Do Peer Support Services Work? How and Why Allen Daniels And - - PDF document

Allen Daniels / Peter Ashenden 10/13/2014 iNAPS Conference Atlanta 1

Do Peer Support Services Work? How and Why

Allen Daniels And Peter Ashenden

Do Peer Support Services Work? How and Why

• Introductions and Overview – A view from the field - Peter
• A review of the evidence – Allen
• Final thoughts and discussion - Peter

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Do Peer Support Services Work?

• 1. A review of the Scientific Literature
• An evidence Review of Peer Support Services
• 2. A Quick Lesson on Scientific Methods – for those that may have

been disinterested or asleep in science class… Or, What does a 50% chance of rain really mean?

• 3. A Strong Evidence Base for Why Peer Support Services Do Work
• 4. Challenges for the Peer Support Services Field in the Evolving

Landscape of Integrated Health Care

A B S T R A C T Background - In mental health services, the past several decades has seen a slow but steady trend towards employment of past or present consumers of the service to work alongside mental health professionals in providing services. However the effects of this employment on clients (service recipients) and services has remained unclear. We conducted a systematic review of randomised trials assessing the effects of employing consumers of mental health services as providers of mental health services to clients. The consumer- provider’s role can encompass peer support, coaching, advocacy, case management or outreach, crisis worker or assertive community treatment worker, or providing social support programmes. Authors’ conclusions Involving consumer-providers in mental health teams results in psychosocial, mental health symptom and service use outcomes for clients that were no better or worse than those achieved by professionals employed in similar roles, particularly for case management services. There is low quality evidence that involving consumer-providers in mental health teams results in a small reduction in clients’ use of crisis or emergency services. The overall quality of the evidence is moderate to low. There is no evidence of harm associated with involving consumer-providers in mental health teams.

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Results: The level of evidence for each type of peer support service was moderate. Many studies had methodological shortcomings, and outcome measures varied. The effectiveness varied by service type. Across the range of methodological rigor, a majority of studies of two service types— peers added and peers delivering curricula—showed some improvement favoring

• peers. Compared with professional staff, peers were better able

to reduce inpatient use and improve a range of recovery

• utcomes, although one study found a negative impact.

Effectiveness of peers in existing clinical roles was mixed. Conclusions: Peer support services have demonstrated many notable outcomes. However, studies that better differentiate the contributions of the peer role and are conducted with greater specificity, consistency, and rigor would strengthen the evidence.

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Findings - Although scarce in the literature, the few experimental trials show that at the very least, PSWs do not make any difference to mental health outcomes of people using services. When a broader range of studies are taken into account, the benefits of PSW become more apparent. What PSWs appear to be able to do more successfully than professionally qualified staff is promote hope and belief in the possibility of recovery; empowerment and increased self-esteem, self-efficacy and self-management of difficulties and social inclusion, engagement and increased social networks. It is just these outcomes that people with lived experience have associated with their own recovery; indeed these have been proposed as the central tenets of recovery: hope, control/agency and opportunity. In addition, employment as a PSW brings benefits for the PSWs themselves in every reported evaluation.

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Part 2

A Quick Lesson on Scientific Methods – for those that may have been disinterested or asleep in science class – Or, tools to evaluate the research on peer support services And, What does a 50% chance of rain really mean?

What is a Randomized Controlled Trial?

A Randomized Controlled Trial is the gold standard in scientific research, and is study in which people are allocated at random to receive one of several interventions

Trial Participants Experimental Group Receives New/Test Intervention Control Group can be: Conventional Practice; No Intervention; or, Placebo

Result = Does the new intervention out perform treatment as usual, no intervention, or placebo

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Source: BMJ VOLUME 327 20–27 DECEMBER 2003

More Science - Do Parachutes Really Work?

