Bergeson: Cost Effectiveness of Using Peers as Providers

NYAPRS Note: Here's a well-documented timely account of peer services' cost effectiveness from Optum's Sue Bergeson. 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 (http://www.cms.hhs.gov/SMDL/downloads/SMD081507A.pdf).

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. (http://www.iom.edu/Reports/2005/Improving-the-Quality-ofHealth-Care-for-Mental-and-Substance-Use-Conditions-Quality-ChasmSeries.aspx).

The 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 (http://www.annapoliscoalition.org/pages/).

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 three areas: * 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 versus 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 Stephen Beller 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 2009. That means that 71% percent of the people the Peer Bridgers worked with were able to stay out of the hospital in 2009. http://www.nyaprs.org/peer-services/peer-bridger/

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 OptumHealth analysis).

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 reduce readmission.

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 http://www.recoveryinnovations.org/pdf/RIA%20Programs%20and%20Outcomes.pdf

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, & Knight, 2002).

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. 2002) 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)

Conclusion 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.

Selected References

* Campbell, J. and Schraiber, R. (1989). In pursuit of wellness: The Well-Being Project. Sacramento, CA: California Department of Mental Health.

* Carpinello, S., Knight, E., and Janis, L. (1992). A study of the meaning of self-help, self-help processes, and outcomes. Paper presented at the Third Annual Conference on State Mental Health Agency Services Research, Arlington, VA: NASMHPD Research Institute, Inc., 37-44.

* Carpinello, S., Knight, E., Videka-Sherman, L., Sofka, C., and Markowitz, F. (1996). Self-selection distinguishing factors: Participants and non participants of mental health self-help groups. Center for the Study of Issues in Public Mental Health: Unpublished report.

* Chamberlin, J., Rogers, E. S. and Ellison, M. (1996). Self-help programs: A description of their characteristics and their members. Psychiatric Rehabilitation Journal 19, 33-42.

* Copeland, M. E. (2004). Self-determination in mental health recovery: Taking back our lives. In J. Jonikas & J. Cook (Eds.), UIC NRTC's National Self-Determination and Psychiatric Disability Invitational Conference: Conference Papers (pp. 68-82). Chicago, IL: UIC National Research and Training Center on Psychiatric Disability.

* Corring, D. (2002). Quality of life: Perspectives of people with mental illnesses and family members. Psychiatric Rehabilitation Journal 25.

* DeMasi, M., Carpinello, S., Knight, E., Videka-Sherman, L., Sofka, C., and Markowitz F. (1997). The role of self-help in the recovery process. Center for the Study of Issues in Public Mental Health: Unpublished Report.

* Dumont, J. and Jones, K. (2002, Spring). Findings from a consumer/survivor defined alternative to psychiatric hospitalization. Outlook, 4-6.

* Edmunson, E., Bedell, J., et al., (1982). Integrating skill building and peer support in mental health treatment: The early intervention and community network development projects. In E. Jeger and R. Slotnick (eds.) Community Mental Health and Behavioral Ecology. New York: Plenum Press, 127-139.

* Emerick, R. (1990). Self-help groups for former patients: Relations with mental health professionals. Hospital and Community Psychiatry 41, 401-407.

* Forquer, S. and Knight, E. (2001). Managed care: Recovery enhancer or Inhibitor? Psychiatric Services 52(1), 25-26.

* Galanter, M. (1988a). Research on social supports and mental illness. American Journal of Psychiatry, 145(10), 1270-1272.

* Galanter, M. (1988b). Zealous self-help groups as adjuncts to psychiatric treatment: A study of Recovery, Inc. American Journal of Psychiatry, 145(10), 1248-1253.

* Holter, M., Mowbray, C., Bellamy, C., MacFarlane, P. & Dukarski, J. (2004). Critical ingredients of consumer run services: Results of a national survey. Community Mental Health Journal, 40(1), 47-63.

