NYAPRS Note: In accordance with the 21th Century Cures Act, first Assistant HHS Secretary for Mental Health and Substance Use Dr. Elinore McKance-Katz formed an Interdepartmental Serious Mental Illness (and Serious Emotional Disturbance) Coordinating Committee (ISMICC) to recommend strategies "to improve federal coordination of efforts that address the pressing needs of adults with serious mental illness and children and youth with serious emotional disturbance," who too often lack access to evidence-based treatment and supports and experience high rates of suicide, unemployment, homelessness, criminal justice involvement and other negative outcomes." Just as the stakeholder comment period was ending, I was fortunate to get a meeting last week with Dr. McKance-Katz at her SAMHSA office during which I delivered and discussed the attached response from NYAPRS. The focus of this first letter from NYAPRS was in demonstrating the effectiveness of numerous models of peer run services, with recommendations that the federal government invest in research to further explore their impact of people with extensive mental health and substance use related conditions and to also dedicate funding to expand and incentivize peer services to help reduce avoidable relapses and readmissions, incarceration, homelessness and suicide for at-risk individuals with the most advanced conditions. Dr. McCance-Katz expressed very positive support for peer services and shared a passionate commitment to the advancement of criminal justice reforms as regards people with behavioral health conditions and an interest in advancing discussions among consumers, families and psychiatrists. -------------- October 10, 2017 To:Elinore McCance-Katz, MD, PhD, Assistant Secretary for Mental Health and Substance Use From:Harvey Rosenthal, executive director, New York Association of Psychiatric Rehabilitation Services Re: Input to the Interdepartmental Serious Mental Illness (and Serious Emotional Disturbance) Coordinating Committee (ISMICC) Thank you for this opportunity to offer input into the critically important work of the ISMICC to identify advances in treatment, recovery and prevention of serious mental illnesses and to make specific recommendations that will make these approaches available to Americans in the greatest need. I offer these recommendations from several vantage points. I am a person in long term mental health recovery that began with an extensive psychiatric hospitalization on Long Island dating back to 1970, when I was 19. I have had 18 years of experience, from 1975-93 in delivering mental health services for individuals with the most extensive and ongoing conditions, in a NYS psychiatric center and outpatient clinic and as director of a clubhouse styled program in Albany, New York. I have served since 1994 as the executive director of the New York Association of Psychiatric Rehabilitation Services (NYAPRS), a unique peer-led coalition of New Yorkers who receive and/or delivery community based recovery focused services who have been dedicated to improving social conditions, community-based services and public policies that advance recovery, rehabilitation, rights and full community inclusion for people with mental health and/or trauma related conditions. And, over the past few decades, I have served on numerous state and national bodies, which currently include New York's Medicaid Redesign Team and Behavioral Health Work Group and our Value-Based Payment Work Group and Most Integrated Setting Coordinating Council and as a trustee of the Bazelon Center for Mental Health Law. Based on my own experience and existing studies and evaluations, I'd like to begin my comments by asserting that there is ample evidence that community mental health recovery and peer support services have decades of experience in serving at risk individuals with the most serious behavioral health needs. While some have maintained that these approaches do not apply to people in the greatest need and that these providers actively exclude and avoid serving these individuals, millions of Americans would indeed be lost in helpless cycles of recidivism in and out of our state and local hospitals and emergency departments or would be chronically homeless, incarcerated and/or seriously ill or dead were it not for these approaches and services. The greatest tragedy is that while we know so much now about how to effectively serve the most disabled or reluctant individuals, millions of these Americans and their families are not gaining access to these groundbreaking advances. We see so much preventable suffering each day but have not found the way and the will to cut through the barriers and bureaucracy or to address the inadequacy of the array and outlay of public dollars necessary to extend hope and recovery to all. While there are a large number of very successful psychiatric rehabilitative models