Strategies for Using Peer Support and Peer Support Specialists to Save Healthcare Dollars: PART 2 - Strategies to Avoid

In this and the prior post, we’ve been talking about the very high Individual costs of healthcare in the US (Dieleman et al., 2020) and the reasonable need to find ways to save money while maintaining or improving the quality of the care.  There is considerable pressure on healthcare administrators to find ways to reduce costs – pressure that can motivate our efforts to find appropriate strategies but also can motivate inappropriate strategies.  I would define an inappropriate strategy as one that:

A.    Reduces cost by changing services in a way that lowers quality or success rates.

B.     Reduces cost by asking staff to work outside their training or expertise.

When Peer Support Specialists were first being introduced into healthcare settings, there was great enthusiasm about adding their personal expertise with recovery to clinical settings.  I know healthcare administrators who also saw this as an opportunity to reduce healthcare costs.   This is not necessarily inappropriate, but we want to be very explicit about when it is inappropriate and call that out when we see it.  Consider the following examples of strategies that should be avoided.

1. Reassigning Work Done Clinicians to Peer Support Specialists When that Work Actually Requires the Skills and/or License of a Clinician.

In the early role out of Peer Support Specialist positions across the country in mental health programs, I saw multiple examples of this strategy.  Programs would replace case manager-, social worker- or vocational rehabilitation specialist-positions with Peer Support Specialist positions, while asking the Peer Support Specialist to carry out the same clinical duties.  The duties were clearly complex clinically and involved duties that required a clinical license.  Sometimes this was an explicit change in staffing, and other times there was effort to change the way the new duties were described, but in each case the same work was shifted from a licensed clinician to a Peer Support Specialist who had no graduate training or license to be doing that work.  The cost savings was a result of the relatively lower salary paid to the Peer Support Specialists.

This is clearly inappropriate because there is no evidence that a Peer Support Specialist could provide those services effectively.  They had not been trained to do so.  They did not have the requisite education.  They did not have a license that indicated that the work was appropriate for their position.  Not surprisingly, this strategy often resulted in poor clinical outcomes.  Fortunately, these changes became less common over time.

2. Replacing Programs Staffed by Clinicians with Less Expensive but Less Effective Programs Staffed by Peer Support Specialists. 

If we look at de-institutionalization in the US in the 1950’s and 60’s, we can see that it started as a response to public alarm about the negative conditions in inpatient mental healthcare.  In the short run, it resulted in most clients moving to the community and/or less restrictive levels of care.  Government agencies embraced deinstitutionalization, in part because of the potential cost savings (Sutherland, 2015).  Overtime, the field has reconsidered the long-term impact of de-institutionalization.  It is now seen as not an improvement in quality of life for clients but an unfortunate and poorly planned shift in responsibilities in community resources, with more adults with mental illness seen in jails and prisons, rotating through healthcare institutions, and on the street (Lamb, 2001; Sutherland, 2015). In this way, deinstitutionalization is the poster child for the hidden risks of programmatic changes, including changing programs or program staffing in a way that includes more Peer Support Specialist staff and peer support, when the outcome for the clients will be poorer.  It is also a cautionary tale about making changes in programs before we know what the impact on the clients will be.  We want to always keep our client’s welfare as the key target for evaluating changes, and be vocal about that.  Changing programs to save money without evidence about clinical outcomes is inappropriate.

3. Using Peer Support Specialists to Complete Work That is in the Skills and Training of Other Professionals.   Peer Support Specialists have expressed a great deal of concern in the past decade about being assigned work that is inappropriate for their training and their role.  This has been such a large concern that the National Association of Peer Supporters (NAPS) developed guidance for supervisors about work assignments (NAPS, 2019).  I have personally seen it in several different forms.  In some cases, Peer Support Specialists were assigned clients, serving as “case managers”, when the decisions involved for that work required significant clinical training.  The supervisors portrayed the work as simply “extensions” of the clinicians, the reality was that the peers had to make complex clinical decisions on their own, putting themselves and the clients at risk.  I’ve also seen Peer Support Specialists assigned to non-clinical work that has nothing to do with the peer role.  Peers have been assigned to work as drivers, cleaners and custodians, and clerical support staff.  This typically happens when there is a vacancy in these other non-clinical positions and so the Peer Support Specialists are asked “to cover”.  Peers often want to be team players and so they step in to help.  Often the assignments last for weeks to months.  It can be tricky to determine when these requests are inappropriate.  I use the following questions to help me make this determination:

A. Does the work have anything to do with the job description and specific skills and knowledge of a Peer Support Specialist?

B. Would they ask a clinician to do this same role?  If not, why not?

C. Does the assignment fit with the NAPS Supervisory Guidance issued in 2019?

If the answers to these questions are ‘no’, there is a great probability that this assignment is inappropriate, and is an effort to save money at the cost of the Peer Support Specialist.

I want to point out an important danger associated with inappropriately assigning Peer Support Specialists to work that is not in their training and role.  There are always clinicians and other healthcare professionals who do not understand the role of Peer Support Specialists and are skeptical about the need for them.  When peers are assigned work inappropriately it often results in the work being poorly done.  I have seen skeptical providers point to these incidents as evidence that “Peer Support Specialists are not appropriate for work in clinical settings”.  I am quick to point out that when peers provide the services they are trained to do, they typically add greatly to clinical care, and it is not surprising that they have trouble when they are inappropriately assigned.  Keeping peers within duties that fit their role will help avoid the types of problems that others can use to undermine their involvement in care.

Clinicians, administrators and Peer Support Specialists should look for ways to save healthcare dollars, but we should also be on guard against inappropriate strategies that hurt clients and undermine our Peer Specialists.  An open and direct on-going discussion of these issues will help us all keep on the right track in this effort.

REFERENCES

Dieleman, J. L., Cao, J., Chapin, A., Chen, C., Li, Z., Liu, A., ... & Murray, C. J. (2020). US health care spending by payer and health condition, 1996-2016. Jama, 323(9), 863-884.

Lamb, H. R. (2001). Deinstitutionalization at the beginning of the new millennium. New Directions for Mental Health Services, 2001(90), 3-20.

National Association of Peer Supporters (2019). National Practice Guidelines for Peer Specialists and Supervisors. Washington, DC: N.A.P.S.

Sutherland, E. (2015). Shifting burdens: The failures of the deinstitutionalization movement from the 1940s to the 1960s in American society. Constellations, 6(2).

KEY WORDS: Peer Support Specialist, Role, Peer Support, Peer Support Jobs, Healthcare Costs