Introduction by the column editor: In the wake of the passage of the Affordable Care Act, the U.S. health system is rapidly moving toward new models of service delivery that are shifting the historical boundaries between mental health care and primary care. Care is moving from a clinical focus to a population focus, from provider-centric to patient-centered approaches, and from treating mental disorders to treating the full spectrum of needs of people with mental disorders. New payment systems and information technology tools are making this transformation possible.
Psychiatric Services’ new integrated care column will focus on tracking and understanding these new service and policy initiatives at the local, state, and federal levels. What are the active ingredients in these models of care? What are the roles of different provider groups in delivering services? And how well do these different approaches work?
The inaugural column is written by Margaret Swarbrick, a national leader in designing and evaluating consumer-led wellness programs. Dr. Swarbrick traces the origins of the peer movement and how it has expanded to include wellness as a key component of recovery. She discusses the tensions and potential tradeoffs between recovery-oriented approaches to wellness and medical models of treatment, concluding that each can benefit from the other.
In the coming years, the peer workforce and recovery orientation are likely to be increasingly central elements of care delivery on the mental health–primary care interface. The mental health community should be proud of these innovations, which could eventually have an important role in the treatment of chronic illnesses in the broader health system.
A growing cohort of people living with a diagnosis of a mental disorder (current and former users of the mental health system) have become influential as leaders in efforts to reform and transform the mental health service delivery system. The peer movement has a 40-year history of designing and offering alternative supports for and by persons who have experiences with the public mental health system. The movement initially organized around the notion of social justice, focusing more on social needs and social inclusion while remaining separate from the traditional mental health system (1,2). Initially, peers established drop-in centers as safe havens for people experiencing difficulties who were otherwise marginalized from society. They advocated for replacing or supplementing traditional care with self-help and mutual support (3). Self-help groups, services, and models are now both complementary and an alternative to the traditional system.
Peers have been influential in the areas of advocacy, policy, and clinical service delivery. They have shown how and why people who have lived experience of mental illness can have an effective and potent influence on the health and healing of another. People in recovery have become providers of psychiatric rehabilitation services (2), and peer specialist roles and services have evolved within the context of the emerging recovery-oriented mental health system.
More recently, peers are integrating the notion of whole health and wellness into peer-delivered services. Peer-driven wellness-oriented approaches, such as whole-health and peer wellness coaching, should be considered an important complement to an integrated care team model helping the system to merge the concept and practice of recovery with physical well-being and overall wellness. This column provides an overview of such approaches and how they can enhance outcomes of integrated care and complement the traditional medical model.
The peer movement rejected the notion of chronicity and the narrow focus on illness, disease, and disability and instead proposed holistic approaches, including the eight-dimension wellness framework (physical, social, intellectual, spiritual, financial, occupational, emotional, and environment), which was adopted by the Substance Abuse and Mental Health Services Administration Wellness Campaign. The campaign is a health promotion strategy that is driven by the poor health status and associated disparities facing people who are served by the public mental health sector. Wellness is not just eating carrot sticks or going to the gym. Wellness is defined as a conscious, deliberate process whereby a person is aware of and makes choices for a more satisfying lifestyle (4–6). A wellness lifestyle includes a self-defined balance of health habits, such as adequate sleep and rest, physical activity and exercise, participation in meaningful activities, eating well, and connecting with supportive people, places, and spaces (4–6). A vision of wellness was viewed as necessary because people with mental health conditions face poor-quality general medical care and poor outcomes as a result of many factors, such as poverty, social isolation, interrupted education, and trauma. The wellness approach offers a person a philosophy that supports healthy lifestyle habits that have positive effects on quality of life. The wellness approach also focuses on other interventions to improve quality of life. Peer coaches, for example, help people have conversations with their treatment team about medication side effects that result in weight gain, which can increase risk factors for metabolic syndrome. Peer coaching focuses on informed shared decision making and self-management to monitor the risk factors for preventable and treatable diseases. Peer specialist roles and services are grounded in the wellness framework.
