Recommendation 3:
Expand Peer Engagement

Expand peer engagement in the system of care improvement process.

• Strategy 1: Continue to enhance engagement into the ASH Redesign process of people from diverse ethnic, racial, sexual orientation, gender identity, and disabilities background.

• Strategy 2: Work to ensure that ASH has a robust financially sustainable peer support program.

The ASH Redesign project has aimed to engage people who experienced the mental health system as a person receiving care, peer support worker, family member, and/or mental health advocate. This critical engagement reflects our first “People First” core principle behind the ASH Redesign efforts, namely:

“Taking excellent care of people is always the first priority in planning with a goal to provide the right care at the right time in the right place.”

As the redesign efforts of ASH continue, this principle remains our top priority guiding project decisions. Throughout the next phase of the redesign, the peer and family work group along with the steering committee developed the following recommendation to strengthen the impact of this principle.

Peer Support Engagement

Peer support specialists provide mutually supportive relationships throughout the recovery process, for both people with a brain (mental) health illness or substance use problems. Peer support is the process of giving and receiving encouragement and assistance to achieve long-term recovery (Mead, 2003). Peer specialists offer emotional support, share knowledge, teach skills, provide practical assistance, and connect people with resources, opportunities, communities of support, and other people (Solomon, 2004). It is through this trusting relationship, which offers companionship, empathy and support, that feelings of isolation and rejection can be replaced with hope and personal control. Similar to peer support, family and/or caregiver partner services support families and caregivers who are caring for a loved one experiencing a mental health illness. Family and caregiver partners provide education on available community care, help to identify resources, and bring a personal understanding of their experience to a supportive relationship. Increasing numbers of peer and family support specialists are being employed nationally, and evidence of the effectiveness and value of these services continues to emerge (Davidson et al, 1999; Klein et al, 1998; Ochocka et al 2006). Moreover, well-developed peer support is cost-effective, in particular reducing use of more expensive, and often unnecessary, services. For example, Sledge et al (2011) reported that people partnered with a peer support service spent fewer days in the state hospital and experienced less recidivism than individuals without this support. Because of the high cost of inpatient care, savings that result from even small changes in hospitalizations quickly outweigh the costs of employing peer and family specialists. ASH has peer services within their treatment teams providing valuable services to people in the hospital. The importance of this care is also emphasized in the design of the new hospital, ensuring space for peer supports within each unit. Efforts through the redesign will continue to focus on increasing collaboration with peers, family members and advocates throughout the ASH service area.

Working closely with the peer support unit at HHSC and maximizing their expertise will enhance all of the recommendations throughout future efforts in the redesign. Continuing town hall discussions with robust conversations about community needs further foster, prioritize, and actualize diversity beyond single representations of peer and family. The ASH Redesign supports increasing peer specialists throughout the system, thereby increasing peer engagement. Collaborations with peer advocacy groups and Community Based Recovery Organizations, as well as meaningful peer integration, will be a central strategy to enhance this important, cost-effective service.

Peer Service Reimbursement

Texas is one of thirty-six states that pay for peer services through Medicaid (Myrick, 2016). Although peer services are supported by Medicaid, a national peer support workforce survey completed by Cronise et al (2016) reported that Texas and Oklahoma pay the lowest rates nationally for peer support specialists, with an average hourly wage of $11.89. In the ASH Redesign, a stakeholder collaborative will review efforts and pathways to increasing reimbursement rates for Medicaid peer services as well as identify alternative funding models to expand and maintain these services. Because of the critical impact that peers have in state hospital care and long-term recovery within the community, we will prioritize approaches to sustain this workforce.

Current funding rules inhibit effective coordination of care by LMHAs as individuals move through the state hospital system. Often care provided by peers in the state hospital ends at discharge and is then picked up by outpatient peer services, usually through the LMHA at a later time in the absence of a “warm hand-off’. This hand-off has a hard cut off in funding, and payment is not available for the transition from inpatient to outpatient care. In order to better coordinate care and encourage a person-centered recovery plan, guiding intentional and meaningful transition through increasingly less restrictive settings requires navigation until the healthcare system is less fragmented. Peer navigators assist with transitions from state hospital to outpatient settings. An example of transitions from hospital to outpatient setting is the evidence-based Peer Bridger model that focuses on outreach and engagement, crisis stabilization, wellness, self-management skills, and community support (SMI Adviser, 2019). The Peer Bridger model, established by New York Association of Psychiatric Rehabilitation Services, Inc. (NYAPRS), reduces hospitalization length of stay, improves quality of life, and reduces re-hospitalization rate after discharge from psychiatric hospitals. Similar navigation to help people maintain recovery and stay engaged with ongoing community-based supports can be utilized when they re-enter the community from the criminal justice setting. Navigation structures have been successfully used by other states such as Pennsylvania and in metro areas, like Miami-Dade County, known for their collaboration between the mental health and legal systems (Guevara, 2015). By allowing peer specialists to follow individuals as they transition from ASH into the community, the barriers of our fragmented system of care may be reduced and eventually eliminated. Post-hospitalization peer support services are an effective bridge from hospital to community-based supports.

Peer and family support, along with care and service coordinators, navigators and other professionals, bridge gaps within the mental health system, provides a critical support network to assist individuals as they move through the continuum of care. With these considerations in mind the Peer and Family Work Group established five recommendations the group will continue to work toward during the next two years. Appendix 10 provides details on the following recommendations:

1. Build a collaborative continuum of care;

2. Create alternative peer-supported programs for competency restoration;

3. Establish peer and family collaboration programs;

4. Create alternatives to hospital approaches that complement and extend the medical model;

5. Ensure diverse representation of family and peers in redesign efforts.

Encompassing the efforts of the Peer and Family Work Group, increased engagement and collaboration with peer specialists and developing a review of reimbursement support will strengthen the “People First” principle of the new ASH and the brain health continuum.