Franz Reichelt AUSTRIAN-FRENCH TAILOR AND INVENTOR DIED (1912) AFTER HE TRIED USING ONE OF HIS SELF-MADE PARACHUTING DEVICES TO JUMP OFF the EIFFEL TOWER in PARIS

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Parachute use to prevent death and major trauma Parachute use to prevent death and major trauma Parachute use to prevent death and major trauma Parachute use to prevent death and major trauma related to related to related to related to gravitational challenge: systematic review gravitational challenge: systematic review gravitational challenge: systematic review gravitational challenge: systematic review of randomized

• f randomized
• f randomized
• f randomized

controlled controlled controlled controlled trials trials trials trials Gordon C S Smith, Jill P Pell, BMJ

BMJ BMJ BMJ 2003;327:1459 2003;327:1459 2003;327:1459 2003;327:1459– – – –61 61 61 61

Abstract Objectives To determine whether parachutes are effective in preventing major trauma related to gravitational challenge. Design Systematic review of randomized controlled trials. Data sources: Medline,Web of Science, Embase, and the Cochrane Library databases; appropriate internet sites and citation lists. Study selection: Studies showing the effects of using a parachute during free fall. Main outcome measure Death or major trauma, defined as an injury severity score > 15. Results We were unable to identify any randomized controlled trials of parachute intervention. Conclusions As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomized controlled

• trials. Advocates of evidence based medicine have criticized the adoption of interventions

evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organized and participated in a double blind, randomized, placebo controlled, crossover trial of the parachute.

How Science Really Works

So, What Does a 50% Chance Of Rain really Mean?

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Part 3 - How Peer Support Services Work: What Peer Specialists do to Foster Recovery

Fricks and Powell in Daniels et al, 2012

Stage 1 - Being overwhelmed by the disabling power of the illness

The Peer Specialist Role – Decreasing the emotional distress by reducing the impact of symptoms:

• The role of the Peer Specialist is to help understand the illness and
• pportunities for improvement
• Knowledge is Power – and the disabling power of the illness is
• vercome through improved health literacy

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Health Literacy

• AMA – defines health literacy as, “The constellation of skills, including the

ability to perform basic reading and numeral tasks required to function in the health care environment” (AMA, 1999).

• Consumers of health care services must employ print literacy (writing and

reading); oral literacy (listening and speaking); and numeracy (using and understanding numbers, such as medication doses) Koh et al (2012) .

• Increasingly, definitions of health literacy include: individual skills (e.g.,

abilities); processes (e.g., informed decision making); outcomes (e.g., good health, quality of life); and social and political contexts in which these processes and outcomes reside (e.g., health promotion, disease prevention) Sørensen et al., (2012).

A Framework for Improved Mental Health Literacy

Canadian Institute of Mental Illness and Mental Health (CAMIMH 2007) model for improving mental health literacy is based on Nutbeam’s (2000) framework. Peer support and self-help initiatives enhance critical mental health literacy by building social capital and supporting collective empowerment.

• Functional literacy is enhanced by improving general health literacy. The results is

increased capacity to understand mental health risks and available services, and supports integration of general and mental health literacy. Providers must asses and be aware of those with low health literacy and adopt a “universal precautions” approach (per: Koh et al., 2013). Providers should assume that all individuals are at risk of not fully understanding information relevant to maintaining and improving their health.

• Interactive literacy is enhanced by attention to personal skill building and knowledge.

This results in increased ability to act on knowledge and make informed choices. Mental health providers can promote interactive literacy by fostering person-centered care and informed decision-making.

• Critical literacy is enhanced by improving the capacity to use information for mobilizing

individual, social, and political actions. This results in benefits to mental health at a population level.

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Health Literacy – – – – a view from the research a view from the research a view from the research a view from the research

• According to the National Assessment of Adult Literacy (NAAL) – 14%
• f adults have below basic health literacy and an additional 22% have
• nly a basic level of health literacy (Kutner, Greenberg, Jin, and

Paulsen, 2006).

• Among community mental health center service users (46%) have low

levels of health literacy (Krishan et al 2012). And, within this group an association between low health literacy and a history of medical inpatient hospitalization is common.

