Impacts of COVID-19 on the NYC Peer Support Workforce: A Brief Report

Photo by 168502358© Designer491|Dreamstime.com ABSTRACT Psychiatric Advance Directives (PADs) can protect the autonomy of those living with severe mental illness (SMI) and improve their treatment outcomes. However, their uptake is low for several documented reasons. Attempts to increase patient uptake of PADs can circumvent risks of undue provider influence in the facilitation process and promote optimal mental health outcomes with a peer-support model, thereby protecting patient autonomy in accordance with the principle of beneficence. Moreover, policymakers and mental health organizations should devote sufficient resources toward establishing peer-support specialist networks to mitigate the inequities those with SMI face. Capability theory can guide state leaders and directors in justifying the distribution of scarce resources to achieve these outcomes. INTRODUCTION Since the mid-twentieth century, scholars have increasingly rejected a strong paternalistic relationship between physician and patient, emphasizing the right of patients to accept or decline medical treatment.[1] With this greater emphasis on patient autonomy, a healthcare model of shared decision-making ascended in the 1980s.[2] Considering limitations in a patient’s capacity to make informed decisions in their treatment, the US Congress passed the Patient Self-Determination Act in 1990.[3] The act legally obliged hospitals and other care facilities that participate in Medicare and Medicaid to ask patients if they have an advance directive. In the absence of such a directive, these institutions are to ask if patients would like to complete one and to abide by it if presented by the patient.[4] These directives give patients control of future medical decisions in three key areas: entrusting an individual to act as a medical decision-making proxy, preferences for and consent to future treatment, and a statement of overall personal values and preferences to help inform future medical decisions by providers.[5] Although professionals initially crafted the law with end-of-life care in mind, 27 states now have mental health-specific provisions included in advance directive statutes.[6] As a subset of advance directives, psychiatric advance directives (PADs) are meant to protect patient autonomy during the treatment of psychiatric episodes when competence is compromised. Despite their promise and protection, PADs are underutilized by those with serious mental illness (SMI). In a survey of psychiatric patients, only 4-13 percent of respondents across multiple US sites reported having completed a PAD.[7] The same study indicated that 66-77 percent of respondents were interested in completing one if given assistance.[8] Having recognized the gap between patient interest and uptake, researchers have explored the possible reasons for this disparity. Several barriers have been identified and characterized at the system, health-professional, and service-user levels.[9] Although exploring interventions targeted at each level individually may be worthwhile, several barriers may be effectively overcome with one cross-level intervention. Specifically, a network of peer-support facilitators may be able to mitigate resource concerns of the system level, provider fears, reluctance, and lack of knowledge of PADs at the health-professional level, and a lack of trust and support among those with SMI within the service-user level.[10] Although the Patient Self-Determination Act mandated protections for patient autonomy, the law did not provide a sufficient mechanism to ensure the broad use of those protections. Much of the logistical burden falls on those living with SMI to educate themselves and initiate the completion of a PAD.[11] However, many of those living with SMI already face additional burdens that prevent their successful navigation of a complex healthcare system, including poverty, marginal housing, and food insecurity.[12] In addition, individuals with SMI tend to be more socially isolated, with few others to trust besides their providers.[13] Efforts to promote the uptake of PADs by those living with SMI that neglect these additional burdens risk exacerbating health inequities faced by those with SMI. Attempts to increase patient uptake of PADs should circumvent risks of undue provider influence in the facilitation process and promote optimal mental health outcomes with a peer-support model, thereby protecting patient autonomy per the principle of beneficence. Additionally, policymakers and mental health organizations should devote sufficient resources toward establishing peer-support specialist networks to mitigate the inequities those with SMI face. Capability theory can guide state leaders and directors in justifying the distribution of scarce resources to achieve these outcomes. I. System-Level Barriers to Psychiatric Advanced Directive Uptake At least three barriers to PAD uptake exist at the system level. Still, only one can be effectively addressed by peer-support specialists: resource implications to providers and administrators.