Peer Navigators for the Health Needs of People of Color With Serious Mental Illness

People with serious mental illness die as much as 20 years younger than their same-age peers. Although illness-related factors might partly explain this difference, worse health for these individuals also can be attributed to a fragmented and underresourced health care system. These disparities are markedly worse for people of color with serious mental illness, as are the social disadvantages they often endure (e.g., poverty and criminal legal involvement). One set of solutions, using community health work, requires moving resources to local communities where people from that community assume roles as professional and paraprofessional providers. The purpose of this column was to describe the benefits of one subgroup of community health workers: peer health navigators (PHNs). Specifically, we unpack the significance of the terms “peer” (a person with lived experience of recovery who is from the same racial-ethnic group as a current patient) and “navigator” (a person who helps patients engage in a broad health care system) in the role. We then summarize the key components of PHN practice implemented in local communities.

Morbidity and Mortality among People of Color with Serious Mental Illness

Research consistently shows that people with serious mental illness have significantly higher rates of morbidity and mortality compared with others in their same-age cohort, with greater susceptibility to disease in almost every organ system in the body (1). Some evidence suggests that this pattern occurs because of consequences specific to psychiatric disorders, such as cogenetic vulnerabilities; long-term effects of stress, medication, and other adverse effects of treatment; higher rates of modifiable health risks (e.g., smoking, alcohol use, and poor diet); and social and cognitive disabilities that undermine health literacy, self-management skills, and service engagement (1). However, racial-ethnic, gender, and other disparities are an additional barrier to health and, more specifically, to health care. For example, research consistently shows that people of color with serious mental illness have worse patterns of morbidity leading to early death compared with White people with serious mental illness (2). Social disadvantage further worsens this trend. Outcomes include higher rates of poverty leading to lower education and employment, housing instability, and food insecurity (3). The two sides of criminal legal involvement—trauma related to being a victim and the loss of freedoms from being arrested—also interact with health care. Foreign-born U.S. residents have additional disadvantages related to language, immigration, and refugee status. Engagement with individuals who have shown resilience to these challenges is an important addition to the experience of peer support.

Health care for people of color with serious mental illness is often fragmented and underresourced. Access and availability are further undermined for people who are homeless or undocumented or for ex-offenders. Existing services often fail to be culturally relevant or competent, such that patients do not fully engage in care.

The Potential of Community Health Work

Cook and Mueser (4) argue that community health workers (CHWs) have significant potential to advance the integrated health needs of people with serious mental illness. They define CHWs as “indigenous members of a person’s community” trained to provide support, education, and care coordination to improve health and wellness among low-income and other at-risk groups. Although CHWs vary in their paraprofessional and professional backgrounds, their work is guided by priorities related to cultural relevance and services within the community (5).

PHNs

The role of PHN evolved from a narrower class of CHWs called patient navigators, trained CHWs who escort and support patients through multiple levels of care and help them access applicable benefits. Patient navigators first appeared in cancer clinics to meet patients’ complex needs. Successful navigators essentially interface between patients and the overwhelming number of other services and service providers that patients encounter, including the physician or nurse practitioner leading the treatment team, ancillary diagnosticians and treatment specialists, behavioral health care providers, hospice and palliative care workers, community support services, and faith-based ministries. The Patient Navigator Outreach and Chronic Disease Prevention Act described PHNs’ essential tasks as assisting in the coordination of health care services, facilitating involvement of community organizations to help patients access care, anticipating and helping patients overcome barriers, coordinating with insurers, and conducting ongoing outreach, especially to populations affected by health disparities (6).

The patient navigator role evolved into the “peer navigator” in cancer care when these individuals were recruited from a racial-ethnically diverse group of previous cancer patients. Patients of color report emotional support, “being there,” and “feeling heard” as essential elements of successful peer navigators with whom they share a racial-ethnic background (7). This arrangement enhances patients’ perceptions of trust that culturally sensitive providers understand their perspectives and are looking out for their concerns.

In a parallel development, peers with lived experience of recovery from serious mental illness have shown value in services for others with psychiatric disorders. “Peerness” is the essential component in peer support services grounded in recovery. Recovery is complex and holistic, occurs in varied pathways, and is steeped in hope, goals, and self-determination. These attributes describe recovery-based approaches to mental health care in general, but disclosure and shared lived experience are the unique components of peerness (8). Disclosure involves three steps. First, people identify themselves as individuals with mental illness and an experience of recovery. Second, they generally share experiences that describe this identity with others. Third, as providers, they strategically disclose experiences that help service users realize their goals.