* Kaufmann, C., Ward-Colesante, M. and Farmer, M. (1993). Development and evaluation of drop-in centers operated by mental health consumers, Hospital and Community Psychiatry 44(7), 675-678.

* Kaufmann, C., Schulberg, H. and Schooler, N. (1994). Self help group participation among people with severe mental illness. Prevention in Human Services 11, 315-331.

* Kaufmann, C. (1995). The self-help employment center: Some outcomes from the first year. Psychosocial Rehabilitation Journal 18, 145-162.

* Kennedy, M. (1990). Psychiatric hospitalization of GROWers. Paper presented at the Second Biennial Conference on Community Research and Action. East Lansing, Michigan.

* Kessler, R., & Mickelson, K. (1997). Patterns and correlates of selfhelp group membership in the United States. Social Policy, 27(3), 27-47.

* Klein, R., Cnaan, R., and Whitecraft, J. (1998). Significance of peer support with dually diagnosed clients: Findings from a pilot study. Research in Social Work Practice 8, 529-551.

* Kurtz, L. (1988). Mutual aid for affective disorders: The Manic Depressive and Depressive Association. American Journal of Orthopsychiatry, 58.

* Luke, D., Roberts, L, and Rappaport, J. (1994). Individual, group context, and individual-group fit predictors of self-help group attendance. In Powell, T. J.(Ed), Understanding the self-help organization: Frameworks and findings. Thousand Oaks, CA: SAGE Publications, 88-114.

* Magura, S., Laudet, A., Mahmood, D., Rosenblum, A. and Knight, E. (2002). Adherence to medication regimens and participation in dualfocus self-help groups. Psychiatric Services, 53(3), 310-316.

* Mowbray, C., Wellwood, R. and Chamberlain, P. (1988). Project Stay: A Consumer-run support service. Psychosocial Rehabilitation Journal 12, 33-42.

* Mowbray, C. and Tan, C. (1993). Consumer-operated drop-in centers: Evaluation of operations and impact. Journal of Mental Health Administration 20(1), 8-19.

* Powell, T., Hill, E., Warner, L., Yeaton, W., & Silk, K. (2000). Encouraging people with mood disorders to attend a self-help group. Journal of Applied Social Psychology, 30, 2270-2288.

* Raiff, N. (1984). Some health related outcomes of self-help participation. In Gartner, A. and Riessman, F. (Eds.) The Self-Help Revolution. New York: Human Sciences Press.

* Rappaport, J., Seidman, E., Paul, T. A., McFadden, L., Reischl, T.,

* Roberts, L. J., Salem, D., Stein, C. and Zimmerman, M. (1985). Collaborative research with a self-help organization. Social Policy 15, 12-24.

* Roberts, L., Salem, D., Rappaport, J., Toro, P., Luke, D., and Seidman, E. (1999). Giving and receiving help: Interpersonal transactions in mutual-help meetings and psychosocial adjustment of members. American Journal of Community Psychology, 27, 841-868.

* Salzer, M.S., & Mental Health Association of Southeastern Pennsylvania Best Practices Team (2002). Consumer-Delivered Services as a Best Practice in Mental Health Care and the Development of Practice Guidelines." Psychiatric Rehabilitation Skills, 6, 355-382.

* Segal, S. Silverman, C. and Temkin, T. (1995b). Characteristics and service use of long-term members of self-help agencies for mental health clients. Psychiatric Services 46(3), 269-274.

* Trainor, J., Shepherd, M., Boydell, K., Leff, A. and Crawford, E. (1997). Beyond the services paradigm: The impact of consumer/survivor initiatives. Psychiatric Rehabilitation Journal 21(2), 132-140.

* Van Tosh, L. and del Vecchio, P. (2000). Consumer-operated self-help programs: A technical report. Rockville, MD: Center for Mental Health Services.

* Yanos, P., Primavera, L., and Knight, E. (2001). Consumer-run service participation, recovery of social functioning, and the mediating role of psychological factors. Psychiatric Services, 52(4), 493-500.

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