[14] In one study, 71 percent of administrators and 52 percent of clinicians believed that a shortage of time would prevent adequate facilitation of PAD completion among those with SMI.[15] Logistical difficulties, such as incorporation into routine documentation and making them easily accessible, were mentioned by 25 percent of respondents in another study.[16] Professionals should take clinical burdens seriously since they can impact care and patient outcomes. Shifting to a peer-support model would alleviate these constraints on providers, who could then focus on other aspects of patient care. II. Health Professional-Level Barriers to Psychiatric Advance Directive Uptake Barriers at the health-professional level, which include a lack of knowledge and training, fear of complete treatment refusals, and a reluctance to facilitate PAD creation, keep patient uptake of PADs low.[17] Among these barriers is a need for more knowledge and training among healthcare professionals. In one study, 55 percent of health professionals had never heard of PADs; only 11 percent claimed they were "very familiar" with PADs.[18] In a survey of professionals, 45 percent voiced concern that the potential disadvantages such as the use of PADs to refuse medications could outweigh the benefits.[19] The reluctance of providers to assist service users in completing a PAD stemmed from concerns over time constraints and the providers’ ability to facilitate the completion of a PAD without bias.[20] These concerns are serious and hint at the asymmetrical power dynamic between providers and patients. By removing the responsibility of unbiased communication from the provider and placing it with peer-support facilitators, the risk to patient autonomy would be significantly lessened. III. Service User-Level Barriers to Psychiatric Advance Directive Uptake Several barriers exist at the service-user level that prevent the widespread adoption of PADs. These include a lack of trust, support, and knowledge of PADs, as well as a lack of understanding in completing a PAD.[21] Concerning trust, one study found that 43 percent of patients did not feel they had someone they could trust to help them complete their PAD.[22] Other studies indicated that patients had limited trust in their healthcare professionals.[23] Regarding the lack of support, one survey found that 94 percent of respondents would be unable to complete a PAD without assistance or without a facilitator.[24] Many patients lack knowledge and awareness of PADs, how to complete, and what to include in them.[25] Due to their complex legal nature, over half of the respondents in one survey indicated that they had problems understanding the PAD.[26] Similarly, 79 percent of clients interviewed in one study felt that PADs posed too much of a burden.[27] Through their shared lived experience, peer-support facilitators would be in a greater position to foster trust with patients and create the environment necessary for patients to explore their values and preferences through this process. IV. Circumventing Undue Provider Influence on Patient Autonomy The risk to patient autonomy is pervasive because of the advanced nature of medical practice and the dependence of patients to providers. In their delineation of bioethical principles, Beauchamp and Childress state: "To respect autonomous agents is to acknowledge their right to hold views, to make choices, and to take actions based on their values and beliefs."[28] This duty extends through a respectful attitude toward the patient and respectful action toward the patient.[29] On average, patients with SMI take 14.6 minutes to complete a PAD, which is well within the 30-minute time limit imposed by insurance reimbursement schedules.[30] However, as other researchers have indicated, this time of completion does not take into account the time required to inform and discuss the implications of future treatment decisions adequately.[31] Given that those living with SMI are often affected by cognitive deficits, the ability of a provider to relay complex health and legal information promptly may be further hamstrung.[32] By offloading the burden of providing efficient and practical education to patients with various levels of cognitive impairment, peer-support specialists could provide the necessary space and time to obtain informed consent and protect patient autonomy. Much of the moral force behind advance directives is the respect for patient autonomy, which has been a focus of researchers over the past several years.[33] Because psychiatric episodes severely limit the ability of a patient to make well-informed treatment decisions in a crisis, PADs are a way to protect the patient from paternalistic interventions. This takes on greater weight in treating patients experiencing a psychiatric episode when the threat and use of coercive treatment o