PHNs for serious mental illness therefore subsume three concepts: peerness, health, and navigation. First, as peers, they are people with a shared experience of serious mental illness and are from the same racial-ethnic backgrounds as patients. PHNs may also share their experiences with other health concerns—managing HIV and AIDS or dealing with the COVID-19 pandemic—or their histories of resilience in the face of social disadvantages such as homelessness or incarceration. Second, PHNs’ primary focus is on a person’s general medical health and wellness goals, and mental health is an obvious integrated element. Third, PHNs act as navigators by helping people engage in the health care system, coordinating health services, and helping them access care. Engagement is a multilevel process. It includes establishing links to available and accessible health care that is also interpersonally and culturally relevant to patients so that they fully participate in planning and implementation.

Research on PHNs

Three research programs have examined PHN services from different perspectives. First, the Health and Recovery Peer Program integrated health literacy and self-management skills training with one-on-one peer coaching, leading to significant improvements in participants’ reports of general medical and mental health as well as recovery (9). Second, the Bridge intervention had a similar focus on self-management skills, offering peer provider guidance grounded in real-world health settings. Results showed that participants reported fewer symptoms of pain or poor health as well as heightened preference for primary care rather than emergency department services (10). Last, the PHN program focused on creating linkages, whereby peers helped patients schedule health appointments and then accompanied them to those appointments. This program led to significantly greater use of existing health care services (11). These overall findings support the use of PHN services and underscore the varied ways in which PHNs might help people with meeting their health goals.

Key Components of the PHN Practice

Implementation scientists believe that identifying key components of evidence-based approaches is important for ongoing effectiveness research in general, as well as for studies about deployability and scalability. We propose eight components here as a heuristic for ongoing conceptual and practical development of a PHN intervention and its corresponding evaluation. We do not assert that these components are unique to PHNs per se; many are generally relevant to integrated care. However, as a group, they become the defining set of strategies that guide training, fidelity, and outcomes assessment and lead to PHN programs.

First, engagement in health services is the priority. The goal of the PHN practice is to help people obtain and fully interact with the existing network of services that can meet their health needs. This can be a labor-intensive undertaking for disenfranchised people served by a fragmented public health system, for example, for people who need to coordinate travel to a county hospital for respiratory problems, a community clinic for podiatry, a dentist working out of a traveling van, a city mental health clinic, or a chain store pharmacy. This kind of coordination can be even more challenging when people lack a primary care home that coordinates health consultations and interventions over time.

Second, health services are broadly construed. PHNs assist the person in identifying and engaging in the broadest range of services, including not only allopathic medicine and allied health but also the growing array of complementary medical offerings that individuals believe will address their health needs. These may also include faith-based strategies or other culturally defined approaches to health. PHNs are active in addressing administrative barriers, such as third-party payers necessary for the provision of timely services. Services also include various opportunities that promote wellness and prevention.

Third, assessment is ongoing in order to identify dynamic health needs. All services are driven by the individuals’ perspective of health and wellness. These needs are likely to change over time, so PHNs engage in ongoing assessment, leading to adjustments in services.

Fourth, PHNs assist with practical tasks related to service visits. The goal is to help people engage in health care services, which may include scheduling timely appointments, traveling with the person to the clinic, accompanying the person to the examination with the provider, advocating when needed, and resolving billing and paperwork concerns. PHNs often keep a diary listing steps of previous treatment engagement as well as a calendar of future appointments. PHNs work from a base of interpersonal support, using basic listening and related skills to understand people and their goals and then to partner with the person.

Fifth, service engagement is enhanced by improving health literacy and self-management skills. People are better able to accomplish health and wellness skills when they understand their specific health challenges and the interventions to address them. Practical skills to self-manage one’s health plan are equally useful.

Sixth, peers are people in recovery. Consistent with evolving consensus guidelines, PHNs are people in recovery from serious mental illness (i.e., people who report being able to address their life goals after a period of disabling mental illness). PHN programs often include peers who also have lived experience as a member of a minority group and lived experience of social disadvantage. Unique to PHNs is peerness, the strategic disclosure of shared experience that advances personal health goals.

Seventh, interventions are team based and embedded within a larger service system. PHNs share duties within a team of other PHNs. The team works in a larger system of providers where they are fully integrated within an existing infrastructure to assist people with their needs related to but outside of health per se (e.g., housing instability, food insecurity, substance use, criminal legal involvement, employment, and education).

Finally, service is unending. PHN services are not time limited. They are offered for as long as people request them. Engagement with PHNs might start and stop as patients’ perceptions about the course of their health concerns evolve.

Conclusions

The significantly increased health and wellness needs of people with serious mental illness are clearly worsened by racial-ethnic disparities and corresponding social disadvantage. These circumstances subject people with serious mental illness to a fragmented and underresourced health care system that often lacks cultural competence. PHNs, a form of CHW, are people with lived experience of recovery and resilience to social disadvantage who provide practical services to help patients meet personally identified goals. PHN programs have been shown to enhance engagement, preference for primary care rather than emergency department services, and self-report of improved health and recovery. The eight key components outlined in this column represent a first step to define a common framework in order to enhance PHN services.