• One-third (36%) of American adults—87 million people—are

considered functionally illiterate (i.e., cannot read or write) (Vernon, Trujillo, Rosenbaum, and DeBuono, 2007).

Peer Specialists Improve Health Literacy and Support Recovery – – – – a view from the research a view from the research a view from the research a view from the research

• Low health literacy has been associated with poor health outcomes,

and low health literacy is associated with higher mortality rates among elderly adults (Koh et al., 2012)

• Individuals with low health literacy are less likely to use preventive

services and to self-manage their conditions; use more emergency based care and unnecessary hospitalizations; results in poorer health

• utcomes; and increased health care costs (U.S. Department of

Health and Human Services, 2010)

• Health literacy disproportionately impacts minority and lower

socioeconomic groups and exacerbates health disparities (HHS, 2010)

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Stage 2 – Feeling that Life Will Never be the Same Again

The Peer Specialist Role – Instil hope, a sense of possibility and rebuild self-image

• The role of the Peer Specialist is to build on the strength of individuals
• Determination is the key to successful outcomes – and defined in the

educational field as Grit

Grit – a Powerful Predictor of Individual’s Success

Common Tasks Promoted By the Peer Specialist? Common Tasks Promoted By the Peer Specialist? Common Tasks Promoted By the Peer Specialist? Common Tasks Promoted By the Peer Specialist?

Research define grit as: perseverance and passion for long-term goals As a trait, grit has better predictability for success than IQ. The attributes/building blocks of grit include:

• A clear goal
• Determination despite others' doubts
• Self-confidence about figuring it out
• Humility about knowing it doesn't

come easy

• Persistence despite fear
• Patience to handle the small obstacles

that obscure the path

• A code of ethics to live by
• Flexibility in the face of roadblocks
• A capacity for human connection and

collaboration

• A recognition that accepting help does

not equate to weakness

• A focus and appreciation of each step

in the journey

• An appreciation of other people's grit
• A loyalty that never sacrifices

connections along the way

• An inner strength to help propel you

to your goal

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Peer Specialists Improve Grit and Support Recovery – a view from the research a view from the research a view from the research a view from the research

• “Gritty individuals are tortoise-like, distinguished by their propensity to maintain ‘effort and

interest over years despite failure, adversity, and plateaus in progress’ (Duckworth, Peterson, Matthews, & Kelly, 2007). Less gritty individuals are, in contrast, more easily discouraged, prone to take ‘naps’ mid-course, and frequently led off track by new passions.” (“True Grit,” Association for Psychological Science Observer, vol. 26, no. 4, April 2013) Some of the characteristics of individuals with grit include:

• They have had more opportunities to develop a resilient approach to failure and setbacks

(which explains why many people get grittier with age and experience);

• They have a growing appreciation of the efficacy and rewards of long-term effort; and
• They self-motivate in deliberate practice, or more hours engaging in activities designed

to improve performance.

• Another possible trait being explored in continued studies of grit includes people possessing

an “optimistic explanatory style,” or those viewing challenges and setbacks as opportunities rather than resigning to a failure.

Peer Specialists Improve Grit and Support Recovery – a view from the research a view from the research a view from the research a view from the research

• Across four studies, grittier individuals were less likely to drop out of

their respective life commitments:

• Grittier soldiers were more likely to complete an Army Special

Operations Forces (ARSOF) selection course (Study 1);

• Grittier sales employees were more likely to keep their jobs(Study 2);
• Grittier students were more likely to graduate from high school (Study

3); and,

• Grittier men were more likely to stay married (Study 4).

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Stage 3 – Recognizing that Change is Possible and Life can be Different

The Peer Specialist Role – Empower the person to participate in their

• wn recovery by beginning to take small steps
• Engagement is the first step in illness management and recovery
• A journey of 1,000 miles begins with a single step (Lao-tzu 604 BC –

531 BC)

The Peer Specialist Role The Peer Specialist Role The Peer Specialist Role The Peer Specialist Role – – – – Empowering Empowering Empowering Empowering the the the the person to person to person to person to engage engage engage engage in their own recovery in their own recovery in their own recovery in their own recovery

• Patient engagement in health care has been termed the “blockbuster

drug of the century,” with the potential to transform the practice of medicine (Kish 2012).