that successfully serve individuals and families in the greatest need, I'd like to pay special attention here to enumerating the nature and great value of peer run service models that are playing such critically valued and effective roles in communities across our nation. The great success of peer support lies in the power, experience and authenticity of the personal relationships we offer. We start where people are in their lives....and offer the support, faith and encouragement to define and move towards the goals and the life they seek. In contrast with office or telephonically based approaches, we also go to and start our work where people live, recognizing that so many with the greatest needs often don't have stable housing, finances and social supports. We bring hope, empathy, examples, understanding, support and love to people who have been victimized by devastating conditions, traumatic backgrounds and routine system failures. And we try to see the world through the eyes of the people we support, rather than viewing them through a purely illness, diagnostic and deficit based lens. And we are very respectful....and at the same time relentless in our dedication to reach even the most disabled or reluctant individual. Over the past decade, the development of peer services in America has given rise to mature, robust and innovative approaches that are being delivered by highly experienced, trained and certified peer supporters in a variety of well-articulated peer-run service models, including crisis respite programs and warm lines, recovery centers, peer run supported housing and employment services and peer bridger services. Peer specialists can now be found in every setting, in hospitals, emergency rooms, behavioral health and medical clinics, homeless shelters, prisons and jails and in central roles in the emerging health home collaborative systems that are taking hold across the country. Peer specialists are highly trained individuals: many receive training in intentional peer support (Mead), wellness recovery action programs (Copeland), whole health action management (Fricks), wellness coaching based on the 8 Dimensions of Wellness (Swarbrick) and program specific training, e.g. peer bridger or recovery coach training. What follows are some examples of evidence-based peer support service models in New York and nationally. Peer Bridger Created in 1994, the NYAPRS peer bridger model began as a state hospital-to- community transitional model of personalized support that has helped thousands who had resided in NYS psychiatric centers for years to decades to successfully live in their home communities. In 1998, National Health Data Systems found that our bridger services had helped reduce re-hospitalization rates by 41% and by 2009, we had data showing that that figures had increased to 71%. One respondent to a 2003 qualitative assessment conducted by Dr. Cheryl MacNeil amply described our staff's unique value: "She talked to me. She talked straight at me. She's the only one. She's got a knack for going on the underlying thing and really getting at it. And I've never had anyone look me straight in the eye, and actually relate to somebody. And I love her for it." In 2011, we adapted our model to include a new approach that was focused on helping to engage and ground at risk individuals with very frequent relapses and readmissions and cycles of homelessness or incarceration to successfully engage in their recoveries and their lives. Working throughout the boroughs of New York City, we were able to support a 47.9% reduction in those using inpatient services, a 62.5% drop in unnecessary inpatient days and a 41.7% reduction in Medicaid managed care plan spending, from $9.900 to $5,200 in 2013 (source: Optum Health). Peer Crisis Respite Programs Operated by national leader PEOPLe, Inc, Rose House is a successful 100% peer-run alternative to psychiatric emergency rooms and inpatient settings, featuring a weeklong stay in a warm and welcoming home like environment that is in stark contrast to the often traumatizing experience of the emergency room or inpatient ward. The Rose House model has been replicated throughout New York, the nation and even in Holland and beyond. A 2014 evaluation demonstrated that the program served 128 unique guests for 506 residence days, too 3,400 warm line calls, made 207 mobile visits at a scant operating cost of $249,000. 