Hello and welcome. I'm Dr. Benjamin Druss, Professor and Rosalind Carter Chair in Mental Health at the Rollins School of Public Health at Emory University and health systems expert for SMI Advisor. I'm pleased that you are joining us for today's SMI Advisor webinar, recognizing the value of peer support specialists, strategies for increasing wages and developing career pathways. Next slide. 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. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one continuing education credit for psychologists, and one continuing education credit for social workers. Credit for participating in today's webinar will be available until July 11, 2022. Next slide. Slides for the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve about 10 to 15 minutes at the end of the presentation for Q&A. Next slide. Now I'd like to introduce you to the faculty for today's webinar. Noah Abdenoor, Stacey Manzer, Brandy Hemsley, and Jeremy Reed. Noah Abdenoor is the Director of Peer and Recovery Services Programs, Planning, and Policy at the Texas Health and Human Services Commission. Stacey Manzer is the Co-Director of the Texas Institute for Excellence in Mental Health and a research scientist at the University of Texas at Austin School of Social Work. Brandy Hemsley is the Director of the Office of Recovery and Resilience at the Oregon Health Authority, and Jeremy Reed is the Director of Workforce Development at Community Bridges in Mesa, Arizona. Thank you all for leading today's webinar. Good afternoon. My name is Noah Abdenoor. As was stated before, I'm the Director of Peer and Recovery Services Programs, Planning, and Policy at Texas Health and Human Services Commission. I'm a certified peer specialist and ready to get going this afternoon. Next slide. So our learning objectives are going to look at explaining the value of peer support specialists and recognizing the financial barriers and advancement challenges they face in developing their careers, developing strategies to overcome these barriers to create a more competitive reimbursement rates, to increase salaries, and to provide career ladders for peer specialists to advance, and then to list the steps that can be taken to initiate changes in legislation, increasing Medicaid rates, and contracting with peer-run organizations, as well as developing career paths for peer specialists. Next slide. So a disclosure, no relationships or conflicts of interest related to this presentation. So next slide. So as stated before, I'm the Director of Peer and Recovery Services Programs, Planning, and Policy, which is a unit at Texas Health and Human Services Commission. Next slide. So a bit of background, I think some level setting that a peer specialist is somebody who has lived experience in the case of what our unit oversees with either a mental health or substance use recovery, and they go through a training to hone competencies and they obtain a certification, adhering to a code of ethics, and then they hone those competencies by, you know, doing continuing education to maintain their certification. And those peer specialists provide peer support services, and those services look like providing emotional support, you know, sharing knowledge, providing practical assistance. But I think most of all, it's walking alongside someone and helping them to find their own path of recovery or doing the things that they want to do in their life. Next slide. So the creation of our unit really dates back to the passage of legislation in 2017 to create a peer services Medicaid benefit in Texas. And that really was a culmination of about a decade's investment that the state of Texas had made into developing the peer support workforce and implementing recovery, as well as probably more than two decades of work that our stakeholders had been doing around, you know, advocating and getting these services out there. So, next slide. In order to support that legislation, the state, HHSC, decided that they needed to have a team of people inside of their office that was overseeing the implementation of that benefit, but then also overseeing all of the programs and projects related to peer and recovery services. I think one of the really big things that the legislation did to increase career paths and help peer specialists have more opportunities was we codified into our state plan a path for a peer specialist to become a supervisor under the Medicaid benefit, what we call a qualified peer supervisor. So that was, you know, a very tangible thing that came out of the legislation directly to support creating career paths and opportunities for peer specialists. Next slide. So, with the creation of our unit, we got started in 2019, in February of 2019. The first thing that we did was we were immediately implementing that new Medicaid benefit. But the next thing that we had was we were inheriting all of the previously held block grant programs that were inside of our mental health and substance use areas. And we really needed to come up with a vision for how we were going to implement these services. So one thing our team worked on was creating a vision statement, which you can see here, which is to, we see a Texas where everyone can access peer and recovery support to achieve their ideal quality of life. Our team really, we also went out and we did focus groups with stakeholders. We bring our own experiences. We've been hiring peer specialists to join our team and help with the implementation of these projects and programs. But we really broke things down into three main goals or focuses. One was to develop the workforce. The next was to expand the capacity of our system to provide peer and recovery services. And the last was to align data and research elements. Next slide. So our workforce development team, they're really focused on all things kind of related to the Medicaid benefits. So that's curriculum attached to that, administration of the certification. We partner with a certification entity that we oversee. And then we do kind of broader stakeholder engagement. You know, how do we engage with the broader peer support communities? I think one thing that that team has really been focused on that directly supports the peer support workforce is the development of a workforce. We call it a workforce development hub or training coordination hub. And that was through a partnership with UT Health Science San Antonio and the San Antonio Clubhouse. And they provide an entity called peer force that really acts as like peer support to the peer support workforce. You know, they help somebody that's interested in becoming a peer specialist. They help them locate training opportunities. They assist like through the steps of becoming certified. They can help people locate supervisors for the supervised work hours that they need to obtain for the certification. They help people locate continuing education. They also will help organizations with recruitment. They host