National Networking Teleconference

Hosted by the National Mental Health Consumers’ Self-Help Clearinghouse May 20, 2014, 8 p.m. ET

Minutes (Please note the hyperlinks within the minutes for more information.)

Participants: CA (2), CO (1), GA (1), IL (1), ME (2), MD (1), MA (1), NH (1), NY (1), NC (1), OK (1), Pennsylvania (4), WI (1) AGENDA: This call was devoted to the topic of peer specialists, and included a presentation by Joseph Rogers followed by a Q&A session. If anything crucial has been omitted or if there are any errors, please contact Susan Rogers at srogers@mhasp.org. Note: This is not a verbatim transcript. Peer Specialists Joseph Rogers, executive director of the National Mental Health Consumers’ Self-Help Clearinghouse – the sponsor of these monthly national networking teleconferences – began with a presentation on peer workers/peer specialists/people who work as peers, both in Pennsylvania and around the country. Joseph said, “I understand that some people don’t like the terms ‘peer’ or ‘peer specialist,’ but that’s what the states are calling people who are working in such positions, particularly those who receive Medicaid reimbursement to work in self-help/mutual support activities.” What follows is Joseph’s presentation, including Q&A.

The first state that organized and got funding through Medicaid for peer-to-peer activities was Georgia. (Click here.) They are the ones who came up with the term “peer specialists.” Previously, many states and localities had activities such as mutual support/consumer-run services/recovery centers, run by and for people who are labeled or diagnosed with mental illnesses. But, in most states, the funding came through a contractual relationship with the state and the local government. In fact, many people preferred that model over the fee-for-service model you have with Medicaid, because there is some controversy over programs that become Medicaid-reimbursable because they are then part of a whole medical system of care. You have to do billing and a lot of paperwork. In Pennsylvania, we had developed peer-to-peer programs: programs run by and for people in recovery, people who are survivors of the psychiatric system. This June, we will be celebrating 30 years in Philadelphia of our first efforts in organizing such programs. Our first efforts were to organize advocacy/mutual support. We eventually opened centers where we would provide mutual support/self-help groups and activities along the lines of the Alcoholics Anonymous model of mutual support. We then advocated and got funding for what has become to be known as peer specialist programs. That is a Medicaid designation; states are allowed to call the program something different, but that is what Medicaid called the programs. In Pennsylvania, there is a two-week training and certification process for someone to become certified as a peer specialist.

From a Pennsylvania website: “On February 22, 2007, the Centers for Medicare and Medicaid Services (CMS) approved Pennsylvania’s Medicaid State Plan Amendment to include Peer Support Services as a component of rehabilitative services. This was accomplished through a broad partnership of individuals and organizations.” (For more information, click here.) The Mental Health Association of Southeastern Pennsylvania (MHASP) had a peer-to-peer program called The Friends Connection, established in 1989, which was very successful in working with people who had a mental health and substance abuse diagnosis. (The Friends Connection ceased operations a couple of years ago.) [Another model program operated by MHASP with peer specialists is the Consumer Recovery Investment Funds Self-Directed Care program. For more information, click here.] To get funding for a reimbursable, fee-for-service, peer-to-peer program, you need a Medicaid waiver. There are various kinds of waivers, and you can modify your existing waiver. Each period, the state has to submit a plan to CMS about how they are going to provide Medicaid services. There are mandated Medicaid services that each state must provide in order to receive the federal Medicaid dollars. There are a certain number of services that are required under the federal Medicaid program in mental health or behavioral health (which also now includes substance abuse), and those programs can add on additional services. With its Medicaid dollars, a state can decide to create additional services. So that’s the waiver process: that’s changing the plan to a waiver that allows the state to provide other services besides the mandated services. There has to be a stated purpose for the state to do that. It has to be demonstrated that it will meet some of the central goals of Medicaid, such as helping people live healthy and more integrated lives. One of the things Medicaid has emphasized is moving people away from institutions to the community. So if your state wants to do peer-to-peer services, they need to demonstrate that that is what they are doing. Now, according to Inside Health Policy – “Peer-Support Specialists Gain Funding and Ground in Medicaid Programs,” Jan. 22, 2014 – “[t]hirty-five state Medicaid programs have expanded to reimburse peer-support specialists since 2001, which experts in the mental and substance abuse fields say is a sea-tide of change that could eventually result in validation and creation of a profession that fits well with accountable care organizations and the push for value-based purchasing. The experts say there is enough data to make the case for a federal program to expand peer support programs, even into the duals demonstrations, and suggest expanding peer specialists' role could be a huge cost saver and a potential add-on to a deficit reduction bill.” In most states there are variations on two models for provision of peer-to-peer services. One model is a stand-alone model of an independent program run by and for peers (people with psychiatric lived experience). Most states want to use that model. Information on how