Peer Support Specialists Can Play Important Role in Patients’ Lives

BackgroundPrior to the outbreak of coronavirus disease (COVID-19), telemental health to support mental health services was primarily designed for individuals with professional clinical degrees, such as psychologists, psychiatrists, registered nurses, and licensed clinical social workers. For the first the time in history, peer support specialists are offering Medicaid-reimbursable telemental health services during the COVID-19 crisis; however, little effort has been made to train peer support specialists on telehealth practice and delivery.ObjectiveThe aim of this study was to explore the impact of the Digital Peer Support Certification on peer support specialists’ capacity to use digital peer support technology.MethodsThe Digital Peer Support Certification was co-produced with peer support specialists and included an education and simulation training session, synchronous and asynchronous support services, and audit and feedback. Participants included 9 certified peer support specialists between the ages of 25 and 54 years (mean 39 years) who were employed as peer support specialists for 1 to 11 years (mean 4.25 years) and had access to a work-funded smartphone device and data plan. A pre-post design was implemented to examine the impact of the Digital Peer Support Certification on peer support specialists’ capacity to use technology over a 3-month timeframe. Data were collected at baseline, 1 month, 2 months, and 3 months.ResultsOverall, an upward trend in peer support specialists’ capacity to offer digital peer support occurred during the 3-month certification period.ConclusionsThe Digital Peer Support Certification shows promising evidence of increasing the capacity of peer support specialists to use specific digital peer support technology features. Our findings also highlighted that this capacity was less likely to increase with training alone and that a combinational knowledge translation approach that includes both training and management will be more successful.

Emergency Department Peer Support Specialist Program.

BackgroundWhen the COVID-19 pandemic lockdown measures were instituted, the wide-scale necessity for remote mental health care increased among professional clinicians, such as psychiatrists, psychologists, social workers, and certified peer support (CPS) specialists. Factors contributing to increased demand include concern for the safety of loved ones, the safety of oneself, overall well-being, unemployment, and loneliness for older individuals. While demand continues to increase and a shortage of mental health professionals persists, understanding the training, technology, media, and delivery of digital peer support services can facilitate community-based support services to assist patients in coping with mental health symptoms between clinical encounters with licensed professionals. Digital peer support consists of asynchronous and synchronous, live or automated, peer support services such as applications, social media, and phone calls.ObjectiveThe purpose of this cross-sectional study is to determine how digital peer support is delivered, by which technologies it is delivered, and how certified digital peer supporters are trained within the United States to inform future delivery of digital peer support.MethodsWe used an online cross-sectional self-report survey developed alongside certified peer specialists. The study included questions regarding the types of peer support training and the delivery methods used within their practices. We advertised the survey through a certified peer support specialist listserve, Facebook, and Twitter.ResultsCertified peer specialists provide mutual social emotional support to those with a similar mental health condition. Of certified peer specialists trained in CPS, the majority of CPS specialists were trained in peer support (418/426, 98.1%). Peer support specialists deliver services via telephone calls (182/293, 62.1%), via videoconference-based services (160/293, 54.6%), via SMS text messages (123/293, 42%), via smartphone apps (68/293, 23.2%), and via social media (65/293, 22.2%). Certified peer specialists deliver services through virtual reality (11/293, 3.8%) and through video games (6/293, 2%). Virtual reality and video games may represent emerging technologies to develop and deliver community-based support.ConclusionsThis study examined the modes of digital peer support intervention as well as the training and demographic background of peer supporters. Given the demand for mental health care, digital peer support emerges as one option to increase access. These results suggest that CPS specialists commonly use SMS text messaging, phone calls, and videoconferences to engage in peer support. Less frequently, they may use diverse modes such as apps, social media, and video games. It is important to consider the backgrounds of peer supporters and the mediums of communication to best accommodate areas where access to peer support is emerging. Larger longitudinal studies and a variety of experimental designs may be considered to understand the efficacy of digital interventions and digital peer support training to direct optimal care.

