioral health system. Ours is funded by the county Department of Mental Health. That represents the vast majority of peer respites is getting a grant. Ours was an innovation grant, but getting a grant to add a peer respite to the system. There's other peer respites that have operated it through foundations and fundraising, but the sustainability, it becomes the issue. And that's where proving effective they are as an alternative to or in addition to our current system and appealing to the behavioral health, local behavioral health helps sustain them. Okay, great. So, there's not, is there typically Medicaid funding? A lot of people ask specifically about Medicaid. Is that something that they fund? Or do you know the answer to that? You know, I don't specifically know the answer. I chuckled briefly because we're so blessed, we don't bill Medicaid. That would drastically change. I don't know of a peer respite that does bill Medicaid. And I want to say why. For the obvious reason, the minute we start billing Medicaid, you now require medical necessity. It's everything that's wrapped up into even just documenting that note that you need to do in order to get reimbursed. So, it's, ours is through what we call COS, Community Outreach Services. It is aid billing, but it's not Medicaid. Got it. We also had some questions around the peer model in general being kind of accepted by a more traditional mental health system. So, the peer role itself, as well as peer respites, do you have any advice or just recommendations around how peer respites or the peer role works within a more traditional mental health system? Yeah. So, wonderful question. So, one thing that I always like to tell people to keep in mind is, again, if you're interested in adding peers, even in a traditional system or if you want it to work in a traditional system, there's some key things in understanding. These are things that, if done poorly, backfire. And so, one is understanding that peers, just by the nature of being a peer or having that peer in the title, it implies and it's overt that I will self-disclose more so than, and I don't say more details, but more frequently than maybe someone that's in a more traditional role. And so, it's imperative, and I'm using that one specific example, it's imperative that if bringing peers on, they need to be seen as a full member of the team. The agency hopefully understands that what we want on a team is that viewpoint diversity. You want that really good tension that comes up when people are talking about the people we serve and how we ought to intervene. And how important and critical it is that just as a psychiatrist might add an observation about a side effect or symptom the person is experiencing, and a clinician might add some skills that they might be working with them, that a peer might add this additional perspective. And I use those three as an example of how it would be critical for an organization to see how all these different viewpoints complement each other. And that's exactly what we want. But we also have to understand that a peer is going to hopefully be the advocate for the person around choice. And also, they would be more prone to self-disclosure. So, there's some things that have to happen internally. But the evidence seems to be pretty good that even adding one peer to a traditional system, allowing them to do what a peer does, like I was describing, without pushing it down, really seems to benefit people. Right. So, there were a few questions around the day-to-day operations, kind of what it looks like. So, I'll break them down. How long is a typical stay for people at the peer respite house? Yeah, so that varies by peer respite. Our average is about five days, three to five days. We know peer respite will allow people to stay beyond, say, 28 days, which is why we don't typically take people that are unhoused. So, I would say three to five days is pretty much the average. Okay. And then, there are a few more, but I want to get to one, make sure we get to this one in particular. So, what happens when somebody does experience a crisis where they're at risk of harm to self or others? What happens then in the peer respite setting? Yeah. So, in our peer respite, we use a model that we train our staff on called QPR to do that preliminary assessment. We have had in the, what is it, seven, eight years that we've been in existence with a peer respite, we've only had a couple of times where we required someone to come in and do that next level assessment and write a hold. We've literally probably only had that happen a couple of times. We have had police come in once or twice for someone acting out violently. It's super rare, but we do what many other agencies would do is, if we feel that it's beyond our ability to address, we will access the next level outside resources, but it's super rare. Great. Yeah, there were a lot around that. And then, just more about the day-to-day. So, if somebody does have medications, is there somebody who assists with that? Do you ever bring in outside maybe a therapist or is it really all the peers who run the program? Yeah, really wonderful question. I love how it gets down to like the core of like what's happening at 10 o'clock on Wednesday, right? I love it. So, when people come in, they have a, in our house, it's a single person. It's one person per room and we give them a lock box. If they have medications and quite frankly, if they have any drugs that we have not searched them for, we orient people, hey, put your belongings that you need to keep safe like medications and stuff like that. Lock them in this box. We have a key because we don't want to be replacing boxes, but this box only you access. So, we encourage people to become obviously more responsible and so that's one way to help. We don't, typically, we don't bring in anyone from the outside to like prescribe or monitor. Now, having said that, we have worked with occupational therapist interns around like they developed a garden that they then worked on and things like that, but we don't bring in outside clinical assistants. I want to thank everyone. There's a lot of good questions. I just, so we can't get to all of them. So, I just have one more around the criteria for acceptance. So, is that, is there any limitations? Because there were a couple around what are the criteria to accept somebody into the peer respite house and then when there are limitations such as a history of violence that would preclude somebody from being able to stay. Oh, great. So, the only thing that would truly preclude someone at our house is if they're on the Megan's Law website. We do that check and the reason why we do is we're embedded in a social service and housing community called the Villages at Cabrillo and there are children service providers there. So, that's really the only thing that would, that we would absolutely deny someone for. History of violence, we're not screening for. History of arson, we're not screening for. Previous hospitalizations, we're not screening for. Are they connected to a provider? We're not, when I say we're not screening for, meaning we're not screening it to use it as a point of denial. So, most peer respites keep that upfront information gathering to a real simple point and so ours is Megan's Law. That would be about it. If they've been to prison, they've been to jail, they've done all that other stuff, we'll still help them. All right, great. Thank you so much, Guyton, and thank you everyone for all your excellent questions. If you do have follow-up questions about this or any topic related to evidence-based care for people with serious mental illness, our clinical experts are now available for online consultations. Any mental health clinicians can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We encourage you to explore the resources available on the Mental Health, Addiction, and Prevention TTCs as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. Thank you so much for joining us all. Until next time, take care. you

Guyton Colantwano

Executive Director

Project Return Peer Support Network

peer respites

mental health system

crisis care

peer support techniques

self-directed recovery

county mental health departments