a job board. Right now we're at a point where they're starting to get engaged into social media platforms. Really, we're trying to have a proactive relationship with our workforce to try to get supports out there with barriers that they may be seeing. So we think that's an important thing that we've added in the last couple months to help the development of our workforce. Next slide. So our service capacity team, they're really over all the programs and projects that are delivering direct services to people. A lot of those are coming from the substance use and mental health block grants. We have recovery support services projects and programs, youth recovery services programs. We support peer run organizations. And out of the mental health block grant, there's consumer operated service providers that we're supporting, as well as mental health club houses. And I think one of the things that we're really doing here, and this is where, you know, through those focus groups and coming up with a plan on how we were going to build these services across the state, we've really determined that investing in the development of peer and recovery organizations that are in the community, that's really the thing that will unlock more opportunities for peer specialists to grow into other types of jobs, aside from just, you know, providing direct services if they wanted to proceed to different things in their career. So, you know, another thing that we heard from our organizations out there providing peer services is that, you know, they had not received, or generally the technical assistance they're receiving is around, you know, what recovery support or peer support is. A lot of the folks in Texas, and I'm sure around the country, we have folks, you know, that are experts in that already. But the thing that they didn't necessarily have was support on how to have a more sophisticated business. So we really looked and found a partnership with the University of North Carolina and North Carolina State to bring what they call the Leadership Fellows Academy to Texas. And that's really supporting peer support organizations and doing things like developing a board of directors or how to create a more diversified funding stream or marketing strategies. Another thing that's been really a challenge for our organizations is creating succession planning. When you have a leader that's going to be retiring or moving on to another role, how do you ensure that that organization continues to grow and build? And so that's something that we see as vital, not only to supporting current organizations, but in seeding and supporting the growth of new organizations that can deliver these services. Next slide. The last piece is really around data and research alignment. As I stated before, we inherited programs from a siloed system. And so our team has, you know, stuff from the substance use side, stuff from the mental health side, adults, young people. And we're really working with our university research partners, who you're going to be hearing from one of those momentarily, on how we can better align these research efforts so that we have an unsiloed approach to the provision of technical assistance. You know, really helping with our contract strategy, seeing that as a tool for the future to encourage our clinical organizations to look to these peer organizations more often to formally contract with or partner with to provide peer support and recovery services or around supervision. We know that they're experts at this, and we really need to help our clinical and treatment organizations partner closer with them. And we need to do everything we can to support that, if that's something that the organizations deem that they want to do. Another thing that we've done, you know, in getting this kind of information out, is we were able to increase our Medicaid rate just for peer services. It was something that stakeholders felt strongly was not in an adequate place. And through, you know, sharing the different information that we had in our office, our stakeholder community and advocacy community really pushed very hard, and they spoke up, and the rates area made a determination, and we just had a new rate go into effect in March. That was an increase, I think, of around 45 to 49 percent of what the rate was at before. So that's a really exciting thing that our community's been able to do. And then as we look towards program development and strategic planning into the future, we really see, you know, coordinating the different technical assistance and partnerships with our universities as being key to unlocking things like, you know, how peer specialists in our service systems is going to be able to engage in things like the rollout of 988, peer specialists in crisis settings. There's a pilot project we're running. It's, you know, how to support peer support or peer specialists in a rural crisis response, and we'll be kicking that off in September with a partnership with our universities to, you know, do everything we can to support organizations and learning how, and then, you know, utilizing recruitment techniques to be able to better implement a peer services program. And the final thing is, you know, the CCBHC model, we really want to work to ensure that the peer services that are required inside of that certification are meeting fidelity. So we're currently looking at ways that we can create either an accreditation or a certification that's ensuring that those organizations are providing peer services that are in fidelity with our model. Next slide. Thank you all so much. Hi, everyone. Thanks so much, SMI, for having us here today and letting us share some of what we're doing in the state, and thank you, Noah, for inviting me to. It's great to hear you talk, and I think that what I'll be sharing with you all today will tie really nicely to what Noah just shared. As Ben said, I'm Stacey Manser. I work at the Texas Institute for Accidental Mental Health at UT Austin, the School of Social Work, and before I continue, I just want to acknowledge Noah's team at HHSC that we work really closely with them. I want to acknowledge my colleagues at TIMH, Drs. Leona Peterson, Amy Lodge, Pallavi Singh, and Julie Early, who do so much work to support the advancement of the peer workforce in Texas, as well as all the peers and consultants, peer consultants that we work with in the field that I'll be talking about in just a sec. I have no really conflict of interest to disclose, and so if we want to go on to the next slide, thank you. So what I wanted to do first was do a little bit of a history looking at the way that the state has used data strategies for peer specialist support, and I want to tie back to Noah's presentation and share some of the specific ways, a little bit more of the specific ways, that Texas has used evaluation to increase wages and develop career pathways. So I really want to give credit to Texas Health and Human Service leadership. Going