I'm Amy Cohen, Associate Director for SMI Advisor and a clinical psychologist. I am pleased that you are joining us for today's SMI Advisor webinar, Peer Support in Transitioning Crisis Care, Variations on the NIAPRS Peer Region Model. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoting 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 faculty for today's webinar, Patrick Hendry. Patrick is Vice President of Peer Advocacy, Support, and Services for Mental Health America, where he provides national advocacy and develops new services and training, peers, consumers within the behavioral health system. He's worked as an advocate and initiator of peer-run services for 27 years in a variety of leadership roles, including as the former director of Nextstack and as a consultant for the National Council for Behavioral Health, the University of South Florida, SAMHSA, NASMHP, and other agencies. Patrick also serves as a valuable member of SMI Advisor's Clinical Expert Team. Patrick, thank you, as always, for leading today's webinar. Thank you, Amy. And just to start off, I'd like to assure everybody that there are no conflicts of interest in this presentation today. So we're going to talk about a really interesting subject today, and we have a couple of things that we're hoping that you'll be able to get out of this. One is to really understand the core principles behind the peer-bridger support model, and that's our focus for today. And to be able to give examples of multiple settings and situations in which this model can be used. It's very flexible. And then to compare outcomes for individuals transitioning levels of care who have received this type of services and then those who have not. So in 1994, which is very early in the peer support, peer specialist world and movement, the peer-bridger model was developed by the New York Association of Psychiatric Rehabilitation Services, better known as NIAPRAS, to assist people who had had many hospitalizations or long-term hospitalizations and trying to transition back into the community. The program was funded by the New York Office of Mental Health. The people who were involved in creating this model were way ahead of their time because this model stands today as the most effective single model of peer support that we know of. And we're going to talk about all the different ways that it's effective. One of the people who headed up the team was Dr. Ed Knight, and Ed was a brilliant man who brought so much information to the peer movement and to the clinical community, too. Unfortunately, Ed is no longer with us. Cheryl McNeil, and then the NIAPRAS Executive Director, Harvey Rosenthal, who also has been just a leader for nearly 30 years in the peer movement and in behavioral health. So they offered four primary interventions when they were creating this model. They wanted to be able to engage people, and it's very difficult, particularly with people who have been ill since they were very young, who have had multiple hospitalizations, who have been in the system of care for a long time. It's difficult sometimes to engage them, particularly during crisis. So they wanted to come up with a very unique approach, and they did. They also wanted to create peer support meetings inside the hospital environment and then following into the community to continue it post-discharge. They wanted to provide linkage to the community and to the services there and natural supports that a person could rely on after coming out of the hospital. And people who were coming out, particularly in the early 90s, we were just kind of ending the phase where people have very long-term stays in many state psychiatric hospitals. So it wasn't infrequent to have people come out who had perhaps been there five, 10, even 15 or 20 years. Nowadays, it's very unusual for somebody to stay a sustained length of time like that. There was also the skill-building aspect. They wanted to teach community adjustment and to help people to learn self-management skills. And that was very far ahead of its time, too, in the peer community. So peer support itself addresses transitioning levels of care in a lot of different ways. But the peer-bridger model has been the most successful year after year and the most reproduced in many variations. It's an evidence-based model of care that focuses on outreach and engagement, wellness and self-management, supporting recovery, and then providing community supports. So when people are coming back into the community, it can be extremely stressful. Even if the inpatient stay has been relatively short and successful in supporting the individual through a crisis, when they come back into the community, frequently they face the same types of stressors that were there when they began the crisis. In the original program, the primary role of the bridger is to offer support to the individual in a state psychiatric hospital. So these original people were long-term stays. And the bridger generally works for the person in those cases for two to three months prior to their discharge. So they go in and this allows them to build a trusting relationship, to begin to prepare people for going back into the community. It provides people to plan for their release and what they're going to do following it and knowing that they're going to have support when they leave the hospital. So if we talk a little bit about how this model works. The program prioritizes individuals who've been in inpatient services for a long time or have had a lot or a high rate of admissions. That's, again, we're talking about the original model of peer bridger. So the peer bridger engages the person who is voluntarily interested in participating in the program. No one, this is not a compulsory program for anyone in the hospital, strictly for people who want to be part of it. And so consequently, when Niapus was first starting this, they needed to do a lot of education because for one thing, peer support itself was a relatively new concept. It began in the early 80s, but it wasn't formalized really until the 90s. So they would go into the hospital and they would hold group meetings to explain to people about the nature of peer support and then to explain the specifics about this model of care. The bridger and the individual receiving services would complete a formal agreement that would outline their goals and their responsibilities on both sides and the needs that are identified by completing skills and support inventory for each individual. So this, you know, some of this is what you would do in a comprehensive discharge plan, but