So, the first question that's come in is, when does the peer-bridger relationship end? Is it time limited or is it based on some other criteria? Well, it is time limited and it's based really on the particular contract that the service is being offered under, so it varies from service to service. But I know that some of the programs that I've looked at have been able to provide ongoing bridger services back in the community for up to a year. Six months is probably the healthy number to go for. Some places it's 30 days, some it's 90 days. A lot of this has to do just with local contracting and who's paying, whether it's a Medicaid program or it's paid for with state dollars or some sort of grant program. The essential part is that the peer-bridger doesn't just abandon you, they actually connect you to ongoing support in the community and hopefully in communities that have active peer support available. Terrific. You touched on, in your response, a question from somebody else, which is, who pays the peer-bridger? Well, for instance, we did a peer-bridger program in Mental Health America. We did some pilots with a large hospital chain and we worked in two hospitals in the Palm Beach County in Florida. And we placed people in their units, which were locked door crisis units, and then they followed the people back into the community. And that was paid for during the pilot time, it was paid for directly by the hospital itself. The ongoing programs utilize a lot of Medicaid funding. And so they have to be structured correctly to be able to utilize Medicaid, but it's lots of different ways. I mean, the original program was paid for by the New York Mental Health Office. It's probably now, because New York system has gone almost completely to Medicaid, it's probably coming in under Medicaid dollars now. Most of the time when it first starts up, the dollars probably come from state tax revenues. And then when the concept is approved, then they go on to more sustainable funding like Medicaid. One of the things I should add is one of the best ways to set up a good bridger program is when the peer-bridger is not actually an employee of the hospital itself, but is employed hopefully by a peer-run organization or an organization that's extremely familiar with peer support. In doing it that way, and then contracting for those services into the hospital or facility, in doing it that way, the bridger gets the type of support that they need to continue with this type of work. So there's a pair of questions that have come in, and I want to read both of them. But basically the idea is, how does one become a bridger? So one person wrote, how does one become a bridger? But the other one asked even more specific, does the individual have to have a degree, certification, or can a peer be one that is just has the experience as a peer be considered a valuable person that could be a bridger? So how does one get to be a bridger? Well, actually, yesterday I was on the phone with Harvey Rosenthal, who was one of the originators of this program, and they're actually working now on an online course. It's not going to come out anytime real soon, but they want to eventually have some kind of certification for bridger services. What you, you know, who can do this varies from state to state, depending on what types of certifications are involved. Almost always, I mean, I think it's 47 states, it may still be 46 states, have peer support certification at this point. But in those places, you cannot provide services and be reimbursed with Medicaid dollars or state funding unless you have that state certification. Then there's places like California that has not created certification yet, but they do it on a local basis or a county by county basis, and then they have their own requirements. Generally, what we say is that the person needs to be a peer specialist, and they need to be experienced in doing peer support work, because now you're going in to deal with people transitioning from crisis, and you're working with them, perhaps while they're still in crisis. So that takes somebody who is pretty solid in their own recovery, extremely skilled in peer support techniques and methods, and, you know, has learned to be able to work with people in all of the various states that we experience in crises. So very experienced people, gone through peer support training, certified if that's available. And then I don't know of any programs like this where people can go into it without some kind of formalized training ahead of time. Then some states offer some additional training, and some of the organizations offer some additional training in more intensive ideas about trauma-informed peer support, for instance, or ways of communicating with people during first episode psychosis. So any of these additional skills that we give people just make them better at their job, but you really do need people who are well-seasoned and very comfortable in that role. So as you're talking, one of the things I'm thinking about is sort of the caseload. So when we think about like ACT teams, we know it's really intensive work with individuals who are utilizing services often. And so we know that the people who work on an ACT team need a smaller caseload. And that idea seems to be parallel to what you're talking about. And I'm wondering if there's any guidance about how many individuals, if I were a full-time bridger, like how many individuals could I carry on my caseload reasonably? Well, there's a number of things that influence it, because when you're a bridger and you're following the person into the community, geography becomes very important. You know, if you're trying to provide services, you know, across county lines, you know, you may have long periods of drive time, so your caseload needs to be lower. The programs that we set up, you know, if I can make an optimum program, and rarely can we afford to do it, we would probably try to put it at 10 to 12, 15 is probably the most common number of active people in the community. And then you're continuing on a lower basis to follow new people. So hopefully you've got, you know, people going through the system, utilizing less of your time, so that you can then provide more intensive time to people coming into your system. But some of the programs I've looked at have been 20, 25 people, which I think is probably too big of a caseload. Hmm, interesting. How would someone find out if their state has peer bridger programs? For example, this person was asking specifically about Minnesota, but are there ways where they're listed? Or how would you find out? I probably would do it through whatever the state office of behavioral health is. Most states now have a liaison type position or a directorship of consumer and family affairs or peer family affairs, so that they represent the voice of both the individuals receiving services and then frequently represent the voice of the family. Sometimes that's split into two positions. But going through the department of behavioral health in your state, they're almost sure at least to know about any type of system that's going on in the state, unless it happens to be one of the pilots that is going on in the private system at this point. Like Kaiser Permanente, you know, they don't work through the public system. It's the largest HMO in the United States. So the other way you can find out is by checking with, you know, community mental health services. If there's a peer organization in your state, most states have some type of peer network or peer specialist coalition, and you can just Google some of those terms in your state and see what you can find. I don't think there's any central listing of any place yet. Not yet, but it's coming, right Patrick? Stuff like that's going to come, for sure. So this person was asking, so would you or would developers of this program recommend, for example, to have a bridger for everyone who's discharged post-crisis from the ER or the hospital? Or would you say that there's a different kind of criteria where it wouldn't be everybody, but it would be maybe everybody who has no support or every, you know, like what, how would you decide who should get a bridger? Well, first criteria is that it's voluntary. So you know, not everyone is going to choose to have that type of service. So that is part of your audience. The other thing, you know, it's based upon the availability, you know, how big of a program is available to people. If it's only a few people who can work in this role in a system, then you may have to prioritize people who have had, you know, multiple hospitalizations, who have the least amount of support, perhaps dealing mostly with people who are homeless, trying to transition into housing. Every program that I've helped to set up around the country, there's been some type of admission criteria that needed to be established because none of the programs have been well-funded enough to provide it to everybody who might benefit from it. Right. So in an ideal world, there would be enough bridgers to offer the service to everybody. And of course it would be voluntary. But your point is, until we get to that point, hopefully sometime in the future, we typically make choices based on sort of the severity of what they're returning to or the severity of use of utilization of inpatient hospitalization or crises. Yeah. Absolutely. And, you know, one of the interesting things is that peer support is evolving very quickly. I mean, what we think of now is the capabilities of a peer support specialist is far beyond what we expected in the 2000s and, you know, already back into the 90s. It's becoming really a profession. It is a profession because it meets all the criteria of specialized training, required certification or, you know, in some states are even talking about licensing. It requires ongoing education. So anyway, peer support has become more effective and that means that, you know, even a smaller number as time goes by, people are going to be able to serve a greater number of people because they'll have a much higher effective success rate. One of the reasons that's held us back from fully evolving to what peer support I think can be and will be is that we've always measured our successes against the traditional system. And so we were looking at, you know, re-hospitalizations in a traditional system. Well, systems have changed over time. But really is that even that bar, the bar we want to use, you know, maybe it's a higher bar, maybe peer support can hold itself to a higher level than just doing better than treatment as normal, as usual.

peer-bridger programs

payment for peer-bridgers

requirements for becoming a bridger

optimal caseload for a bridger

evolving nature of peer support