back to 2005, they've really been linking their funding strategies to projects to evaluation. It started with Mental Health Transformation State Incentive Grant. That's when the peer training and certification began to be developed in Texas. It continued with block grant shifts to improve peers and recovery supports, and kind of like Noah was just saying, it continues to the present day with new funding sources, the Medicaid funding CCBHC, and some of the ARPA funds that have come down from the federal government. So what we've done over the years that Texas has done really well, I think, is learning from successful existing models. So early on, we did a lot of environmental scans. So we wanted to learn from what was going on out there and see what we could apply in Texas. And so this really included looking at the training models from Appalachian Consulting, RA International, others, and particularly for us at the university at TimeMH, we really looked to the Yale Program for Recovery and Community Health, Larry Davidson, Janice Tondora, Cheryl Bellamy. They were really generous in sharing their expertise and sharing their tools. So early on in all of our evaluation of the state initiatives, we used measures of recovery and the work that we did. And in the early initiatives with the recovery-focused learning communities, the recovery self-assessment and their practice guidelines for recovery-oriented behavioral health care were used to kind of develop and guide that as the hope structure of those opportunities for organizations. And then finally, we've had ongoing partnerships. Texas Health and Human Services has had ongoing partnerships with universities to implement projects, to evaluate process and make improvements, and really importantly, have always included peer consultants and peer organizations in the development, implementation, and in guiding strategies around peer workforce development and capacity building. Next slide, please. And I'm going to apologize right off the bat. This is a lot of information on one slide. And Noah talked a lot about these things just a second ago, but I wanted to show some of the structure that Texas Health and Human Services, the Peer and Recovery Unit under Noah's leadership, are using to really get out there and not only support project implementation, but also do evaluation. So if we start on the left-hand side with Noah's group, they then contract with us, TIMH. They contract with Addiction Research Institute, also at the University of Texas. And then they also contract with the University of Texas Health Sciences in San Antonio. And then really those two goal areas that Noah talked about, the peer workforce expansion projects, and then the service capacity expansion projects in the middle. These things listed there are some of the initiatives that are going on, as well as some of the way that Noah's third goal of aligning research and evaluation, we've done research and evaluation around these areas to then help guide the state as they move forward. So for example, we've done peer workforce outcome surveys since the very beginning of peer training certification in Texas, so back in 2010. And a lot of the outcomes of this service have been used to guide what's needed out in the field. So I'll get to a side of this further in a next slide later, but looking at supervision, looking at recovery orientation of organizations, hearing back from the peer workforces really then help the state guide their initiatives and some of the work that they do. And then finally, on the right-hand side, Noah also mentioned this. What's been helpful, I think, for the state in contracting with university partners is then it's easier for us to contract with other partners. So a lot of the initiatives, we can contract with North Carolina State University. We can contract with Faces and Voices of Recovery and San Antonio Clubhouse. All of these things are tied to initiatives and programs and projects that the state wants to carry forward for workforce expansion and service capacity expansion of the peer workforce. Next slide, please. And I can't show you everything that we have been able to do over the years, but I wanted to give you some snapshots. So this is some of the data that we've been able to collect in that Noah refuses to inform some of their strategies. So for example, the map on the left, it's focused on peer service expansion. So we've looked at where the consumer-operated services providers are, the recovery community organizations, the youth recovery community organizations, recovery services and supports. We map all of these organizations so then the state can see what they have in terms of capacity and what areas of the state that they need to build. So, on the right-hand side, then, is a map of the peer workforce. So, these are all the certified peer specialists in Texas. The stars represent where they are. So, if you look, you can see that the Texas triangle, so at the top where there's the heaviest concentration of stars is down in the Fort Worth area. On the right-hand side, that's Houston. And then on the left-hand side, that's Austin, San Antonio. So, that really shows you the concentration of peers in Texas is focused in that Texas triangle where the most population in Texas lives, but that doesn't mean that there aren't peers and people needing peer support across the state. And so, they've been using some of this data to then target, like Noah was talking about, how do we get into the rural areas to effectively provide peer support in those areas? Next slide, please. So, then getting into a little bit about peer workforce development and what Noah's been trying to accomplish. For the 10 years, actually longer than 10 years now, that we've been doing the peer workforce surveys, we've been looking at salaries. And so, you can see on the graph on the bottom right, you can see in 2011, the average salary was $12.09, and then the average salary in 2021 was $16.30 an hour for peer specialists working in the field. We can also look at this data by public health regions. So, you can really look at the top, the map on the top right, and see in different parts of the state where peers are paid a little bit more and where they're paid less. And so, again, going back to that triangle of where the highest population is, and really the urban centers of Texas, that's typically where the higher salaries are. And so, with the Medicaid benefit and with some of the other initiatives that those groups got going on, we can start targeting the other areas, CCBHCs, and see where we can start increasing salaries. And then just really quickly, the survey that we've been doing, I want to touch just on the 2021 survey, a lot of the surveys kind of showing the successes over the years, and then also where there are still opportunities that we can make an impact for the peer workforce in Texas. So, for example, in the 2021 survey, there's still, with the peers in Texas, there's