this is engaging the individual far more in deciding what that discharge is going to look like. Upon consent by the individual, the facility will give historical information to the peer bridger. We know that the keys to developing a successful relationship with an individual are based on trust and mutuality in peer support. And those two things, trust and mutuality, are closely tied to this idea that we have that we call peerness. The fact that a peer bridger has also had lived experience with a psychiatric disorder has more than likely, if they're part of the bridger program, experienced multiple hospitalizations or long-term hospitalizations. And so they're able to relate to what the individual's going through, the way their life has been affected, and they come together as equals, which is a bit of a strange concept when you realize that one person is serving the other person in a support role. They still, in terms of knowledge about the individual, knowledge about what people are going to experience or have experienced, and then knowledge about what has helped them move into recovery, the two people come together as much as possible without that power differential that takes place normally between a clinical role and a person receiving services. And really essential to doing that is a respect, mutual respect. Both people have to establish respect for each other. So that involves long-time conversations, getting to know each other on a fairly deep level, being able to talk back and forth and share stories. The bridger's role is not to tell their complete story, and in peer support in general, it's not. But peer support specialists and bridgers utilize the parts of their own story that can apply to the individual they're working with in order to help that person to look at their own story and then relate it and come away with an idea and an understanding of how they can move forward from there. So it's also based on the establishment, as I said, of a trusting relationship that creates a sense of partnership. And, you know, there's been this model of decision-making in the medical world for many, many years, and it really began to kind of come forth in behavioral health more in the 2000s, but it's shared decision-making. And that's essentially where the individual who's receiving services works in partnership with whoever is the provider of those services. And there's so much benefit to that, because when a person feels that they are an equal partner in their own services, then they're invested in those services succeeding, and they're far more likely to continue with services, to work hard at moving towards recovery. And in the bridger program, it's just as important that they be able to do this. The bridger encourages the person to go to support groups that are held in the hospital ahead of time. And these support groups are based around a number of different skill-building ideas. One of them is about life in the community. They may also hold one that will specifically deal with people who are living with the experience of trauma in their lives. So the bridger performs a very useful role during the hospitalization, and is there for both the individual and groups. And then they work on building familiarity with community resources, so that when the person comes out, they know what to expect, and they can identify ahead of time certain skills that they may need that they can work on while they're still in the hospital before their discharge. After discharge, intensified peer support is essential to the bridger model. So basically what happens is the bridger forms this relationship while the person's in the hospital, and then they follow them into the community. And based on the specific contract that they're working under, that community engagement, peer support engagement, can go for an extended period of time. I think in most of the bridger programs with state hospitals, it's generally about six months. Some other types of programs that we're going to talk about in a few minutes, it may be less, like 90 days, three months, or it may be even up to a year. So through honest and open communication, the peer bridger is able to increase the level of support that person may need, or to understand when they need them to kind of step back and let the person work on their own. Community supports and the establishment of circle friends and circles of support are really extremely important. We're only in the last 10 years, I think, becoming really truly aware of just how important connections are. In the mid to late 90s, when we started talking about recovery, and it was when we really first started using that word, we, the peer community around the country, I was running an organization in the state of Florida, and we participated in some national surveys that went out and asking people, essentially, what do you attribute to your success in recovery? What do you most attribute your success to in recovery? And the number one answer, we did these surveys three years in a row, and the number one answer that always appeared was having at least one person who believes in them, one person who has their back. And so in the beginning, when people, especially coming out of a long-term stay in a hospital or any kind of institution, they may not have someone who has their back, who believes in them. And the peer bridger takes on that role. This is where the role of a peer support specialist is original and different, because the boundaries between being a support person and being a friend are vague. And it's a fine line that we walk, because we know that we can't continue always to be in a person's life. So it's not that you're trying to replace natural connections and friendships, but you're trying to fill in that gap during that really critical time post-hospitalization. We know that post-hospitalization, there are some critical times when people may be most likely to be re-hospitalized, 30 days, 90 days, within the next year are the most frequent times when people are re-hospitalized. And the point of the bridger program was to try to reduce those rates. Another thing that they really encourage is that they encourage people to take risks. If someone has been in a hospital for an extended period of time, and you're in a place where your day-to-day life is regimented, you have very few decisions that you can make about what your life is going to be like. You're basically told when to get up, and when the meals are served, and what groups you have to attend, and all of that. And there's some free time, but mostly it's a fairly