often they do it is spotty because, with the Medicaid fee-for-service model, there are lots of requirements in terms of billing for units for service. Units of service are 15 minutes, and you have to do a lot of documentation. A lot of peer-run programs find that difficult. Another way is for peer programs to be providing peer support services in conjunction with other kinds of programs within a mental health agency. In Philadelphia we have a lot of programs for people who have been homeless for a long time. Early on, they wanted to include a lot of mutual support activities, so they heavily funded people [to provide peer support] within each team in the Housing First model. Those are the two models that there is an opportunity to look at, and I would urge the California folks or the folks in any other state to get ahead of the game. It’s the wave of the future. I would urge people to ask what planning is going on and how they are involving people with lived experience in the planning. You can shape how the program looks, what its ethos is, what its priorities are. There are limitations because there are Medicaid standards, but we were able to create a lot more of a recovery approach and where the peer worker would work much more on a self-directed-care basis, where the person really gets a chance to direct what the service looks like according to what they need. It’s a mixed bag: You are working in the mental health system for the most part. Even if you are operating a stand-alone program, you are under the mental health system. So there are risks in regard to how you create a program based on the values of recovery and hope. Even if you already have a program, it’s not too late because programs can be modified and new regulations can be created. I have seen states that started out with one kind of program and people weren’t happy with it, and they advocated and changed some of the values of the program. But it still involves working within the mental health system, so there are definite issues. That’s why, in some states, like California, there has been controversy. Now I would like to throw the discussion open for questions.

The questions below are digested from the remarks of teleconference participants, with responses from Joseph Rogers (JR): Q: What do you do when certified peer specialists are not given duties consistent with what they were trained for? JR: That is a big issue in Pennsylvania and in other states. In Pennsylvania, what we did to address that – and I think we have done a pretty good job – is that we created model job descriptions (see below for one such description) so that Human Resources departments could just adopt the job descriptions. (For “Results from a National Survey of Certified Peer Specialist Job Titles and Job Descriptions,” click here.) In Pennsylvania, we have gotten a PROMISe number that licenses you to be a peer specialist program and do third party billing. To get that PROMISe number, you have to do a detailed description of the work that the peer specialist will be doing, and that has to go through a committee to be approved. Then you get re-licensed and re-certified as a program because your program’s PROMISe number is renewed every couple of years. They come in and review what your program is doing; they review your

program notes. There is a lot of strict monitoring because, in the third-party-billing world, whether it is case management or any other kind of program, Medicaid is strict. You can’t say you’re going to bill for one thing and have the person doing something else. For example, there was a problem involving certified peer specialists being used as transportation agents. That’s monitored and, if that is what it looks like your program is doing, you will lose your license and your PROMISe number. You can bring it under any kind of funding, such as California’s Mental Health Services Act. I urge people, when they talk about it in their state, to look at the experiences of some other states. People have learned some lessons. Q: In California, we get Mental Health Services Act (MHSA) funding so a lot of our programs that are peer supported are through MHSA. . . . But they require so much licensing and you have to have the schooling for these positions. And, unfortunately, a lot of peers do not have those kinds of licenses and they are not helping with the funding to get those licenses. JR: These are common issues. In Pennsylvania we require a high school diploma. We don’t require advanced education for peer specialists other than peer specialist certification training. And it’s not a requirement of Medicaid that the person have a bachelor’s degree. So if they are requiring that, that is something they have come up with locally or statewide. It’s not a federal requirement that a person needs a bachelor’s degree to be a certified peer specialist and for that position to be reimbursed by Medicaid. The state is required to establish some sort of training – and the state has a lot of flexibility in regard to that training – and the state is required to have some sort of certification program. I know that, in some states, the training program has to be based in a college. Again, that’s a state decision, not a federal decision. Q: In Maine . . . they are using Shery Mead’s Intentional Peer Support model. I would have liked them to blend that model with the Amistad model; I believe that would have made a more consumer-friendly model. In central Maine, there are a lot of people who are homeless, and many people don’t want to have anything to do with peer specialists at all. But there are many people who aren’t using mental health services who still need the advantage of having peers talk with them and connect with them. JR: One of the things we have advocated for with a certain success, at least in Pennsylvania, is to continue funding to the non-Medicaid-reimbursed programs. We are a county-based system so it varies from county to county, and there were a series of budget cuts and we have lost ground on that, but we really fought for the continued funding of what we call consumer centers, now called recovery centers. The people running those programs and providing support and advocacy and mutual support groups did not necessarily have to be certified peer specialists (CPS). Some centers opted to work toward getting CPS so that they could fund on the program level as well as on the reimbursed level. We have about 60 of these peer/survivor-operated programs, and they provide a lot of the non-certified work, people who have not necessarily gone through a certification program. We also find that programs specializing in homeless outreach employ people who have been homeless themselves. They can be peer workers and, because we are in a managed care state, the case rate can be such that the system, whatever the program is, can afford to hire these folks and not necessarily have them be CPS because they can work as peer workers without the certification. Q: When you talked about the committee that approved the job duties, in regard to the PROMISe number, was that made up of peers?

