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The Surgeon General's landmark 1999 Mental Health Report gives consumers and their families a prominent place in the mental health system as advocates, participants in overseeing policy, and providers of services (1). Managed care programs, when adequately funded and wisely managed, can, should, and sometimes do promote all three objectives (2).
The rationale for a more consumer-centric approach to managed care derives from a clinical prediction that services provided in this manner will lead to improved outcomes (3) and a view of democratic process that calls for robust citizen involvement beyond that provided by representative government alone (4).
The state of Georgia has pioneered a certified peer specialist program that combines consumer-provided services, consumer advocacy, and consumer influence on policy in a highly innovative manner. In this column, the seventh in a series on strengthening the consumer voice in managed care (5,6,7,8,9,10), we present lessons about enhancing the consumer role derived from Georgia's unique program. Although Georgia's program is currently one of a kind, the values and strategy that inform the program could have wide application.
Since 1999, the Georgia Division of Mental Health, Developmental Disabilities, and Addictive Diseases has placed a strong emphasis on recovery-oriented programming and peer support in its approach to providing services for clients who have serious and persistent mental illness (11). Public-sector officials and consumer leaders concluded that in order to achieve stable funding for peer-support services, the services would have to be developed in a way that made them eligible for Medicaid funding under Medicaid's psychiatric rehabilitation option (12). Accomplishing this objective required melding two cultures: the consumer recovery movement—with its informality, vision, and energy—and Medicaid, with its complex bureaucratic requirements.
The certified peer specialist role is the fulcrum of Georgia's effort to manage its services for persons with serious and persistent disorders in a manner that promotes consumer-friendly recovery values. The role is open only to current or former recipients of mental health services for a major mental illness who openly identify themselves as consumers and have had advocacy or advisory experience, in addition to "demonstrated effort at self-directed mental health recovery" (13). The certification process includes two required weeklong training modules followed by a written and oral examination. In addition, many of those who become certified have already participated in advocacy training as part of their personal recovery process.
The primary responsibility of the certified peer specialist is to provide direct services "designed to assist consumers in regaining control over their own lives and control over their recovery processes." Peer specialists are expected to "model competence and the possibility of recovery" and to "assist consumers in developing the perspective and skills that facilitate recovery" (13). The job description lists 17 specific supportive activities ranging from helping consumers create a wellness recovery action plan (14) to "support[ing] the vocational choices consumers make and assist[ing] them in overcoming job-related anxiety" and "inform[ing] consumers about community and natural supports and how to utilize these in the recovery process."
As part of revamping its service system for persons with severe and persistent mental disorders, Georgia made peer support a new billable service under Medicaid (15). The aim of peer support is "to provide an opportunity for consumers to direct their own recovery and advocacy process and to teach and support each other in the acquisition and exercise of skills needed for management of symptoms and for utilization of natural resources within the community." The staffing specifications require the program leader to be a certified peer specialist.
However, in addition to providing direct services, certified peer specialists are explicitly asked to act as change agents in the mental health system by providing professional, clinical, and administrative colleagues with "their unique insight into mental illness and what makes recovery possible." Within clinical team meetings they are asked to "promote consumer use of self-directed recovery tools." Given that as of March 2003 there are 119 certified peer specialists working in Georgia, the state has clearly created a substantial opportunity for strengthening the consumer voice within the mental health system. The Georgia program is by no means a token effort.
Ken Whiddon, president of AmericanWork, a private agency that operates peer centers in south Georgia, commented that "ten years ago it was unheard of to hire self-identified consumers, but when the state moved to the Medicaid rehabilitation option it really bought into the peer-support concept." The fact that Georgia has made certified peer specialists a requirement for reimbursement for services such as assertive community treatment, community support teams, and adult peer support programs makes hiring of trained consumers a necessity for funding.
For Georgia to make its service system a more consumer-friendly, recovery-oriented one, two things must be accomplished. The certified peer specialist role is central in both.
First, services must be aligned with consumer objectives, which typically center on areas such as obtaining better housing, acquiring and keeping a job, and cultivating more friends—objectives for which consumer-provided services and peer support may be especially effective. Although Aaron Lazare developed an elegant clinical model designed to foster a more consumer-centric approach almost 30 years ago (16), it is still common for consumers to complain that clinicians are more attuned to their own agendas than to those of their patients. It is reasonable to hope that, as providers of services, certified peer specialists will align themselves better with consumers' objectives and preferences, thereby promoting improved outcomes.
Second, to move services in a more consumer-friendly, recovery-oriented direction, administrators and clinicians must "buy in" to the consumer-centric philosophy (9). Typical efforts to elicit this buy-in include exhortation, training, and organizational development interventions. Georgia has added direct seeding of program staff with certified peer specialists as an additional approach and has put muscle behind this approach through its staffing requirements for Medicaid reimbursement. It is reasonable to hope that the dissemination of trained and certified peer specialists throughout the Georgia service system will, over time, have a positive effect on buy-in among professional staff.
The hypothesis underlying this series of columns on strengthening the consumer voice in managed care is that heightened consumer participation will lead to better outcomes and wider stakeholder acceptance of the system as legitimate and fair. From this perspective, Georgia's decision to develop its clinical services with a strong emphasis on peer support and consumer providers—and to govern its policy and program planning process with inclusion of substantial consumer voice—has strong face validity. Georgia recognizes, however, that face validity and hope for a positive impact are not the same as proven efficacy.
By embedding the certified peer specialist program in a system of training, monitoring, and managerial assessment, Georgia is reshaping its service system in a responsible and accountable manner. The presence of certified peer specialists cannot compensate for inadequate funding or other impediments to effective programs, but Georgia is providing a model initiative for strengthening consumer-oriented clinical services and consumer voice in program and policy management. The six previous columns in this series suggest that enhanced consumer participation promotes improved deliberation in the policy planning process, greater transparency about the content and rationales for policy choices, and a more robust try-it/fix-it approach to policy improvement. Over time, Georgia's unique program will allow important learning about the ways in which enhanced consumer participation can lead to improved quality in service delivery and program planning.
The authors thank Beth Filson, Larry Fricks, Kathy Gosier, Iris McIlvaine, Karl Schwarzkopf, Mary Sloan, and Ken Whiddon.
Dr. Sabin, who is editor of this column, is clinical professor of psychiatry at Harvard Medical School and director of the ethics program at Harvard Pilgrim Health Care in Boston. Dr. Daniels is professor of ethics and population health in the department of population and international health at Harvard School of Public Health in Boston. Send correspondence to Dr. Sabin at the Department of Ambulatory Care and Prevention, 126 Brookline Avenue, Sixth Floor, Boston, Massachusetts 02215 (e-mail, email@example.com).
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