Peer support specialists and perinatal opioid use disorder: Someone that’s been there, lived it, seen it

Peer support specialists (PSSs) in mental healthcare services are individuals recovering from mental health conditions and providing formal peer support to clients with similar conditions. Despite evidence of the benefits of this modality and the increasing demand for it, little is known about the PSSs' experiences in mental healthcare services. This review systematically synthesises available qualitative data on the certified PSSs' experiences in providing formal peer support in mental healthcare services. A search was performed across six electronic databases and one grey literature database for all published and unpublished qualitative studies in English between 2014 and 2022. Mixed-methods studies were included if their qualitative data were extractable. This review included PSSs who provided formal peer support to clients with similar mental health conditions. The included studies were appraised through the Critical Appraisal Skills Program Qualitative checklist, while data extraction was done through a customised tool. Our meta-synthesis revealed an overarching theme on certified PSSs' journey in mental healthcare services, alongside four main themes: (i) emotional impacts of being PSSs, (ii) struggle to justify their roles, (iii) complex roles of PSSs and (iv) sources of support. The review has provided an insightful understanding of the PSSs' roles and needs, for which there is a need to cultivate a supportive working environment. Given the difficulties in adopting the PSSs' roles, as demonstrated by our findings, future research should explore how mental healthcare organisations can address their work-related challenges and cultivate a supportive working environment.

BackgroundUsing the lived experience as their expertise, peer support specialists (PSS) focus on the empowerment of individuals with mental health conditions. Despite its value, peer support services in Singapore are relatively uncommon. Perspectives from mental health workers may provide insights on targeted strategies to address the organisational changes needed for the continued growth of the lived experience workforce.AimsThe study aims to explore the attitudes and perceptions of mental health workers regarding the benefits, challenges, and potential strategies in the implementation of peer support services across mental health settings in Singapore.MethodsA total of 59 responses were gathered for an online survey via convenience sampling. Descriptive statistics were generated for quantitative data, while an inductive thematic analytic method was utilised for qualitative inputs. The coding and refinement of themes were discussed between both authors.ResultsThe majority of the respondents were willing to accept PSS as a healthcare profession (72.9%), willing to work with PSS (89.8%) and perceived there should be PSS where they worked (64.4%). Key themes identified highlighted a supportive and inclusive workplace environment, the power of the lived experience, and recovery-oriented contribution as the underlying benefits and potential challenges in implementing PSS in Singapore.ImplicationsPolicymakers could consider funding initiatives and regulatory standards to support the implementation of PSS across mental health settings in Singapore, while organisations could implement training programmes and supervision targeted at enhancing the practice of recovery-oriented care amongst its staff.

BackgroundEngaging peer support to augment and enhance traditional mental health services presents novel opportunities to improve service engagement and delivery. However, there has not been an in-depth analysis of the processes and methods behind the coordination of physical health and mental health care by peer support specialists.Study aimTo explore the potential of peer support specialists in community mental health centers and as a means to improve coordination of physical health and mental health services for people with a serious mental illness.MethodsWe conducted 28 semi-structured qualitative interviews with peer support specialists and mental healthcare professionals in community mental health centers in two states (blinded for review) in the United States. Data were triangulated to explore peer support specialists and mental health professionals’ perspectives.ResultsWe found five themes characterizing the role of peer support services in the coordination of physical health and mental health services for individuals with serious mental illness: (1) Advocacy in interprofessional meetings, clinical teams, and advisory councils; (2) Sharing lived experiences and connecting with available resources and services; (3) Preparing for mental health and physical health care visits; (4) Mutuality; and (5) Affiliations, funding, and sustainability of peer support services.ConclusionThis study suggests that peer support specialists can uniquely contribute to the coordination of physical health and mental health services for individuals with serious mental illness.