regimented schedule in most hospitals. So when a person comes out, if you ask them, what are your goals? The most frequent answer is to stay out of the hospital, to stay out of jail, to stay on my medications. And that's about as far as people can initially see. So the bridger's role is to help them to understand that there's a whole world out there that's available to them, that it can be far more than just a world built around their disorder or their diagnosis or their services. And I have to say, in doing peer support work for as many years as I have, that is the most rewarding moment that you can possibly have providing support, is when the person you're working with suddenly has that vision that they can actually have a life in the community that they want, and that they can really set their goals wherever they wish, and then find ways to work towards those goals. So the individual may continue to receive support over an extended period of time, but as that time goes on, they take greater risks in the sense that they take more and more control, make more and more essential decisions about what their life is going to be like. In peer support, we don't set goals for people. Goals belong to the individual. What we can do is help people to see that there's a wider range of possibilities, and then we can also help them to plan how they're going to achieve those goals. But it's really essential that it's always the individual. And the Bridger movement and the Bridger model got this very early on. It really came out of the survivor movement of the late 1970s, early 1980s, when deinstitutionalization was turning tens of thousands, even hundreds of thousands of people out of hospitals and back into the community, and with very few supports, because the money did not follow people into the community. Now, in 1955, there was a census done for a number of people in state psychiatric facilities, and there were 550,000 people at that time. Currently there's about 50,000, and maybe slightly below that or slightly above that now. And many of us still think that that's too many, but when you look at that difference from over a half a million people who were hospitalized in psychiatric hospitals, and then over a period of about 10 years, we began to reduce those numbers and they began to come into the community. And since the money didn't follow to the community, there were no services for a lot of people. Plus, there was a lot of anger. The services that you received in psychiatric hospitals in the 50s and 60s and on into the 70s, sometimes was pretty traumatizing and pretty brutal. And so a lot of people came out very angry and they didn't want to have anything to do with the system. And then some people realized that if we're going to have a system, we have to get involved. And that's where the peer support movement came from. And as I said before, Ed Knight, who was really just a guru for peer support, really one of the most forward thinking people at this time, saw that that was the value. That was the way to connect the individual to the system that could be changed in a way that it would provide opportunities for success. Ultimately, the goal of a Bridger system, just like any other system for peer support, is for the person to not only attain their own goals, but also to establish a life in the community that has the kind of meaning and purpose that we all want for ourselves. So we've got a few examples that we can look at. There's not been a lot published on the outcomes on peer support. There are a number of articles that have been written about it over the years. These are just some typical numbers that I've seen. The New York State Office of Mental Health Psychiatric Hospitals, the original group that started this movement, reported that the reduction in number of people using inpatient services was 47.5 percent, and the decrease in number of inpatient days on the yearly rate was 62.5 percent, and the increase in outpatient visits was 28 percent, and that's a number we have to think about very seriously because we want people to receive outpatient services. So, anything we can do that reduces inpatient days and increases outpatient visits is a positive. Wisconsin had very similar experiences in their state hospitals. Their services were also set up by the same group out of New York, so they saw a reduction in the number of people by 38.6 percent, a decrease in number of inpatient days by nearly 30 percent, and an increase in outpatient visits by almost 23 percent. The Bridger model has proven to be very flexible, so around the country this model is beginning to take on many, many different forms because essentially what we're saying is during the transition from crisis level of care to outpatient-type services where a person can truly begin to move into their own personal view of recovery, the availability of support in that transition is incredibly important. And so peer support does this frequently, and we have peers working in crisis units around the country. We have peers working in inpatient hospital stays, emergency rooms, all kinds of places, but they don't all use that model where they follow the person, so they don't really, they're not involved in the real transition, and that's the brilliance of the Bridger model. A lot of states have initiated Bridger-type services, and they've done it in many different, like I said, many different ways. In the type of model that we're talking about, if you introduce, for instance, peer support and you want to do that transitional care into a typical crisis unit, you know, you're talking about somebody with a very short-term stay generally, and I think the average stay in a crisis unit is somewhere from five to seven days for the most part. And so the Bridger, the peer support specialist, needs to be able to establish the respect and some degree of rapport very quickly, and it's that trust that they have to build because the person then has to agree to allow this peer specialist to accompany them on the journey back into the community. So crisis services have posed a unique kind of challenge to providing that transitional care, but we have found that even though you can't do that long-term preparation and you can't do all of those skill-building opportunities that you have when people are in longer hospitalizations, you still have time to build a degree of trust and to also make sure that the person fully understands what it is that you're offering them. I've worked in crisis units myself, and I've managed programs in crisis units, and it's still not unusual for people coming