still a majority of women, non-Hispanic and white, so there are some opportunities to really do some reach-outs to different groups of folks who can become peer specialists in the field to better represent the communities that we work in. Right now, working as a peer specialist, the average is 5.3 years in 2021. Back in 2017, it was four and a half years. I'm trying to figure out why that number's increasing. We're happy that it is increasing, and there's still shortages in the peer workforce like there are across all the workforces, but it's exciting to see that tenure increasing. A lot of the peers talked about the lack of career advancement opportunities in their survey responses, and so the supervision, looking at leadership positions in organizations, looking at opportunities to work in different areas within quality management, within HR, at universities, within training entities, really trying to broaden the ways in which peers work in the field. The peer unit at HHSC has been focused on that. The other thing that we've been noticing, which is exciting, is the recovery-oriented service assessment. We're seeing increasing scores over the years. When we started back in 2011, the scores were lower, and that's when recovery orientation, understanding of peer support wasn't quite what it is today, so it's been nice to see that increasing, but that's still showing what they're working on and showing who they're working with in the survey. There's still a lot of room for growth in terms of being included on teams, being provided opportunities to advance, so the recovery orientation of the organization is increasing, but there's still more opportunities for peers to advance. We're finding that about 56.5 percent of their time is spent on direct peer support and 37.7 is more on administrative tasks, so how do we found that balance? How do we make a balance so they can really spend time working with people rather than doing more of the admin tasks? And then also, Noah mentioned this. Respondents with a peer supervisor reported significantly higher ROSA scores, supervisor understanding of the peer role, and satisfaction in their job when they had a peer supervisor, so how do we create more opportunities and get some of those peers who are working as peer specialists to become peer supervisors to increase those scores and increase retention in the field? Next slide. So this one, again, I apologize, trying to get all this information out there, but this one is really focused on peer services capacity, so Texas and Noah, the group is focusing really on how do we expand service capacity in the state, and that's by peer run organizations. So in 2020-2021, the state sponsored three capacity expansion projects, and so one of our researchers did field observations of all of these, participated in all of the events, all the meetings, collected data from all of these initiatives that were going on, and then provided a report to the state on that, so within this, we looked at the leadership and the capacity areas needing attention, and of those, Noah mentioned one of these when he was talking earlier, there's some need of support around leadership and governance, there's some need of support or some training technical assistance around fundraising, how they develop plans, identify and cultivate funds, obtain and maintain funding, there's some need for support around human resources, and then, again, looking at other areas, data and evaluation, marketing and outreach, strategic planning, financial management, and policies and procedures, and a lot of these are about the capacity of the organization, and there are projects that are in place to help them think about developing this capacity, but when you have a small peer run organization, and the leader is really serving as the leader, they're serving as the service provider, they're serving as HR, they're serving as accounting, we're really trying to figure out how do we get additional funding to this organization so they can really build this capacity and be independent service providers in the community. Next slide. And then, finally, looking at peer services capacity expansion, and the peer support Medicaid benefit. It's been really exciting to look at this data. We looked at 2020, but from 2020 back to 2016, so as the benefit went to effect 2019, you can see that really huge increase in the provision of peer support. I'm only sharing the individual peer support service increases, but it jumped, like, what is that, about 80 something percent, 16,000 to 30,000 units of service provided, and if you look on the right-hand side, this, again, shows the opportunity for the peer support Medicaid benefit. The shaded areas show the centers that utilize the individual peer support benefit, so anything in white means that those local mental health authorities, local behavioral health authorities did not utilize the benefit. So we still have a lot of room for growth. We're analyzing the 2021 data right now, seeing that there are increasing uptake of that, and with the increase in the rates, we think that we'll see even more of that increasing. But as of 2020, when you look at that map also, the darker shades show that there were four local mental health authorities that accounted for almost 90% of the benefit, so we've had a lot of opportunity to increase the use of that benefit, and then let's go to the next slide, and then, finally, one of the ways that we've been trying to show the value of peer support is by doing little mini-studies in different service settings, so we've been doing studies in inpatient mental health services, outpatient mental health services, within crisis respite, homeless services, with consumer operating service providers. So we've done these studies, and it's really hard to tease out the actual outcomes of the peer-provided service within the service, but despite that, we've really found that people in services within these organizations, if they're working with a peer, they report much higher personal recovery and much higher reports of the organization's recovery orientation, so we've been trying to do these little studies as we can to support the value of peers and promote the value of peers in the state, and then in the future, like starting now, we can start looking at that Medicaid data and start seeing what the peer outcomes are with that. And I realized as we went, this has really been an ongoing iterative, collaborative process, kind of like Noah talked about. He's got a lot of great partners in universities, a lot of great peer partners out in the field and consultants to move this forward, and the creation of the Peer and Recovery Services unit at the state has really provided a better way to bring all of these things together and kind of leverage all of that knowledge and expertise and wisdom out there to move things forward and really hopefully get to achieve his vision of a Texas where everyone can access peer and recovery