Strategies for Using Peer Support and Peer Support Specialists to Save Healthcare Dollars: Seven Strategies to Pursue

Individual costs of healthcare in the US are higher than for almost any other country (Dieleman et al., 2020).  This has led to continuous efforts to find ways to reduce those costs. 

The primary goal of incorporating Peer Support Specialists and peer support into healthcare is to improve client recovery, not to reduce costs.  However, given the need to address the high costs of healthcare, it is worth considering whether peer support and the work of Peer Support Specialists can be used appropriately to save healthcare dollars.

When Peer Support Specialists were first being introduced into healthcare settings, concern was voiced by some clinicians that this effort reflected an inappropriate strategy by hospital administrators to reduce costs by simply replacing expensive clinicians with less expensive Peer Support Specialists.  While there is no evidence that their claim was accurate, it does make the point that, if we are going to look at Peer Support Specialists and healthcare costs, it is reasonable to distinguish strategies that meet the goal of improving care and those that do not.

Appropriate strategies will result in positive improvement in quality of life for clients and not put clients or Peer Support Specialists in vulnerable positions by asking those peers to provide services they are not trained to provide.

Strategy 1: Integrating Peer Support/Self-Help into Traditional Healthcare.

When peer support is integrated into traditional healthcare, the success rate is often improved while the cost is reduced.  Dr. Keith Humphreys and his colleagues (Humphreys & Moos, 2007) at the Palo Alto VA compared the outcomes of 887 VA clients, half of whom participated in a SUD treatment program that emphasized 12-step peer support resources, and half in programs that emphasized clinical resources such as CBT.  The 12-step-peer support-based programs placed substantially more emphasis on 12-step concepts, had more staff members “in recovery,” and promoted self-help group involvement much more extensively than did the CBT programs.

At both 1- and 2-years after participation, the 12-step participants were more successful in terms of abstinence (49.5% vs. 37.0%).  Just as important, the subsequent healthcare cost of the 12-step participants was 30% lower than the CBT group (an average savings of $2,440 per client).  It appears that 12-step participants were more successful but also less dependent on clinicians and more engaged in peer support in the 2 years after treatment.  By integrating self-help principals and peer support into formal clinical treatment, participants learned the value of peer support and then used community-based free self-help effectively with better clinical results compared to those who relied more heavily on costly clinical supports.   

Given the large and growing self-help networks for most medical and mental health conditions, this finding is relevant to the care for many more disorders than simply substance use disorders.

Strategy 2: Peer Support Services that Safely and Effectively Divert People from More Expensive Care.

In general, use of peer support is predictive of reduced risk of psychiatric hospitalization (Landers & Zhou, 2011). Peer respite programs are voluntary, short-term, overnight programs that provide community-based, nonclinical support for people experiencing or at risk of acute psychiatric crisis.  They are staffed by Peer Support Specialists and peer counselors.  The available research suggests they are effective at reducing more expensive inpatient care while improving mental health outcomes and reducing self-stigma (Bologna & Pulice, 2011; Pelot, & Ostrow, 2021; Robinson et al., 2010).  Peer respite and other diversion programs are included in SAMHSA’s advisory on crisis care Substance Abuse and Mental Health Services Administration (SAMHSA).

Strategy 3: Using Peer Support Specialists to Deliver Disease Self-Management Services. 

Self-management is “the individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition” (Barlow, Wright, Sheasby, Turner, Hainsworth, 2002).  Self-management is consistent with the SAMHSA definition of recovery.  Services that enhance self- management in chronic medical or mental health diseases are associated with better disease control, quality of life, daily functioning, but also reduced cost in terms of fewer emergency department visits and acute admission episodes (Howell et al., 2021). 

 Chronic health conditions account for 90% of healthcare dollars spent.  Virtually all chronic healthcare conditions require elements of disease self-management over significant periods of time.  Peer support, either in individual or group formats for clients and/or caregivers, has been found useful in virtually every one of the top 10 most costly chronic health conditions including heart disease, stroke, cancer, diabetes, obesity, arthritis, dementia, epilepsy and lung disease.  Explicit peer-taught disease self-management skills have been shown to be effective in a number of disorders (Druss et al., 2018).  Expanding the use of Peer Support Providers to provide disease self-management skills consistently across the range of chronic medical and mental illnesses would improve a range of clinical outcomes while substantially reducing costs.