• Affordable Care Act: engaging patients in their own health care

fundamentally relies on health literacy—that is, their ability to obtain, process, communicate, and understand basic health information and services (Koh et al., 2013).

• Unfortunately, relatively few people are proficient in understanding

and acting on available health information to fully engage in their

• wn care (Kutner et al., 2006)

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Engagement – The First Step in Improved Health and Well-being

• Engagement is different from activation and is the process by which an

individual and health systems are able to establish a bond that links health, illness, and well-being to a system of care. Peer Specialists foster and support engagement.

• Important barriers that impede or limit the access and engagement to

health care include: poverty; diminished resources; social and psychological impediments (including poor/traumatizing past experiences); and, access/availability of needed services.

• It is also important to note that an individual can be engaged with a system
• f care and not activated to improve their health and wellbeing. (example:

someone who has a PCP, attends annual visits, and is not activated for improved self-care).

Peer Specialists Empower the person to participate in their own recovery by beginning to take small steps– – – – a a a a view from the research view from the research view from the research view from the research

• A growing body of evidence (Carmen et al., 2013) suggests that patient

engagement can lead to better health outcomes (Epstein and Street 2008) contribute to improvements in quality and patient safety (Coulter and Ellins 2006), and help control health care costs (Charmel and Frampton 2008)

• A recent literature review concluded that patient engagement had a positive

impact on health outcomes, medication adherence, and rates of hospital admission (National Voices, Prioritizing person centered care: the evidence London: National Voices; 2014)

• A Cochrane of engagement suggested that the most highly developed

interventions are directed at modifying patient medication compliance, chronic disease self-management, and traditional behaviors associated with promoting health and preventing disease such as: smoking, diet and exercise. Interventions directed at enhancing clinical encounters have largely focused on encouraging patients to ask questions through coaching or written encouragement (Center for Advancing Health 2010).

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Stage 4 – Making a commitment to change and exploring the challenging and disabling power of the illness

The Peer Specialist Role – Help Identify a persons strengths and needs in terms of skills, resources, and supports

• Engagement in care is the first step, the next step is activation which

includes deciding to implement strategies for change and recovery

Activation – a Key Role for Peer Support Services

• Activation is closely linked to empowerment and self-management

which support recovery from behavioral and other chronic health conditions.

• Individuals with behavioral health conditions must have a belief that

they can have a substantial positive impact on their own health and recovery, self-efficacy, and opportunities to support successful behavior change.

• Activation requires partnerships with health care systems that are

strength based and promote shared decision making as standards of care, and make available peer supportive services that facilitate its use.

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Motivation, Capacity and Opportunity – How Peer Specialists Support Engagement and Activation

Motivation = Discomfort + Hope (balanced)

Discomfort Hope

High Discomfort and Low Hope = Despair

Hope

High Hope and Low Discomfort = Complacency

Discomfort

Opportunity = Engagement & Capacity = Activation

Motivation, Capacity, and Opportunity - Ripple, L., Social Services Review, 1955

Levels of Activation – Peer Support Services Help Increase the Levels of Activation

Patient Activation Measure (PAM) : 22-item (Hibbard et al., 2004) and 13-item forms (Hibbard et al., 2005). The PAM also has been adapted for use in mental health specialty settings (PAM-MH; Green et al., 2010) http://www.insigniahealth.com/

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Peer Support Specialists Promote and Improve Activation– – – – a view from the research a view from the research a view from the research a view from the research

• Activation has been positively associated with health self-management

activities, including health screening completion and the use of Internet health resources (Greene & Hibbard, 2012; Mosen et al., 2007). And, it is inversely related to unhealthy behaviors and conditions such as smoking and obesity (Greene & Hibbard, 2012)