89% were not admitted to inpatient within 30 days of leaving the program.Source: PEOPLE Inc executive director Steve Miccio at stevemiccio at projectstoempower.org<mailto:stevemiccio at projectstoempower.org>. Peer-run Warm Lines Peer-run warm lines are call-in centers that often operate "after hours" when other clinical/peer services are not available. They serve as a "pre-crisis" alternative to crisis hotlines. Trained peers offer emotional support, hope, and the benefit of their experience, and also knowledge of when to transfer the individual to a crisis line. A 2011 exploratory study described the impact of a peer-run warm line on the lives of individuals with psychiatric disabilities. Phone surveys were completed with 480 warm line callers over four years. "Warm line callers reported a reduction in the use of crisis services and a reduction of feelings of isolation. The results indicate that peer-run warm lines can fill an important void in the lives of individuals living with mental illnesses." The study concluded that warm lines staffed with appropriately trained and supervised, compensated peer specialists can help round out mental health services in rural and urban communities. Source: Sustaining Recovery through the Night: Impact of a Peer-Run Warm Line. Dalgin, R. S., Maline, S., & Driscoll, P. (2011). Psychiatric Rehabilitation Journal, 35(1), 65-68. http://dx.doi.org/10.2975/35.1.2011.65.68<http://psycnet.apa.org/doi/10.2975/35.1.2011.65.68> Peer Supported Crisis Stabilization Center Working with Dutchess County leadership and local community providers, PEOPle Inc has played a central role in the development of a pioneering Crisis Stabilization Center that has been dedicated to providing immediate assistance and relief to individuals with the most serious conditions and circumstances who have endured years of struggles with serious mental illnesses and addictions, homelessness and incarceration. Since its opening back in February of this year, the Stabilization Center has seen over 1,000 people to date. Over 400 guests have been by police officers directly to the center, preventing avoidable arrests and ED visits. Preliminary outcomes show a 17% reduction in ED visits. Suicide Prevention PEOPLe Inc's Steve Miccio is a co-founding member of the About the AFSP Hudson Valley chapter which focuses on eliminating the loss of life from suicide by delivering innovative prevention programs, educating the public about risk factors and warning signs, raising funds for suicide research and programs, and reaching out to those individuals who have lost someone to suicide. Peer Forensic Bridger and Community Drop In Programs Founded in 1988, Hands Across Long Island (HALI) has grown to serving almost 3,000 individuals a year in Suffolk County, NY. HALI is one of the first peer programs in the nation to develop a prison to community peer bridger program out of Sing Sing prison in Ossining, NY. The program engages participants in peer support groups 90 days before release, preparing individuals for re-entry and for what they can expect returning back into the community. They support returning ex-prisoners to successfully interact with parole, service providers, housing providers, and the community at large and to avoiding people, places and things that helped result in their incarceration. HALI also operates a Drop In Center in New York City that is aimed at reconnecting individuals with services and supports and to help them to avoid "falling through the cracks" of our behavioral health, social and criminal justice systems. 2016 program data indicates that of the 198 former individuals who received post-release services, 89% continued engagement and successfully lived in the community, 95% requested ongoing and additional assistance, 90% followed up with appointments, 82% had decreased police involvement, 93% saw decreased hospitalizations, 90% saw physical conditions improved and 84% either decreased or stopped historic drug/alcohol use. Source: HALI executive director Ellen Healion at ellen at hali88.org<mailto:ellen at hali88.org>. Peer Homeless Outreach and Linkage Initiative Most recently, HALI launched a mobile shower unit that has served 278 individuals since November 2016. Thanks to this 'on the ground' level of engagement, 92% engaged in the program, 73% requested assistance and 42% followed up with appointment, resulting in decreased police involvement, hospitalization, illness and drug/alcohol use. Peer Hospital Diversion Crisis Intervention Service Independent Living, Inc engaged 189 high needs individuals lasts years who were typically referred from hospital emergency departments, mobile crisis unit and local police departments. As a result of their work, 177 individuals who previously had high readmission rates, often within a few days, did not return to the hospital within 30 days, a 94% success rate that was verified by a 2015 survey by Health Forum, LLC, an affiliate of the American Hospital Association. For more details, contact executive director Doug Hovey at DHovey at myindependentliving.org<mailto:DHovey at myindependentliving.org>. Peer-run Supported Housing Housing Options Made Easy (HOME) in western New York operates a full line of community services, including supported housing, a multi-county recovery center, a peer bridger program, youth transitional program, peer-run short term crisis respites