JR: Yes, there are peers on the committee; they work for the Department. There is a peer review. All of the procedures and manuals were developed in consultation with our peer consumer/survivor network and with us in our work here in Philadelphia. The standards were set by a collective approach. The programs individually, because of the state licensing model, they just don’t have the money. I think that would be wonderful and if I could make it different in Pennsylvania I would require that there be peers on the licensing review teams, but they don’t do that. But the standards that they are using for review were set by people with lived experience, both inside and outside the government. Q: I think that would be a great idea because one of the problems we’re having right now in Maine is that agencies are just trying to figure things out as they go along and trying to do a lot of it on their own without any assistance or input from peers on the job duties. So some of these places are hiring peers to do transportation or expecting them to do case management kinds of duties, and it’s not in line with the principles of Intentional Peer Support. So it would be great to have a committee that would go around and evaluate the programs. JR: One of the things we did develop in Pennsylvania is what we call “Consumer Satisfaction Teams,” which are peer teams, consumer/survivor teams, that review every program in a county, both peer and non-peer. So this is an opportunity to get peer input into what’s going on. Is the peer helpful? Is the peer doing things I need help for? Is it really self-directed? So that’s another layer we have. Q: Are there any consequences for the agency if they don’t pass the inspection? JR: They lose the ability to do third-party billing. Q: I’m a peer specialist with Magellan. What we are looking for [in reviewing peer programs] is that the peer [participant] has a clear goal, is learning skills to get to the goal, and has action steps to take. Also, that they are developing a social support system that includes friends and possibly family outreach. And all the normal things you would normally look for in charts, diagnosis code, etc. JR: That’s the Magellan review, not the state review. That’s interesting to point out: Our peer programs not only get reviewed by the state, they get reviewed by the managed care organization, and in Magellan’s case they are using peer support-type people to do the review. Q: One concern I have is that, when they do evaluations on the peer workers, it is the director of the program who is doing the evaluations. But our notes are not given to the director unless we hand-deliver them, because we are not honored on the same level as paid staff. JR: I would be happy to talk more about ways that you might advocate around some of those issues. It sounds like you have a complex set of issues. Q: Why is Pennsylvania’s system county-based and not statewide? JR: We’re called a home rule charter state. A lot of the sovereign power of the state is given to the counties. The counties administer all of our mental health or behavioral health programs. The state is more of a granting and licensing entity; it doesn’t run programs. It’s a Pennsylvania model that probably goes back to the way Quakers wanted to do things – probably in the 1600s.