support to achieve their ideal quality of life. Thank you for having me. I realized that I did not include the link to the reports that we have where we have all of these reports. I can put that into the chat if that's helpful, but thanks so much, and I'll turn it over to the next person. My name is Brandy Hensley. I'm the director of the Office of Recovering Resilience at the Oregon Health Authority. I lead a team of people with lived experience who are charged with both engagement of behavioral health consumers around the state and also oversight of peer-delivered services programming in Oregon. Next, please. I have no disclosures to make at this time, so I won't spend a ton of time on this, but just to provide some context, I wanted to say a little bit about what peer-delivered services looks like here in Oregon. There are a couple of different certification paths and worker types that folks can take. We have peer support specialists, which are your typical, what people think of as peers. We also have a certification for peer wellness specialists where those folks, they have lived experience with behavioral health, but in their training, they also get extra training on whole health, wellness, and integrated care. And then we certify folks as either adult, addiction, or mental health. We also have peer certifications for youth support and family support. And basically, our peers, anywhere you find people with behavioral health needs, anywhere you find people, you will find peers, clinical and community-based settings. Next, please. So I want to talk a little bit about the opportunities and challenges that we've discovered here in Oregon while engaging with our peer workforce. And then I'll say a little bit about some of the work we've done to address those things. So, you know, some of the challenges that folks have identified, background checks. There was actually a needs study conducted in 2020, and they found that the majority of people, when they talked about the barriers they had to entering and remaining in the workforce, this was the primary barrier for a lot of folks. You know, we understand that the background check process can be very confusing and difficult to navigate. There are long wait times for background checks to come through, and folks felt that the process itself was overly stringent and just very, very difficult. You know, we've also heard that, you know, this can have a disproportionate impact on people who come from underrepresented communities who may have experienced disproportionate rates of arrests or convictions and incarcerations, and that this becomes a real equity issue and really exacerbates our existing, the existing lack of diversity in our peer workforce. Another challenge or barrier that peer workers have identified is a lack of availability of training and education for other peer workers. Availability is a big issue, and this was made worse by COVID, as a lot of things were, and this challenge is particularly acute for people living in rural and remote areas of our state and for people who are looking for training in providing culturally specific peer services, and that needs assessment that I mentioned earlier found that about, when they broke down what trainings were available, about 76 percent of those initial training programs were intended for people going into addiction peer support work, and so there's a real disparity in terms of what's available. You know, they found that about 10 percent of our programming were focused on training mental health peers, and 14 percent were focused on family support, and there was only one training program in the entire state that trains folks to provide youth support, so that's definitely a challenge. There also are peer workers have, and other kinds of providers, have identified a real need for technical assistance for non-peer workers. People report that they don't really understand how to appropriately support or integrate peer workers. Peers in the workforce have talked about their struggle to be taken seriously, feeling like their roles aren't understood or valued, and that they often feel disempowered, especially when they're working in clinical settings, and we've also noticed that stigma really plays a part in this, particularly for our addiction peers. We found that some providers, especially, again, clinical providers, will sometimes choose to fill peer support roles with other worker types, maybe people who don't have lived experience, or they might use, for example, they might use a family support specialist to support people who have adult mental health needs, and that's not always appropriate, and again, that comes to that place of people having a stigma about people with certain types of lived experience. And then another challenge that's been identified is the need for more culturally specific programming, training for culturally specific providers, and sustainable funding, which is an issue that always seems to come up. Next, please. So, some of the opportunities that we have right now, some of the good news, we have a growing awareness and understanding of the role of peer providers, what it really is, what the role means, and along with that has come an increased interest and desire for peer support. You know, we have in our unit, we have folks, clinical providers and community-based folks reaching out, asking for assistance in creating a program or recruiting peers or supporting their peers, so that's great news for us. You know, our state also has seen historic levels of investment in behavioral health services. Our programs were underfunded for many years, but this last legislative session, our legislature came together and between the federal investments we were able to leverage and our state general funds had a combined investment of about $1.25 billion into our behavioral health system, and that has provided lots of funding for new peer programs. And we have a number of new initiatives in our state, some connected to those investments that are leveraging peer delivered services in new ways and really expanding the availability of peer services, and those things include our work with the 988 crisis system, ballot measure 110, which some of you all may have heard about. It's a measure that passed in November of 2020 and decriminalized certain drugs and also provided more access to treatment and supports. It included about $300 million worth of funding for addiction treatment and support and has a very heavy focus on harm reduction and peer delivered services. We've also seen new investments in aid and assist, which is what we refer to. Those are folks who encounter the legal system due to mental health or behavioral health challenges and those kind of intensive services and expanded investments and use in family support. Next, please. So some of the current work that we're doing right now. One thing that we've been able to do is to make some investments from our block grant funding, and those have