• Behavioral health activation is linked to accepting and managing one’s

condition, assuming a proactive role with providers, and using a variety of strategies to cope with symptoms (Salyers et al., 2012)

• Participation in interventions associated with increased activation levels

promotes improvements in both physical and behavioral health self- management behaviors (Alegria et al., 2008; Cook et al., 2009; Druss et al., 2010; Lorig et al., 1999)

Stage 5 – Moving beyond the disabling power

• f the illness and adopting actions for change

The Peer Specialist Role – Help a person use their strengths and get the necessary skills resources and supports

• Recovery from Mental Disorders and/or Substance Use Disorders: A

process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential (WWW.SAMHSA.GOV)

• A central concept in self-management is self-efficacy—confidence to

carry out a behavior necessary to reach a desired goal. Self-efficacy is enhanced when patients succeed in solving patient-identified problems (Bodenheimer et al., 2002)

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Are the Principles of Wellness Self- Management the Same as Recovery?

Source: AU National Chronic Disease Strategy, ‘05

Peer Support Specialists Promote Wellness Self- Management Through Seven Essential Activities

• 1. Giving information
• 2. Teaching disease-specific skills
• 3. Negotiating healthy behavior change
• 4. Providing training in problem-solving skills
• 5. Assisting with the emotional impact of having a chronic condition
• 6. Providing regular and sustained follow-up
• 7. Encouraging active participation in the management of the disease

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Peer Support Specialists Promote Wellness Self-Management– – – – a view from the research a view from the research a view from the research a view from the research

• Evidence from controlled clinical trials suggests that (1) programs

teaching self-management skills are more effective than information-

• nly patient education in improving clinical outcomes; (2) self-

management education improves outcomes and can reduce costs; (3) self-management education program bringing together groups of patients with a variety of chronic conditions may improve outcomes and reduce costs (Bodenheimer et al., 2002)

• Promoting health self-management can improve elements of health

status while reducing health care costs in populations with diverse chronic diseases (Lorig et al., 2001)

Evidence From Research Supports Effective Outcomes When Peer Support Services Foster:

• 1. Improved Health Literacy
• 2. Promote an individual’s level of Grit
• 3. Support Engagement in health services
• 4. Increase levels of Activation
• 5. Understanding and improvement of Wellness Self-Management

skills

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Part 4 Final Thoughts on The Future of Health Care and Peer Support Services

• Integrated Systems of Care are rapidly evolving
• Primary care Services are rapidly becoming the anchor of health care
• Reimbursement models are emerging to support population health and

integrated care

• What is the role of Peer Support Services and other community based

services?

• Community Health Workers and Peer Support Services

Peer Support Services and Community Health Workers

Bureau of Labor Statistics – Community Health Worker http://www.bls.gov/soc/2010/soc211094.htm

• Assist individuals and communities to adopt healthy behaviors. Conduct outreach

for medical personnel or health organizations to implement programs in the community that promote, maintain, and improve individual and community health. May provide information on available resources, provide social support and informal counseling, advocate for individuals and community health needs, and provide services such as first aid and blood pressure screening. May collect data to help identify community health needs.

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Fundamental Questions for the Future

• What are the necessary requirements for Peer-ness in support

services for behavioral and general health care?

• How do these differ for integrated systems of care?

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Experience of Trauma Related to Diagnosis Experience of Stigma and Disenfranchisement Related to Diagnosis

Need for “Peer-ness” in Self-Care Management

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 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 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 low high low high Daniels - Oct, 2013 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!

Risks Associated with Integrated Health Care That does Not Adequately Address the Needs

• f Those With Behavioral Health Conditions

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Discussion

• How can the Peer Support Services field best demonstrate that their

activities are helpful to achieving recovery and wellness?

• In your work experience what evidence do you have that correlates

with today’s discussion?

• We are well aware of the statement “I am the evidence.” What

supports that statement from your work and how can we translate that to practice standards and outcomes? Peter.ashenden@optum.com allensdaniels@gmail.com