Q: In Colorado, the state has a hands-off position. They leave it to private enterprise, as in the managed care organizations, to do whatever they want. Then the individual behavioral health organizations do whatever they want, and they do the bare minimum to get Medicaid dollars. It’s very much a competitive private enterprise model, with no continuity. Q: In California and especially in Los Angeles, we’re trying to tie mental health and physical health care together to create an information flow between the medical doctors and mental health doctors for a continuum of care. Note: Joseph Rogers is available to provide additional information by email or phone. To contact Joseph Rogers: jrogers@mhasp.org, 800-553-4539, ext. 3844. Susan Rogers can be reached at srogers@mhasp.org or 800-553-4539, ext. 3812. Joseph’s assistant, Britani Nestel, can be reached at bnestel@mhasp.org, 800-553-4539, ext. 3845. JR: Thank you for having me as your guest speaker. Again, we at the Clearinghouse are very interested in helping people with these issues. I think it is especially a challenge to do Medicaid-reimbursed third-party payment, whether it involves MCOs and even with the state involved. It can depend on the MCO; it can depend on the way the state is contracted with the MCO. In Pennsylvania, the counties are the main entity that contracts with the MCOs, so they have a lot of oversight. It is a struggle, and we’re happy to talk with you about lessons we have learned in our state and around the country. And thanks so much for being on the call. Alternatives 2014: We are in the planning stages and we are going to be sending out a call for presentations by the beginning of June. We have a theme, created through a survey monkey process: Creating the Future: Change, Challenge, Opportunity. At this point, it was necessary to adjourn the call because time had run out. Joseph Rogers invited anyone with additional questions to contact him and said he would be happy to provide technical assistance. Next teleconference: The next networking and technical assistance teleconference will take place on Monday, June 16, 2014, at 1 p.m. ET, noon CT, 11 a.m. MT, 5 p.m. PT. The call-in number is 866-906-0123. The passcode is 5037195#. Respectfully submitted by Susan Rogers (Please see below for a CPS job description.) Certified Peer Specialist Job Description Purpose: The Certified Peer Specialist (CPS) facilitates the development of recovery skills of individuals enrolled in the service. In collaboration with the team and the individual in recovery, their purpose is to provide opportunities for individuals in service to direct their own recovery plan, build self worth and wellness, and build a meaningful life/role in the community. The CPS teaches and supports the acquisition and utilization of skills needed to facilitate an individual’s recovery. They promote the knowledge of and use of available service options and the utilization of community resources. The CPS

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will promote and contribute to the development of a culture of recovery and peer support within the program and the agency as a whole. Supervision Received: Reports to Program Supervisor. Works under close supervision in carrying out specific duties. Supervision Exercised: N/A Qualifications: High school diploma or GED, and Peer Specialist Certification required which must be maintained. A total of 12 months’ – full or part time, paid or volunteer – work experience within the last three years required; one year of college, or other educational experience within the last three years, can be substituted for the work experience. Demonstrated proficiency in reading and writing. Ability to establish positive relationships with peers enrolled in service. Ability to teach daily living skills. Good knowledge of City’s public transit system required; valid driver’s license with acceptable driving record a plus. An ability to use a Personal Computer preferred; willingness to learn required. Certified WRAP Facilitator Preferred Physical Requirements/Working Conditions: Light work requiring considerable moving about or may involve light lifting or carrying, not usually sustained. Frequent local travel using public transportation. Frequent stair climbing, walking within the community in weather conditions including heat, cold and inclement weather. Ability to work a flexible schedule. Duties: Attends and participates in team meetings and case conferences providing feedback to the team about program members, their perspective; utilizes input from meetings to work effectively with individuals. Welcomes newly admitted individuals and assists in their orientation to the program by sharing information on expectations, program structure and opportunities. Meets with individuals and appropriately engages them to identify their interests, goals and aspirations; provides support to individuals towards achieving their life goals. Provides support in the completion of Recovery Self-Assessment tools, Community Participation tools and Quality of Life Scales, as needed. Serves as a role model. Willingly shares personal experience with people In recovery, their families and staff by demonstrating that recovery is possible. Assists in the development of a culture of recovery and peer support. Assists individuals in identifying community resources that support their goals to have a meaningful role in the community. Co-facilitates recovery education for people enrolled in and working in the program; facilitates Wellness Recovery Action Plan (WRAP) and self-help/mutual support groups for individuals in the program.

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Accompanies and supports program members in community and site based social, recreational, educational, occupational and advocacy activities to achieve personal recovery goals. Supports individuals in the development and implementation of their transition plans including from one service to another. Provides support for peers in crisis by listening, giving encouragement and advocating on behalf of the individual. Participates and provides input in the recruitment, interview and selection of program staff.

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