included investments both for direct services, particularly for culturally specific programming to fund culturally specific peer programs. And also we're in the process of developing training and technical assistance for people who work alongside peer delivered service providers so that again, they will get that technical assistance they need to really support and integrate peers into their work settings. We're doing some work right now with our 1115 Medicaid waiver. We're in the application process right now, but we're exploring ways there to expand availability of peer delivered services, both before and after formal treatment for folks. We also have a number of statewide initiatives that I touched on earlier, including our Measure 110 implementation and our work with the 988 crisis system. And again, both of those programs feature peer delivered services very heavily in the work and in the planning. And then we're also implementing some legislation. We have Senate Bill 1512, which was that was passed last year as a first step to reducing some of those barriers related to criminal background checks. And this Senate bill prohibits basically denial or revocation of licensing solely for the reason of a past conviction that doesn't substantially relate to a person's job duties and also put some things in place that the board or commission that's looking at a certification would need to consider. And that includes things like the age that the person was when they had those legal interactions, any mitigating circumstances, and how much time has passed since that legal involvement. So that's a nice first step. Some other legislation that we're implementing, there was House Bill 2086, which was basically our big behavioral health omnibus bill. And that included a couple of things that have had a particular focus on peers, including the behavioral health wage study that included a lot of conversation and work with peers around the state, including focus groups, talking with key informants, and engaging with internal experts in peer-delivered services at OHA. This bill also includes funding for expansion of culturally specific providers, again, including peer-delivered service providers. And that funding is overseen by a community leadership council, which is composed of people from the workforce, again, including peer providers. Another program that we're implementing that I'm super excited about is our peer-run respite. This is the bill that established funding and rules for peer-run respites for the first time in our state. We're in the process of implementing that right now, again, led by our community members who either are peer workers or would be people who might utilize peer respites. And then just this year in our short session, the House passed House Bill 4004, which is our behavioral health provider relief fund. And that has provided funding to increase reimbursement rates for all of our behavioral health providers across the board. And we are in the process of implementing that. This just passed at the end of February. And one of the things we're looking at is providing additional funding for areas that have been underfunded in the past, including peer-delivered services. Next, please. So what's next for us? You know, like I said earlier, Stacey mentioned that Texas had created a peer-delivered services unit. Similar story here in Oregon. I, until about six months ago, was an office of one. We now have a team of nine, including me. And four of those folks are focused solely on work related to Peer Delivered Services. So we're very excited to now have the capacity to really do this work. And all of our work is led by community. And so, we are looking at ways to support workforce development and really engage Peer Delivered Service providers in our planning and decision-making. Some of the work that has been recommended to us that we're beginning to explore, again, expanded programming and training for new workers who provide culturally specific peer services, more training and certification programs generally, especially for people who live in rural or remote communities in our state. We're really looking seriously at how to get better with the recruitment and retention. And that includes things like background checks, making that process more trauma-informed and easier to navigate, perhaps making it less stringent. For example, one recommendation was to have shorter look-back periods for folks who do have legal involvement. And also thinking about the results of that wage study. The wage study found that the average wage for our peer workers in our state is about $18 an hour. And a more realistic wage might be closer to 22 or $23 an hour. So we're looking at ways to increase that, but also provide expanded benefits for folks like insurance, housing stipends, childcare assistance, things like family leave and paid leave. Some other things our community has been interested in is establishing a trade association and possibly an independent certification body for peer services, as opposed to what we have now, where it's all done through the state. And then a peer center for excellence. That's the last thing. We put a proposal together for what we're calling a peer center for excellence, which would work again in partnership with community to develop standards, training, other kinds of recommendations for peer services in our state. So that is everything I had to share today, and I will hand it off to the next person. Thank you. Good afternoon, everyone. My name is Jeremy Reed. I'm the Director of Workforce Development at Community Bridges in Mesa, Arizona. We're gonna be switching gears here a little bit, and I hope to keep the momentum of what I found to be a very informative webinar so far. Community Bridges is a provider and one of the largest nonprofit behavioral health providers in the state of Arizona. You can go to the next slide, please. I have no disclosures to make on the subject of this presentation. There's a nice little teamwork slide. We can keep going if we'd like. But who we are. You can see our mission, our values, and our purpose, and I know we're getting close to time here, so I'm not going to read all of them to you. But I really hope that by the time that I'm done today, that you'll be able to identify how our peer workforce helps us stay true to our mission, and how we can continue to do that. How it helps us stay true to our mission, values, and purpose. Next slide. So a little bit of history of Community Bridges. You'll hear me refer to it also as CBI. We were founded by members of the recovery community in 1982. As the story goes, there were some members of the recovery community that noticed a need in their local communities, got together, and did something about it, and really started out as a homeless outreach program where they would have a van and drive around local communities, engage homeless individuals or those experiencing homelessness, excuse me, in their