NYAPRS Note: Here's a timely piece by a vice president of a national
behavioral health organization (BHO) on the financial advantages of
engaging peer support services that are particularly effective in
reducing avoidable ER and hospital visits. The piece emphasizes how BHOs
have significant experience and investment in such innovative
approaches, a trend not found in generic health plans or HMOs. NYS
advocates are seeing this as another reason to strongly support
proposals to turn state Medicaid behavioral health services over to BHO
coordinated improvements and not to simply fold them into HMO plans.
Cost Effectiveness of Using Peers as Providers
Sue Bergeson, VP, Consumer Affairs, OptumHealth
The Center for Medicaid Services in its 2007 letter to states indicates
that "Peer support services are an evidence-based mental health model of
care which consists of a qualified peer support provider who assists
individuals with their recovery from mental illness and substance use
disorders. CMS recognizes that the experiences of peer support
providers, as consumers of mental health and substance use services, can
be an important component in a State's delivery of effective treatment
The Substance Abuse Mental Health Service Administration, a division of
HHS, identifies per support and consumer operated services as evidence
based practices. The prestigious Institute of Medicine has emphasized
the importance of peer support and peer delivered services in its
landmark report Improving the Quality of Health Care for Mental and
Substance-Use Conditions: Quality Chasm Series.
Annapolis Coalition on the Behavioral Healthcare Workforce has
identified peer delivered services as one of its areas of emphasis to
transform the behavioral health workforce and prepare for anticipated
workforce shortages in the face of healthcare modernization.
The major organizations identified above have all indicated peer
delivered services work, but are they cost effective? The answer to
this question as shown by the research done in this area might be best
broken out into three domains as follows.
1. Using peer specialists instead of traditional day treatment
In 2006 the Georgia Department of Behavioral Health & Developmental
Disabilities compared consumers using certified peer specialists as a
part of their treatment verses consumers who received the normal
services in day treatment (the control group). Consumers were randomly
assigned to each group. Consumers using the services of certified peer
specialists showed improvement as compared to the control group in each
three outcomes over an average of 260 days between assessments in all
* Reduction of current symptoms/behaviors
* Increase in skills/abilities
* Ability to access resources/ and meet their own needs
In comparing the costs of services, those using the certified peer
specialists cost, the state on average per year $997 verses the average
cost of $6491 in day treatment. That's an average costs savings of $5494
per person for the state. (source: Fricks PowerPoint presentation at the
SAMSHA National Mental Health Block Grant and Data Conference 2007)
2. Reduction of Hospitalization
Peer Bridgers are being used in a variety of setting throughout the
country. One program run by NYAPRS was evaluated by Cheryl MacNeil,
Ph.D. National Health Data Systems, who identified and examined several
areas where the project benefited those involved:
"The most substantial finding is that the follow-up re-hospitalization
rate of Matches while enrolled in the Peer Bridger Project was
significantly less than the baseline hospitalization rate (i.e.. the
2-year period prior to enrollment). That is, during the 2-year baseline
period, the Matches were hospitalized an average of 60% of the time,
while enrolled in the program, however, they were re-hospitalized only
19% of the time. That's an improvement of 41%!". (National Health Data
Systems, December 1998)
More recent data analysis in 2008, the Peer Bridger Project worked with
229 individuals and 176 of those consented to the release of their
hospitalization data. After initial review of this data, 125 of these
individuals were not re-hospitalized in the state psychiatric center in
That means that 71% percent of the people the Peer Bridgers worked with
were able to stay out of the hospital in 2009.
The OptumHealth Wisconsin Peer Bridger program targeted people in one
geographic area who had at least two hospitalizations on average each
year. In the past year since this population received Bridger
services, 54% have not been re-hospitalized. (source: internal
In another OptumHealth related example, certified peer specialists were
used for the first time to offer respite services instead of immediately
sending consumers in crisis to the hospital. Using this new service,
Pierce County Washington was able to reduce involuntary hospitalizations
by 32% leading to a savings of 1.99 million dollars in one year.
(source: internal OptumHealth analysis)
In another OptumHealth example, certified peer specialist are being used
as health coaches with late life populations. The average age of the
consumer being served was 71. 100% of the consumers had been
hospitalized prior to having a peer coach, only 3.4% were hospitalized
after getting a coach. The Average length of stay prior to having a
coach was 6 days. The average length of stay after getting a coach was
just 2.3 days. (source: internal OptumHealth analysis)
Recovery Innovations in Arizona offers Peer Advocacy Services. This
Hospital-based peer support is provided every day by Peer Support
Specialists with people who are in the hospital; every unit at both
Desert Vista and the MMC Annex. The Focus is on developing recovery
plans and recovery-oriented discharge plans including strategies to
Since the Peer Support Specialist staff have been working in the two
hospital facilities, there has been, according to hospital
administration, a reduction of 36% in the use of seclusion and a 48%
reduction in the use of restraint, And a 56% reduction in hospital
readmission rates.( Source
3. Increase in Adherence and other Positive Outcomes
There is a wide range of research that shows using trained peers leads
to improvement in psychiatric symptoms and decreased hospitalization
(Galanter, 1988; Kennedy, 1990; Kurtz, 1988). In studies of persons
dually diagnosed with serious mental illness and substance abuse, peer
led interventions were found to significantly reduce substance abuse,
mental illness symptoms, and crisis (Magura, Laudet, Rosenblum, &
Consumers participating in peer programs had better adherence to
medication regimens (Magura, S., Laudet, A., Mahmood, D., Rosenblum, A.
& Knight, E.), had better healing outcomes, greater levels of
empowerment, shorter hospital stays and less hospital admissions (which
resulted in lower costs than control group). (Dumont, J. & Jones, K.
Dr. John Rush, primary researcher on the NIMH STAR*D depression study -
the largest and most comprehensive study ever done in depression, did an
evaluation of over 1,000 members participating in peer run programs
through the Depression and Bipolar Support Alliance (DBSA), 95% of those
surveyed described their participation as helping them better
communicate with their doctor, 97% of those surveyed described their
groups as helping with being motivated to follow instructions, and being
willing to take medication and cope with side effects. Those who had
been participating for more than a year were less likely to have been
hospitalized in the same period (Lewis, 2001).
Those who participate in peer delivered services build larger social
support networks (Carpinello, Knight, & Janis, 1991; Rappaport, Seidman,
Paul, McFadden, Reischl, Roberts, Salem, Stein, & Zimmerman, 1985), and
end up with enhanced self-esteem and social functioning (Markowtiz,
DeMassi, Knight, & Solka, 1996; Kaufmann, Schulberg, & Schooler, 1994).
Peer delivered service participants showed greater levels of
independence, empowerment & self-esteem. Over 60% indicated increased
development of social supports.(Van Tosh, L. & del Vecchio, P. 2000).
Involvement in peer support results in creation of a social network,
change in role from helpee to helper, sharing of coping behaviors,
presence of role model, and existence of a meaningful group structure.
(Carpinello, S., Knight, E., & Janis, L. 1992)
Prestigious and important organizations such as CMS, SAMSHA, the
Institute of Medicine among many others have identified peer delivered
services offered through a certified peer specialists as being valuable
services. In addition research is showing that while increasing
consumer wellness, the use of peer specialists is decreasing costs.
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