Strategy 4: Using Peer Support Specialists to Build Community Integration and Social Support.

In looking at the overall patterns of how people recover from mental illnesses, there is a recurrent pattern of many people who complete formal treatment but fail to move back to roles in their community, whether that is social connection, work, school, etc. The common result is that those people begin to be more isolated and often more symptomatic, followed by greater risk for relapse and re-engagement in treatment.  Peer Support Specialists are ideally positioned to help these clients, particularly those recovering from a mental illness, to transition back to active roles in the community. Peer Support Specialists often work in the community, and can actively help bridge clients to community opportunities, whether they be peer support groups, work opportunities, leisure activities, religious organizations, etc. Peer Support Specialists model real community integration and can educate and support clients in this phase of recovery.  Successful community integration reduces the need for subsequent healthcare, thus reducing cost.

 Peer Support Specialists are also ideally positioned to help people increase social support, particularly when using peer support and self-help groups. Higher levels of social support are predictive of better physical health, mental health, and mortality (Holt-Lunstad, 2021). Social support is also directly related to effective use of healthcare and reduced healthcare costs (Shier, Ginsburg, Howell, Volland, & Golden, 2013).

Strategy 5: Using Peer Support to Reduce Treatment Dropout.

“Treatment dropout” has been defined as occurring when a client has left treatment before obtaining a basic level of improvement or completing treatment goals (Hatchett & Park, 2003).  Dropout in medical and mental health treatment is surprisingly common (Olfson et al., 2009), and is associated with poorer outcomes.  Across mental health services, common rates of dropout fall between 30% and 60% (Swift & Callahan, 2011). Considering the amount of costly treatment provided to clients who subsequently dropout, there is significant healthcare cost caused by dropout and an opportunity for cost reduction by reducing dropout.

Interventions found to reduce dropout are not specific to Peer Support Specialist, but Peer Support Specialists are well positioned to be involved in helping clients make better decisions about dropout (Drebing et al., 2018). Given the direct link between clients’ expectations of treatment success and dropout, the presence of Peer Support Specialists, who are concrete evidence of treatment success, can have a big impact on dropout.  Reducing dropout results in better program success rates while reducing the amount of care provided to people who will not obtain the “requisite level of improvement” (Hernandez-Tejada, Acierno & Sanchez-Carracedo, 2017). 

A special type of dropout applies to potential clients on waiting lists to enter treatment.  Peer Support Specialists and peer support have been successfully used to help people on treatment waiting lists to remain on the list long enough to successfully receive the target intervention (Crotty et al., 2009; Gagliardi et al., 2021).

Strategy 6: Using Peer Support for Prevention.

Preventive care requires an upfront expense but can result in substantial healthcare cost savings as prevented illnesses require no treatment. Peer support and Peer Support Specialists have been involved in a range of preventive interventions with evidence that these interventions can result in significantly reduced risk of subsequent mental health and medical problems that require costly care (Dennis et al., 2009; Fisher et al., 2018; Thankappan et al, 2018).

Strategy 7: Replacing Clinicians with Less Expensive Peer Support Specialists When the Work is Appropriate for Peers and the Success Rates of the Work are Equal or Better.

It is reasonable and even responsible to look at services that can be provided by either a clinician or a Peer Support Specialist, and to use the less expensive alternative if the outcomes are similar or the less expensive alternative produces better outcomes.  Some work by clinicians requires skills and knowledge that Peer Support Specialists don’t have, but some work can be done by either.  For example, Sue Eisen and colleagues (2012) compared recovery groups led by Peer Specialists and by more expensive clinicians, and found that the outcomes were no different.  The content of the groups was within the knowledge base of peers and of clinicians.  After participating in the groups, clients recovered at the same rate.  It is only reasonable to consider using the less expensive providers to lead those groups, saving funds that can be used for additional services to help those clients.

These seven strategies represent potential savings of substantial healthcare dollars.  They justify enthusiasm for including peer support and Peer Support Specialists in greater and greater degrees in our programs.  Peers and clinicians can use these strategies to justify hiring more Peer Support Specialists and building more roles for peer support and peers within existing and new clinical programming.

REFERENCES

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Crotty, M., Prendergast, J., Battersby, M. W., Rowett, D., Graves, S. E., Leach, G., & Giles, L. C. (2009). Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomized controlled trial. Osteoarthritis and Cartilage, 17(11), 1428-1433.

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