Objective To assess the feasibility, acceptability, and preliminary effectiveness of digital peer support integrated medical and psychiatric self-management intervention (“PeerTECH”) for adults with a serious mental illness. Methods Twenty-one adults with a chart diagnosis of a serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or treatment-refractory major depressive disorder) and at least one medical comorbidity (i.e., cardiovascular disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension, and/or high cholesterol) aged 18 years and older received the PeerTECH intervention in the community. Nine peer support specialists were trained to deliver PeerTECH. Data were collected at baseline and 12-weeks. Results This pilot study demonstrated that a 12-week, digital peer support integrated medical and psychiatric self-management intervention for adults with serious mental illness was feasible and acceptable among peer support specialists and patients and was associated with statistically significant improvements in self-efficacy to manage chronic disease and personal empowerment. In addition, pre/post non-statistically significant improvements were observed in psychiatric self-management, medical self-management skills, and feelings of loneliness. Conclusions This single-arm pre/post pilot study demonstrated preliminary evidence peer support specialists could offer a fidelity-adherent digital peer support self-management intervention to adults with serious mental illness. These findings build on the evidence that a digital peer support self-management intervention for adults with serious mental illness designed to improve medical and psychiatric self-management is feasible, acceptable, and shows promising evidence of improvements in clinical outcomes. The use of technology among peer support specialists may be a promising tool to facilitate the delivery of peer support and guided evidence-based self-management support. People with serious mental illness (SMI; defined as individuals diagnosed with schizophrenia spectrum disorder, bipolar disorder, or treatment-refractory major depressive disorder) are increasingly utilizing peer support services to support their health and recovery. Peer support is defined as shared knowledge, experience, emotional, social, and/or practical assistance to support others with similar lived experiences (Solomon, 2004). Most recently the definition also includes the provision of evidence-based peer-supported self-management services (Fortuna et al., 2020). Mental health peer support can augment the traditional mental health treatment system through providing support services to maintain recovery between clinical encounters (Solomon, 2004) and is classified by the World Health Organization as an essential element of recovery (World, Health, and Organization, About social determinants of health, 2017).

Peer telemental health recently became Medicaid reimbursable during the COVID-19 crisis, increasing the need for standardized training on digital peer support (DPS) services. DPS has the potential to reduce barriers to services and expand the reach of peer support specialists. The 4-h Digital Peer Support Training program was developed to train peer support specialists for rapid uptake in providing digital peer support during the COVID-19 crisis. The purpose of this study was to examine the impact of the 4-h DPS course for peer support specialists. Surveys were administered to examine pre-post changes in DPS course for participants (N = 75) related to attitudes/ beliefs towards DPS, ability to use/ engage in DPS, and organizational readiness to implement DPS. Data were analyzed by conducting paired samples t-tests. Linear mixed models were used to explore significant results further. Statistically significant (< .05) changes were observed related to readiness to use DPS, attitudes/ beliefs towards DPS, and ability to use/ engage in DPS. The 4-h DPS course may be beneficial in providing diverse groups of peer support specialists with a standardized training framework. Widespread dissemination of the DPS short course may be beneficial in rapidly equipping peer support specialists with the skills and resources needed to expand the reach of peer support services during the COVID-19 crisis and beyond.

Peer telemental health recently became Medicaid reimbursable during the COVID-19 crisis, increasing the need for standardized training on digital peer support (DPS) services. DPS has the potential to reduce barriers to services and expand the reach of peer support specialists. The 4-h Digital Peer Support Training program was developed to train peer support specialists for rapid uptake in providing digital peer support during the COVID-19 crisis. The purpose of this study was to examine the impact of the 4-h DPS course for peer support specialists. Surveys were administered to examine pre-post changes in DPS course for participants (N = 75) related to attitudes/ beliefs towards DPS, ability to use/ engage in DPS, and organizational readiness to implement DPS. Data were analyzed by conducting paired samples t-tests. Linear mixed models were used to explore significant results further. Statistically significant (< .05) changes were observed related to readiness to use DPS, attitudes/ beliefs towards DPS, and ability to use/ engage in DPS. The 4-h DPS course may be beneficial in providing diverse groups of peer support specialists with a standardized training framework. Widespread dissemination of the DPS short course may be beneficial in rapidly equipping peer support specialists with the skills and resources needed to expand the reach of peer support services during the COVID-19 crisis and beyond.