communities, take them to a treatment center, and hopefully be able to start them on their recovery. That agency started off of a small amount of staff, but largely consisted of volunteers. Over the years, we have grown from that one small facility program in the Phoenix area to over 32 programs and 1,700 employees statewide. Next slide. So over 30% of our workforce identifies as a peer. I want to be clear when I say identifies here. That doesn't mean that they all have peer support specialists in their job description. We have people that identify as a peer in our HR department, IT department, compliance, QM, nurses, medical providers, people on our board. So that's really what I'm talking about when I'm referencing that 30%. But we like to say that peers are the heart of CBI, and some of the things that we do as peers, you can see right below, is we really inspire hope that people can and do recover. Noah talked about this as, you know, having walking with people on their recovery journeys as someone that's in recovery myself. I can say that that piece of my experience with a peer support specialist was monumental in my recovery. Early, we talked about myths and stigma. This is my favorite, is we really are able to dispel those myths around mental health and substance use disorders, and that's one of my favorite things that peers are able to do here in the communities that we serve. We also, as peers, provide education and link people to tools and resources to not only further and continue their recovery, but also their independence. And last but not least, we really want to support people in identifying their hopes, dreams, and sort of creating that roadmap for them to be able to get there. You can go to the next slide, please. So this next slide may look similar in verbiage. It's not the same slide, just with different icons, I promise. But if we believe in what peers do, we also need, as an agency and the values of peers, we also need to have those same values as an agency. So as an agency, we really try to inspire that the peer workforce can and will have lasting, meaningful careers. We like to say that this is a career opportunity when coming to work at Community Bridges and not just a job opportunity. We're able to walk with our peer workforce on those professional journeys. Again, another one of my favorites is, as an agency, we're really able to dispel myths and stigma about meaningful career opportunities. We also provide education and resources to our peer workforce and able to advance their careers. And then lastly, support that workforce in identifying professional goals, their own professional goals, hopes, and dreams, and creating that roadmap for them to be able to get there. Next slide, please. So the things I talked about previously are all really cool when it comes to what we do for our workforce. But we also want to be able to support our peers outside of work, their families and loved ones the best we can. So we offer what I call a robust benefits package, where we have medical, dental, vision available to our workforce, 401k with employer match, paid time off five weeks a year. People usually, that catches people's eyes, usually when they're coming to work at Community Bridges. We have various tuition assistance or reimbursement programs for people to continue their education. It's not in finalization yet, but I think the cat's out of the bag. At the end of this month, we are also launching a student loan repayment program, assistance program for our workforce. We contract with a agency called Work-Life Partnership, and that's an outside agency that we contract that sort of acts as navigators for our workforce. So when life happens and barriers arise, our workforce can call this partnership that we have with Work-Life with complete anonymity, and they will help our peers or our workforce really navigate some of those barriers they're experiencing in their life. We have a life insurance policy and employee assisted programming that we offer for our peers. As someone who's managed peers before, oftentimes there's some education needed to our peer workforce on what EAP is and how it can be beneficial. But we really encourage our peers to take care of themselves as well outside of work so they can be the best they can be while they're here doing their boots-on-the-ground work at Community Bridges. You can go to the next slide. So how do we get here to this? One of the people that was driving that van around several, several years ago is now our CEO. As a volunteer, he started. So we have this dedicated commitment from the top down. And what's happened at Community Bridges is we've cultivated this environment where our peer workforce have a voice. I like to call it having a seat at the table. And we really believe in the value of peers. We use that peer workforce to help drive initiatives and the direction that Community Bridges goes oftentimes. We believe that in order to solve a problem, sometimes the best way to solve that problem is to ask the people closest to the problem. So we have a peer work group made up of our peer workforce and executive leadership. So there's two-way dialogue going back and forth from our executive leadership, the investment of the executive leadership team and that voice of the peers that are doing that boots-on-the-ground work. Again, really helping drive some of the direction and initiatives that we go as an agency. One of the things I'm also proud to say is we've recently created a workforce development department dedicated to our peer workforce. We'll get to that slide here. You can go. So our workforce development department, I'm fortunate to work with three other colleagues. We have a peer support mentor, a peer support educator, and a peer support recruiter. That peer support mentor is really inspiring individuals to explore those career paths and helping them get there. Here at Community Bridges, we have our peer support educator who quarterbacks our peer certification program. So we are approved or have the rubber stamp from the state to provide peer certification internally. So our employees usually get that within 90 days of employment. Like has been talked about earlier too, we also have a continuing education curriculum for our peer workforce. So it sort of works in tandem with that peer mentorship. So as they're getting these learning and education opportunities, right behind them is coming the mentorship. So we're really preparing people to go into that next phase of their career. All that stuff is great, but we need peers working here to be able to do that. So we also have a peer recruiter who does a lot of things, the traditional method of Indeed job boards, but really they're out in the community cultivating partnerships with external stakeholders, excuse me. Creating partnerships with our prison system, jail system, probation officers, recovery homes, other local nonprofits, anyone who would come in contact with people that could identify