covering 3 counties, crisis warmlines, a community reintegration team and membership within local mobile transition teams. HOME currently operate over 400 supportive housing slots in 6 western NY counties and have helped 96% of individuals served to reduce behavioral health hospital admissions, 92% to reduce emergency room visits and 98% to stay in the housing of their choice for 6 months or more. For more details, contact HOME executive director Joseph Woodward at joe at housingoptions.org<mailto:joe at housingoptions.org>. Peer Respite Program A 2015 study found that the Second Story Santa Cruz peer program helped reduce serious relapses and the use of inpatient or emergency rooms by 70% and that people who used the respite program were 78% less likely than similar non-respite users to use inpatient and emergency services (Peer Respite Program on Use of Inpatient and Emergency Services Bevin Croft, M.A., M.P.P., and Nilüfer _ Isvan, Ph.D. Psychiatric Services in Advance, March 2, 2015). For more information, contact bcroft at hsri.org<mailto:bcroft at hsri.org>. Forensic Peer Specialist Services Peerstar Forensic Peer Specialist (FPSs) go into local Pennsylvania county jails 30 - 90 days prior to inmates' release and provide individualized peer support services to inmates in preparation for community re-entry. The FPS provides the inmate with mental and emotional support and mentorship, as well as personalized case management assistance and release planning. In some counties, the FPS may also provide group classes to inmates in the county jail. Upon the inmate's release from the jail, the FPS meets the former inmate at the exit and they attend the first Peerstar community appointment together. At the community appointment, the FPS helps perform an eligibility assessment for medical benefits and begins connecting the consumer to community-based services. Peerstar operates a peer support program in seven Pennsylvania county jails and recently obtained a contract to provide re-entry services in a state prison facility. A preliminary program evaluation recently performed by the Yale School of Medicine's Program for Recovery and Community Health found a reduction in recidivism amongst former county jail inmates with serious mental illness (SMI) who participated in Peerstar's re-entry program. The preliminary evaluation suggests that the reincarceration rate of 24% amongst Peerstar program participants is significantly lower than estimated rates for similar populations. Source: From Recidivism to Recovery: The Case for Peer Support in Texas Correctional Facilities by Megan Randall, randall at cppp.org and Katharine Ligon, ligon at cppp.org<mailto:ligon at cppp.org> August 2014. Peer Support with Dually Diagnosed Individuals A special peer social support program operated by the Mental Health Association of Southeastern Pennsylvania provides support to high-risk dually diagnosed clients. "A pilot study of 10 randomly selected clients in the study group, and 51 in the comparison group, who had been in community care 1 year prior to this investigation was carried out. Service was provided for a 6-month period. Findings suggest that coupling peer social support with intensive case management is associated with positive system outcomes. The number of crisis events of the comparison group far exceeded that of the study group. The number of hospitalizations was dramatically lower for the study group. Clients in the study group reported improved quality of life and perceived their physical and emotional well-being as improved over the course of the study. This pilot study indicates that peer support has a potential of improving system and clients' outcome; however, further replication is required. All eligible clients were severely mentally ill." Source: http://journals.sagepub.com/doi/abs/10.1177/104973159800800503 Peer Addiction Recover Support Groups Researchers identified ten studies that demonstrated associated benefits in the following areas: 1) substance use, 2) treatment engagement, 3) human immunodeficiency virus/hepatitis C virus risk behaviors, and 4) secondary substance-related behaviors such as craving and self-efficacy. Limitations were noted on the relative lack of rigorously tested empirical studies within the literature and inability to disentangle the effects of the group treatment that is often included as a component of other services Source: Benefits of peer support groups in the treatment of addiction, Kathlene Tracy and Samantha P Wallace. Subst Abuse Rehabil. 