IntroductionEmergency departments (ED) are incorporating Peer Support Specialists (PSSs) to help with patient care for substance use disorders (SUDs). Despite rapid growth in this area, little is published regarding workflow, expectations of the peer role, and core components of the PSS intervention. This study describes these elements in a national sample of ED-based peer support intervention programs.MethodsA survey was conducted to assess PSS site characteristics as part of site selection process for a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) evaluating PSS effectiveness, Surveys were distributed to clinical sites affiliated with the 16 CTN nodes. Surveys were completed by a representative(s) of the site and collected data on the PSS role in the ED including details regarding funding and certification, services rendered, role in medications for opioid use disorder (MOUD) and naloxone distribution, and factors impacting implementation and maintenance of ED PSS programs. Quantitative data was summarized with descriptive statistics. Free-text fields were analyzed using qualitative content analysis.ResultsA total of 11 surveys were completed, collected from 9 different states. ED PSS funding was from grants (55%), hospital funds (46%), peer recovery organizations (27%) or other (18%). Funding was anticipated to continue for a mean of 16 months (range 12 to 36 months). The majority of programs provided “general recovery support (81%) Screening, Brief Intervention, and Referral to Treatment (SBIRT) services (55%), and assisted with naloxone distribution to ED patients (64%). A minority assisted with ED-initiated buprenorphine (EDIB) programs (27%). Most (91%) provided services to patients after they were discharged from the ED. Barriers to implementation included lack of outpatient referral sources, barriers to initiating MOUD, stigma at the clinician and system level, and lack of ongoing PSS availability due to short-term grant funding.ConclusionsThe majority of ED-based PSSs were funded through time-limited grants, and short-term grant funding was identified as a barrier for ED PSS programs. There was consistency among sites in the involvement of PSSs in facilitation of transitions of SUD care, coordination of follow-up after ED discharge, and PSS involvement in naloxone distribution.Supplementary InformationThe online version contains supplementary material available at 10.1186/s13722-024-00453-x.

Peer support specialists (PSs) have mental health recovery experience and are hired to assist others with similar challenges. This study is among the first to characterize stress among PSs, compared to data on other groups. Seven hundred and thirty-eight PSs working in U.S. mental health settings completed a cross-sectional online survey that included the Maslach Burnout Inventory, the Secondary Traumatic Stress Scale, and the Perceived Stress Scale (PSS). Participants' scores were compared with those obtained in prior samples of nonreferred adults and nonpeer clinicians. Comparisons are stratified by PSs' level of current symptoms, assessed with the Brief Symptom Inventory. As a group, PSs experienced low to moderate levels of general and work-related stress. PSs endorsed modestly lower levels of general stress (d = -.25) than a normative sample of community residents. Although PSs endorsed lower levels of secondary trauma (d = -.15) than social workers and greater emotional exhaustion (d = .13) than nonpeer clinicians, effect sizes are "smaller than small." A small subgroup (21.6%) of PSs with significant current symptoms experienced substantially greater general stress, secondary trauma, and emotional exhaustion than comparisons (d = 0.77, 1.04, and 1.12, respectively); despite having work conditions similar to other PSs respondents. Overall, PSs appear no more susceptible to general stress and work-related stress than relevant comparison groups of community residents and clinicians. A small subgroup of PSs experience both significant stress and symptoms-as is the case in other populations, given the well-established association between these constructs. Implications for supporting PSs and other clinicians with periods of work stress are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Potential impact of peer support service on SUD treatment engagement following ED visits among Kentucky medicaid beneficiaries.