The Evolving Future of Peer Support Services: A Role for the ACMHA Peer Leadership Group?

1. The Evolving Future of Peer Support Services: A Role for the ACMHA Peer Leadership Group? Allen S. Daniels, Ed.D March, 2014

2. A Role (Cultivating Leaders, Fostering Innovation) for the ACMHA Peer Leadership Group? • Three Potential Areas of focus for ACMHA: 1. Promoting a research agenda to expand the evidence base for Peer Support Services*. 2. Developing a clinical practice agenda to better integrate PSS within the expanding provider roles for engagement and activation in all health services. Focusing on: common training and core competencies; standards and scope of practice, and licensing and certification for all “self-care/self-management advocacy” providers. 3**. Fostering an agenda for sustainable payment and reimbursement for these services in an era of expanding health services integration and managed care. * Note for the purpose of this presentation the term peer support services is used and intended to include peers working in the adult mental health, addictions, and family support services areas ** The principle focus of this presentation

3. Six Fundamental Assumptions The delivery and payment for health care services are rapidly evolving and: • Health services are increasingly being delivered in integrated systems of care (ACOs) and team based provider systems (PCMH, FQHC, other). • Treatment for behavioral health conditions are increasingly being coordinated or integrated with primary care. • Medicaid and Medicare are expanding the use of managed care vehicles to improve quality and control costs. • Over time - Commercial insurance, State Exchanges, and Medicaid and Medicare plans will have greater similarity in form and operations. • Models of reimbursement are shifting to population based outcomes and risk. • Peer Support Services (intentional and professionally delivered) are fundamentally health services, and there is a distinct and emerging role for self-care/self-management advocates in the engagement, activation, and ongoing care for those with chronic illnesses. These include Community Health Workers (CHW) in general health care and Peer Support Specialists (PSS) in specialty behavioral health.

4. Trends in Health Care Delivery Past/Present Present/Future The ongoing proliferation of Information Technology (EMR, care coordination tools and registries, population health management systems, etc.) Era The Era of Health Systems Integration The evolution of Science (personalized medicine), Technology (Google Glass), and Evidence (rigor for what works) Era The Era of Self-care/Self-management Advocacy and the evolution or extinction of the behavioral health Peer Specialist • The Doctor/Patient Era • The emergence of Health Insurance and 3rd party reimbursement for health services Era • The influence of Managed Care (quality, cost, and accountability) for health services Era • The Era of Health Reform and expanded coverage and services • The evolution of Peer Support - from friend to a professional health service and recovery Era

5. Health Care Financing Trends Past/Present Present/Future 74.2% of Medicaid lives are covered in managed care plans (KFF, 2011) Expanded Coverage through managed care plans (eligibility, benefits, and limits on exclusions) and subsidies to support coverage through ACA Support for provider systems improvement, integration (Health Homes, Accountable Care Orgs, etc.), and population health and outcomes based financing models • Late 1930’s/Early 40’s – Health insurance established as employee benefit and tax exemption for premiums • Mid 1960’s – Establishment of Medicaid and Medicare – Government enters health care business • 1974 – Nixon Administration initiates managed care through HMO act and mandates health plan choices • 2007 Medicaid Letter issued supporting Peer Support Services • 2010 – 2014 (+) enactment of the Patient Protection and Affordable Care Act

6. Health Insurance Literacy – How Many of These Terms Can You Define? 11. NCQA 12. Utilization Review 13. Medical Loss Ratio 14. ERISA Exempt Self-Funded Plan - 15. Deductible 16. Co-payment 17. UCR – Usual, customary, and reasonable 18. Open enrollment 19. HMO/PPO/POS 20. Secondary coverage • Covered Benefit - • Medical Necessity - • Provider Credentialing - • CPT/HCPS Codes • DSM/ICD Coding • Level of Care Determination - • Certificate of Coverage/Summary Plan Description - • New/Emerging Technology Review - • HEDIS Metric/ Quality Metrics - • In/Out of Network Provider -

7. 10 Key Challenges for the Reimbursement of Peer Support Services In Managed Care • Are Peer Services Covered Benefitsin the Certificate of Coverage/Summary Plan Description? • Are Peer Services considered Emerging Technologies and can they pass the managed care plan’s evidence review? • Can Peer Specialists be Credentialed as independent providers and included in Provider Networks? • How is Medical Necessitydetermined for peer services? • What are the appropriate Level of Care Guidelinesfor Peer Support Services? • Can Peer Specialists determine a diagnosis and establish a DSM/ICD Code in order to bill for services? • What are the appropriate CPT/HPCS Codes for Peer Support Services and can payer claims systems accept/adjudicate these codes. • What are the appropriate Quality Metrics that should be considered to evaluate the process and outcome of Peer Support Services? • What is the likelihood that managed care plans will voluntarily change/adapt to incorporate Peer Support Services into their standard operations? • If Integrated systems of care become the norm; are there different roles for Peer Support Specialists (PSS) and Community Health Workers (CHW) in these clinical service systems?

8. Next Steps and Opportunities for ACMHA?? Questions? Additional Information: allenSdaniels@gmail.com

9. The ACA is promoting integrated systems of care –Are there opportunities for Peer Support Services?Opportunities and Competitionor… Partner or Perish

10. Six Models of Community Health Workers (HRSA, 2011) Core activities among these different role descriptions include: • Creating more effective linkages between vulnerable populations and the health care system; • Managing care and care transitions for vulnerable populations; • Ensuring cultural competence among health care professionals serving vulnerable populations; • Providing culturally appropriate health education on topics related to chronic disease prevention, physical activity and nutrition, and cultural competence; • Advocating for underserved individuals to receive appropriate services; • Providing informal counseling; and • Building community capacity to address health issues

11. Sample CHW Training and Certification Programs Sample Range = < 6 hours to 14 Credit Certificate Program Daniels, 2013

12. The Chronic Care Model andThe Chronic Care Model for Mental Health and Addictions Daniels et al., 2009 Shifting service models are supporting team based care (ACO/PCMH), and the integration of care for mental health and substance use conditions Integrated Systems of Care are increasingly using CHWs to support community outreach, engagement, and activation

13. Need for “Peer-ness” in Self-Care Advocacy high High Trauma and Lower Stigma DX Examples: Life threatening/life altering physical Illness (serious physical illness, cancer) Need for Peer Support: High Need for Community Health Worker: Moderate High Stigma and High Trauma DX Examples: SMI/SED (bipolar, Psychotic disorders) Addictions Co-morbid mental and chronic physical conditions (life threatening/life altering illness) Need for Peer Support: High Need for Community Health Worker: Moderate - High Experience of Trauma Related to Diagnosis Lower Stigma and Lower Trauma DX Examples: Chronic Physical Conditions (including asthma, diabetes, hypertension) Mild/transient behavioral health & psychosocial condition Need for Community Health Worker: Moderate - High Need for Peer Support: Low - Moderate High Stigma and Lower Trauma DX Examples: Depression/anxiety/other mood SUD Co-morbid mental and physical Need for Peer Support: High Need for Community Health Worker: Moderate Note: Trauma related to DX = the extent to which the receipt of a diagnosis leads the patient to an “oh crap” moment – this is really serious! low Experience of Stigma and DisenfranchisementRelated to Diagnosis Daniels - Oct, 2013 low high