The Peer Wellness Coaches Certificate Program, which was developed on the basis of the wellness approach, was designed to prepare the workforce to address health and wellness needs from a self-management perspective (6,7). Peer wellness coaching is an emerging practice that is based on the wellness model and that has been developed to address comorbid general medical conditions. A key task of the wellness coach is to help the person served explore the eight wellness dimensions in order to better understand his or her experiences, motives, and needs. There is a specific focus on relevant areas of physical wellness that sometimes represent a challenge, including low levels of physical activity (a sedentary lifestyle), access to general medical screenings and management of general medical conditions, oral hygiene and dental health practices, sleep and rest, and reduction or elimination of tobacco use and use of other addictive substances. Peers assist other peers in maintaining a healthy lifestyle (6,7).
Peer wellness coaches (PWCs) are trained and employed to promote health and wellness through approaches based on empowerment, self-direction and self-advocacy, and mutual relationships. In this way, PWCs can intervene in areas where there are modifiable risk factors, such as diet and exercise, and support better access to primary care. The PWC then generally helps the peer “coachee” focus on physical wellness domains that can help contribute to overall balance and health. In their coaching role, peers apply the principles and processes of coaching, effective communication skills, and motivational enhancement strategies to the goal of lifestyle improvement for higher levels of wellness. A person with a co-occurring condition is assisted by his or her PWC to address high-risk behaviors and health risk factors, such as smoking, poor self-management of general medical conditions, infrequent use of primary care, inadequate diet, and infrequent exercise.
PWCs provide ongoing individualized support and reinforcement. They can provide the impetus for building the skills and confidence needed to make changes happen. They offer three key ingredients: education, support, and coaching. PWCs promote self-management, and they thus become a collaborator in the process of health and wellness improvement. Coaching occurs in the context of a positive supportive relationship. A coach helps to guide the person toward successful and long-lasting behavioral change.
Wellness-oriented peer approaches can be delivered by peer support, whole-health specialists and PWCs in integrated care models. These roles and services need to be recognized as a central ingredient of care and support. Peers can work as part of multidisciplinary care teams in integrated care models, helping the team and the person served to shift the focus from illness treatment to wellness and health promotion. Peers may be more likely to understand another’s situation empathically because of shared experiences of living with various conditions, as well as having experienced both challenges and strengths in many of the eight dimensions.
Peer support interventions can include assistance in meeting the challenges of diet, exercise, medication compliance, and illness control through self-monitoring. These interventions can help model for the team how to empower the people they serve to acquire and sustain self-management skills necessary for overall health and wellness. Social isolation is associated with increased morbidity and mortality; the social support provided by peers can help overcome this problem.
Peer whole-health specialists and PWCs are not licensed health professionals, such as physicians, dentists, nutritionists, registered nurses, or physician’s assistants. They are, however, frontline supporters who have the training and are developing the skills to help another make and implement choices around health improvement and health maintenance. They can support peers in lifestyle improvement or change in the areas of diet and smoking reduction or cessation and also support wellness improvements beyond the physical health domain, such as in employment, education, and finances. Some systems are considering using “task shifting” approaches in which peers substitute for nurses and social workers.
There are tradeoffs in involving peers in a medical model of care. Peer whole-health specialists and PWCs can meet some important needs, although they should work hard to remain faithful to the many characteristics that set peer wellness services apart from services operated and provided by individuals other than peers. Peers can interact with health professionals both alongside their peer-clients, and also on behalf of their peer-clients. Although peer staff do not perform diagnostic or therapeutic procedures, they can bridge the gap between the peer-client and the physician by helping the peer with health data gathering and with addressing issues related to self-administration of medication and other similar tasks.
When PWCs are delegated tasks that fall outside the scope of their training, however, challenges will arise. Wellness-oriented peer approaches have core strengths that may conflict with the medical model, although peer approaches and the medical model could nicely complement one another to better help the individuals served. The peer roles and services can help bridge tensions between the medical and wellness models.
The medical model has its benefits, as does the wellness model; they are different in focus but they are not mutually exclusive. Whereas the medical model focuses on symptom reduction, the wellness model and PWCs focus on wellness and consider the goals, values, preferences, interests, and strengths of the individual. The wellness approach is multidimensional, whereas the medical model tends to focus on illness, symptoms, deficiencies, and incapacity. The wellness approach emphasizes the importance of individuals assuming responsibility to help (re)establish roles and pursue health and wellness goals, whereas the medical model places more emphasis on medication or other treatments to eliminate or reduce symptoms or discomfort.