2016; 7: 143-154. Peer Mentors "A randomized controlled design was used, with follow-up at nine months after an index discharge from an academically affiliated psychiatric hospital. Patients were 18 years or older with major mental illness and had been hospitalized three or more times in the prior 18 months. Seventy-four patients were recruited, randomly assigned to usual care (N=36) or to a peer mentor plus usual care (N=38), and assessed at nine months. Results: Participants who were assigned a peer mentor had significantly fewer rehospitalizations (.89±1.35 versus 1.53±1.54; p=.042 [one-tailed]) and fewer hospital days (10.08±17.31 versus 19.08±21.63 days; p<.03, [one tailed]). Source: "Effectiveness of Peer Support in Reducing Readmissions of Persons With Multiple Psychiatric Hospitalizations" William H. Sledge, M.D., Martha Lawless, B.A., David Sells, Ph.D., Melissa Wieland, Ph.D., Maria J. O'Connell, Ph.D. and Larry Davidson, Ph.D.Psychiatric Services 62: 541-544, 2011 Peers in Health Homes "A health home is a person-centered model of care integrating long-term, acute, primary, and behavioral health care. The concept of the health home refers to the coordination of care that takes place on behalf of the person receiving services.Research suggests that health homes (also known as medical homes) improve patient health outcomes as well as reduce both health care costs and hospital readmission rates. Currently, 20 U.S. states have created a total of 29 Medicaid-approved health home models focusing on populations with chronic disease, serious emotional disturbance (SED), serious mental illness (SMI), and substance use disorders (SUD)." "Since Peer Support Specialists are an emerging part of the Texas mental health workforce, assisting people with SMI toward recovery, they can be utilized effectively in the type of health care setting identified by health homes. Peer Providers are equipped to support others in recovery based on their own lived experiences with serious mental illness, and have been utilized as providers of Medicaid-reimbursable health care services in Texas since 2004." Source: Health Homes and Peer Support Specialists in Texas, Texas Institute for Excellence in Mental Health According to "Peers in Behavioral Health Homes - Maine Quality Counts", our experience is that peers are an incredible work force: passionate, talented, compassionate and extremely effective in their work. Peer Work is extremely effective, and often is successful with situations and individuals that traditional approaches have had difficulty engaging. The development of Behavioral Health Homes will provide an unprecedented opportunity to expand the Peer work force, and we are excited by that possibility. Source: https://www.mainequalitycounts.org/image_upload/Peers%20in%20Behavioral%20Health%20Homes%20v2.pdf Healthcare Reform Health homes are a part of the national healthcare reform trends that prioritize value over volume, e.g. outcomes over visits to practitioners and programs. With their expertise in engaging and supporting individuals in the greatest need, peer wellness coaches are beginning to play a major role in the emerging value based reimbursement-based systems of care. NYAPRS subcontracted with a behavioral health organization in a precursor to the health homes in New York, the Chronic Illness Demonstration Project. As one example of our work, our coach was able to engage a 37 year old man with major addiction and mood related conditions as well as kidney disease. She provided daily support for an extended period of time, support that helped him to reduce his relapse and 7 admissions to detox facilities to one in the year she worked with him, and reducing the Medicaid spend from $ $52,282 to $20,650. I greatly hope that this overview emphasizes how committed peer run agencies and services are to helping Americans with the greatest intensity and frequency of need and that the evidence included here substantiates their groundbreaking impact on people, families, communities and state mental health systems. I'd like to offer 2 recommendations to the Committee: 1. There is far too little research that examines the effectiveness of in peer mental health and addiction recovery programs. Accordingly, HHS/SAMHSA must invest in research to evaluate their capability to help our most needy. 2. In addition, HHS/SAMHSA should provide expanded funding for peer services of the kind referenced above: peer services that are expected and incentivized to help reduce avoidable relapses and readmissions, incarceration, homelessness and suicide. Finally, I'd like to emphasize how important it is for Committee members to personally visit programs of this kind and to interview at risk and/or unengaged individuals, their families, community providers and state behavioral health and Medicaid officials about their quality and impact. I would greatly enjoy helping to facilitate these connections and visits. In succeeding letters, I will provide similar information about a range of psychiatric rehabilitation programs that span a full variety of approaches, settings and localities. In the meantime, please feel free to contact me at any time at harveyr at nyaprs.org<mailto:harveyr at nyaprs.org> or via my cell phone, 518-527-0564.