into a crisis stay, it may be their first time, it may be their 10th time, to not really be aware of even what peer support is, let alone peer support that would then follow you into the community. Also when people come into a crisis unit, that in itself is traumatizing. This is an environment that at times can be quite chaotic. It's scary. People don't know what to expect, and having the availability of peers in a support role right there in a crisis unit is tremendous. Having somebody who comes to you with a smile, somebody who comes to you just to listen to you, somebody who wants to support you in the ways that you want to be supported, and those are difficult decisions to make during a crisis. So it's a very difficult role. It's kind of like walking a tightrope from the beginning to build trust and then to make sure that the person desires you to accompany them. Once they're released, they're going back to the same environment that they came out of. And now since we're talking about people in these short-term stays, like in the crisis unit, where it may have been two days, it may have been seven days, it might possibly have been two weeks, but that's very rare. So what they're going back to is the same environment that they were in when the crisis began. And some of those environmental stressors may be just as intense as they were prior to stabilization. So having somebody who can accompany you into that and face it and help you to problem solve about how you're going to address things, what kind of new resources you need to be able to access, what things in your life you need to figure out how to change, and what's the process for producing meaningful change in your life. That's where the Bridger and the peer specialist can be extremely effective. One way that peer support has started, and this was very surprising when this first started, I don't know if many of you are familiar with respite services, and there's a very growing number of peer-run respite facilities. Respite is an alternative to crisis stay. It's kind of a pre-crisis stay. It's a place you can go when you feel like you're beginning to move in that direction that may involve a true crisis. You can go and be outside of your normal environment in a place that's safe, in a place where people can listen to you and understand you and help you to come to the place where you feel safe enough to go back into the environment. So a couple of respites, and particularly, and we're going to talk about this a little more in a minute, but in Western Massachusetts, they started building these respite facilities that had a Bridger-type model, and that was interesting to me because it's not really a transition from crisis care, but in a way, it serves exactly the same purpose. Respites are used as hospital diversions. They're opportunities to take what would normally evolve into a full-blown crisis and use that as a learning experience to be able to see, how did I get to this point where I feel like I'm beginning to lose control, or maybe my life is spinning out of control? How did I get here to the edge, the precipice of full-blown crisis, and what can I put in place to keep me from getting there again, and what can I put in place to help me when I do get there? It's a non-clinical alternative that, again, is focused really on peer-to-peer support in that unique relationship that we set up. Respite programs, peer-run respite programs, create a place where people just know that they're there for support, and as I said, they can access skill-building tools. They can access support groups, or they can just choose to have a safe space to be able to come to terms on their own. Nothing is forced on them. Everything is voluntary. Going into a respite facility is voluntary. As I said, in Western Mass, they started the Peer Bridger Respite Services, and again, they do that same Bridger type model. The Peer Bridger is actually a title of a program that belongs to the New York organization, NIAPRAS, but we use the term Bridger frequently when we talk about these transitional relationships. The responsibility of a Peer Bridger in one of the respite facilities in Western Mass involved providing recovery support. You provide people with information they need that will help them to move in recovery. You make sure that they are setting their own goals. You assist them to access the services that they need, whether it's making an appointment and making it to an appointment. If they choose to be on medication, making sure that they have the ability to access medication. If they want to be involved in community support groups or other types of activities, they need help in housing or transportation. The Bridger's role is to know the community well and know how to steer the person to get the information they need. Very much, they promote self-determination, and self-determination, as I said, and self-management is really where you want a person to get to because when they get there, as I said before, that's when they begin to feel ownership of what's going on in their life. Again, part of crisis for almost all of us who've experienced it is a loss of control and a loss of sense of self. When we begin to take responsibility for our actions, as small as that might be in the beginning, it begins to restore a sense of self-esteem. I remember in running some support groups, somebody asked me to describe my own journey to recovery. I remembered one essential part of it that I still think about today, and that's that going through crises and multiple hospitalizations and all of the things that are involved in that, I felt pretty empty as a person. I had really lost respect for myself, very low self-esteem, and I questioned every decision I made. I felt like I was going through life looking over my own shoulder, trying to decide, is that a good decision or is this another symptom? I was very lucky that I met some people fairly quickly in my own recovery, peer support people who helped me to figure out that I could begin to take that control in small increments in a way that built me up and didn't tear me down. When there were setbacks, I wasn't torn down because I knew that was part of the process. States, as I said, they've been doing a number of different types of reentry programs and being from a hospital, but they're also doing it in prisons and jails. For instance, the state of Colorado is just in the process. They have 20 facilities in Colorado, state prison facilities, and they have provided some very rudimentary training to 200 individuals who are incarcerated to provide support to