The wellness approach views motivation for change as leading to better health and personal control. Peers modeling the wellness strategies may help teams work with an individual’s strengths and capacity to achieve goals, in contrast to highlighting limitations. Focusing on weaknesses can create barriers to progress and self-fulfillment, rather than support positive change. Peers can take the lead in teaching other professionals about empowerment—that is, about making people aware that they have the power to be an active participant in their care and to achieve their wellness goals. Peers can encourage providers to offer education, guidance, support, and informed shared decision making, which contribute to positive behavioral change.
Wellness behavior is the development of an individual’s ability to actively seek to change his or her life situation in order to function at perceived maximum capacity and perceived maximum satisfaction. The criteria for success and satisfaction are determined by the individual. Being well is not just being medication compliant, physically fit, or “stable.” The individual assumes personal responsibility to create his or her own patterns and motivations for change. Treatment or support plans are individualized and involve personal goal setting.
Peers working in integrated settings can help the team and the person served expand their focus to include skills, abilities, and potential to achieve personal goals. Wellness engenders a positive attitude and shifts the focus away from problems, issues, and barriers. Although barriers and problems exist, the wellness approach focuses on strengths. Optimism sparks internal motivation. For example, someone may be motivated to quit smoking and become more active so that she can play with her new grandchildren. Or an individual may want to build stamina and concentration to be able to go back to school. Both may need to change their diet and exercise habits, but the motivations (and ultimately the specific goals and action steps) will differ. Peers help peers to assume or resume the valued social roles necessary to achieve a desired quality of life, rather than simply encourage compliance and adherence to a narrow team-designated goal.
The peer wellness approach empowers another peer to assume personal responsibility and be proactive in the preservation of his or her own health. Individuals are given an active role and responsibilities to self-monitor their own health behaviors and increase activity in the dimension where they perceive an imbalance. The peer acts as a coach, helping to guide the person toward goal identification, goal attainment, and successful behavioral change. The emphasis is on collaboration. A wellness approach involves all members of the team, and the individual served is the most important and active member (4). Strengths of the individual are the basis of treatments and interventions and of interpersonal interactions between the individual and providers. This approach will conflict with the training and practice of some professionals, since they tend to prescribe services, rather than collaborate. Peers encourage commitment to change that comes through personal control and good health, whereas in the medical model, fear is sometimes used to drive change and instill compliance or adherence (4). The fear tactic can compromise the relationship and deter positive change and healing.
Integrating the peer wellness approach into existing or newly forming integrated care teams will surely present challenges. Although peer providers understand the importance of self-determination and the role of choice in motivation, many mental health professionals with traditional credentials continue to see their role as persuasive, at best, and coercive, at worst. They may expect peer providers to “make” people “motivated” to address areas that are overwhelming or unimportant to them. When a peer provider is introduced to a team, training and mentoring should be provided by someone who understands the peer role and philosophy and who can address the tensions that such a role may bring to a traditional team. The team should be trained in creating a safe, nonjudgmental environment in which the peer provider is an active participant on the team, contributing valuable services.
Some of the appeal of hiring peer specialists is that they are less expensive than licensed professionals, such as nurses, nutritionists, and diabetes educators. The peer community has expressed concern that involving peers is a way of providing “more for less.” A glass ceiling often restricts peers’ career advancement.
Peer specialist roles and services are reimbursed by Medicaid in some states, and those states are now beginning to consider including wellness activities as part of the scope of practice. For example, PWCs are a qualified role for the New Jersey licensed integrated care centers that provide integrated behavioral health and primary care services. The PWC credential is included in New Jersey's Community Support Services State Plan Amendment. When the regulations are promulgated, qualifying services delivered by a Certified Wellness Coach will be eligible for Medicaid reimbursement. In June 2012, the Centers for Medicare and Medicaid Services approved Georgia as the first state to have Medicaid-recognized whole-health and wellness peer support provided by certified peer specialists.
The peer movement continues to challenge and inspire the traditional system to better meet the needs of people being served by the public mental health sector. Wellness-oriented peer approaches designed and delivered by people in recovery offer integrated care teams an ingredient that can help people realize their full potential while living longer and more satisfying lives. Peers may provide the critical impetus to help other peers improve their quality of life and lifespans.