as a peer, we're cultivating a relationship with them should their clients really want to come into the helping profession, creating that pipeline of peers coming through the doors at Community Bridges. Next slide. So some of the impacts that's had is we were heavily involved at Community Bridges in Medicaid waiver 1115, which allows for reimbursable outreach services and shelter services here. You heard me talk about that our peer workforce has driven the direction oftentimes that we go as an agency. Well, what that looks like today is we offer a full functional continuum of care from crisis centers to detox to mental health facilities, medication assisted treatment, outpatient residential services all here in Arizona. And by doing that, we're able to increase engagement in self-care and wellness for our communities and members we serve, increase that social support and social functioning and really give people a sense of control and bringing changes to their lives. In tandem with that, we're also able to see some decreases in things such as substance use and psychiatric symptoms, inpatient hospital admission rates, cost of the mental health system. So that peer workforce and that peer services are really driving down the cost to the mental health system and then decreasing that self stigma that often comes with mental health or substance use disorders as well. I apologize for running through that fairly quickly, but I think that's all I have. Thank you so much. Thank you. Thanks so much to all of you for such an inspiring, useful presentation. There are a bunch of questions. We'll hopefully be able to get to them though we're running a bit short on time. But before we shift into Q&A, I do wanna take a moment and let you know that SMI Advisor is accessible from your mobile device. You can use the SMI Advisor app to access resources, education and upcoming events, complete mental health rating scales and even submit questions directly to our team of SMI experts. You can download the app now at smiadvisor.org forward slash app. So let me just start with a couple of questions around billing that folks had. There was, I guess these probably for Noah and Stacey to start with one was about how Medicaid reimbursement in Texas works and kind of how that maybe matches up to the mean hourly wage that Stacey had purported. Well, the billing rate in Texas, I think we're at now around 12, like just under $12 per unit. And so I guess there's a lot of things that come into that equation. What percentage of the population being served, has Medicaid, which we have substance use and mental health. I know the substance use folks have, we see way lower percentage of folks that have that. So we see the Medicaid not necessarily as an answer, but as one of the funding streams that can support, but it's not, I don't think in and of itself, it's the only funding that could support positions. I can hand off to others. Well, there was also a question about private insurance and I'm just curious if anyone, I guess anyone on the panel has a sense about both how common it is for private insurance to fund peer support services. And if so, what the rates look like compared to Medicaid reimbursement. So I'm not an expert on the rates portion, but I am seeing it much more often in especially in substance use services that are being provided. It's sometimes unclear what is meant peer support in private insurance. We've not really seen it be infidelity with what we would consider a peer support services. It tends to kind of be a little more directive closer to replicating other clinical services, but we are seeing a lot of interest, especially in virtual apps. One thing that we did notice when we looked at the salaries by where people worked was that peers who were working in MCOs got a bit higher salaries in comparison to those working out in the community or peers working at the VA seemed to get a bit higher salaries than peers working in the public mental health system. Great. Thanks so much. Sorry, did you have? I was just gonna say it's very similar here in Oregon, although we have a group now that's particularly taking a look at private insurance for youth support and family support services. There's been a real movement there to make that happen in our state. So I'm eager to see where that goes. Great. Thank you all. There was also a question about crisis intervention training. I think Brandy, you had mentioned rollout of 988 and there was a question about the role or experience of integrating peers into first responder or crisis intervention training programs in your states. Yeah, so we have some good models for that already. We have something called the CAHOOTS team out of Lane County. We also have what's called the Portland Street Response that works in the Portland area. Those programs have had a really good experience integrating peer workers into their teams. And as part of our rollout of the 988 crisis system statewide, the plan is to have peer providers embedded in each mobile response team. That's gonna be a minimum requirement that there be at least one peer on each team. So we're doing it. It's exciting. Great. And I'll also say for what we're calling the MRSS, which is the mobile response for youth, a similar model will have families and youth specialists embedded in those teams. Great. Well, perhaps with that, well, that's probably a good place to wrap up. Again, thank you so much. There were a bunch of comments also, I would say, and questions in the question section, just thanking everyone for such a great presentation. So if anyone has follow-up questions about the topic of this webinar or any other topic related to evidence-based care for SMI, our clinical experts are available for online consultations. Any mental health clinician can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. On behalf of SMI Advisor, I'd like to invite you to learn more about the APA's 2022 annual meeting. It's an in-person conference that will be taking place May 21st through the 25th in New Orleans, and a virtual meeting that will take place June 7th to 10th. During the live conference, clinical experts from SMI Advisor are leading a virtual virtual meeting and clinical experts from SMI Advisor are leading a variety of sessions on how to improve care for individuals who have SMI. Topics include the basics on how to use Clozapine, digital navigators, how to make technology work, and how to improve physical health in patients who have SMI, and more. So I encourage you to take a moment right now and browse the agenda. Next slide. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. Next slide. Please join us on June 3rd, 2022, as Melody Medaris will present implementation of peer support specialists in mental health centers. Thank you. Next slide.

peer support specialists

increasing wages

career pathways

SMI Advisor

evidence-based care

workforce development

mental health

substance use disorders

recovery

reducing stigma