their peers through the behavioral health services that are available. Now they want to have those people fully trained to take on a bridge or role. What they will see is this rolling system where people come in, they get training while they're in, they provide support to people, then they are released, and then they come back in in a bridge or role themselves, and then they retrain more people. It will be a self-sustaining system once it gets going. I think it's so fluid thinking of Colorado to do this, and the fact that they've already just on their own started this with 200 people is really phenomenal. Texas uses peer support in their county jail system, and it's been very effective, and there's quite a few articles available on it. The main purpose from the point of view of a Department of Corrections or a county jail system is to cut down on recidivism, to cut down on people coming back into jail. You see almost the same statistics in people being reincarcerated as you do in people being readmitted to hospitalization and crisis shelters. If you can lower that number, you're not only creating a more effective system that can serve more people in a productive way, but you're also making people's lives way better because that revolving door of hospitalizations, emergency room visits, crisis units, jail, prison, that alone creates just ever-increasing numbers of problems for a person to ever have the life that they really want in the community. So multiple states are currently using peer support also in emergency rooms, and Pennsylvania has developed a specific training for peers, and it was developed through cooperation with a peer-run organization and some of the advocacy groups in Pennsylvania working with state authorities to develop a training for peers to work in a number of different types of crisis environments, and ERs or emergency departments was one of them. And in Wisconsin, they've been using that same model as part of their opioid or substance abuse overdose program, and the main goals there are to lower overdoses, reduce emergency department recidivism, and then to increase the kind of supports and services that keep people out of that cycle that they need. And it's been really effective. I mean, this is a topic that is on everybody's talking points, talking about the opioid crisis, talking about the increasing number of overdoses, and what can we effectively do to lower that rate? And we look at medication-assisted treatment. We look at rehabs. For many people in a public system, rehab of any length and quality is difficult to access. So these type of programs where you have that support while you're in whatever facility you're in, whether it's an emergency room or rehab, and then having that availability of that person to come out and be there with you is tremendous in helping people to overcome their substance issues. In Nassau, Queens, Nassau County, Queens, the performing provider system, sorry, that's kind of a tongue twister. They partnered with Niaparas in New York to create a bridger system for their emergency department visits. And in this one, when you go into an emergency room, a peer is there. And you know, most crises seem to happen late at night for people. Things are chaotic in emergency rooms, particularly in a large city. And so coming in in a psychiatric emergency or crisis and coming into that environment can be really scary, extremely traumatizing, and really in many ways serves to make the crisis worse. Having a peer there to actually come out and sit with you in the waiting room and begin that conversation, to follow you back into the services when you're finally called to see the clinical staff, to be able to explain to you ahead of time how the system works and what are the possibilities of what's going to happen. And then, assuming the person is released or maybe they're hospitalized for a period of time, that peer continues to be engaged with them. And under this particular program, they were able to be engaged and are able to be engaged for six months after discharge. It's been extremely successful. So if we look around, there's states that are implementing variations all over the place. North Carolina is currently doing it. Washington state is working currently with Niapra to create bridger models in their prison systems and also in their hospital systems. Tennessee is doing it. Colorado, as I mentioned. Virginia has a bridger program. Florida has had it for quite a while. Mexico, on and on. And there's probably six more states that are not on this list that are already doing this. Because as I said, this model is so flexible that it can be used in so many different ways that it just really is very desirable. If you can bring that model into your system of care, you're really creating something that will be ongoing. We pilot a lot of programs. We test out ideas constantly. And frequently, we get a good idea and we start some type of peer support services, and it's funded for a year or two, and then we lose the funding. The bridger programs have not only proven to be successful in their outcomes, they've also saved a tremendous amount of money. And I worked in setting up a bridger system with Kaiser Permanente in Northern California. And in the first year, with just two peers working in that pilot program, Kaiser told us at the end of the first year that they had a savings in emergency department usage and crisis stay usage of a million dollars in one year. That pilot started six years ago, and it's still going on now as a full-fledged program, and they've increased it, I think, to eight to 10 people still working within that same local system. So we know that this model is flexible. We know that it's going to continue to spread throughout the country. We know that it will find new ways that people receiving intensive outpatient services, for a full range of health conditions, can benefit from a bridger-type program. Peer support is not limited to behavioral health, and the same basic skills that work for us in behavioral health are valuable throughout health care. And we've already got a pretty well-trained workforce, many of whom have serious co-occurring other issues, physical health problems. So you have somebody who is a peer on both those levels who can begin to support people in their whole health goals. So with that, I'd like to thank you for your attention, and I think we're ready to take some questions.

peer support

transitioning crisis care

NIAPRS Peer Region Model

serious mental illness

peer-bridger model

community resources

positive outcomes

flexibility