The Role of Peer Support in Federally Qualified Health Centers

August 13, 2020

The use of peer providers – also known as recovery coaches (PRCs), peer support specialists, and patient navigators – has become a promising practice in substance use disorder (SUD) treatment. As more evidence emerges on the importance of peer support for SUD recovery, findings demonstrate that peer support services are associated with several key improved health outcomes, including: reduced substance use, increased treatment retention, reduced relapse rates, greater housing stability, decreased criminal justice involvement, and more. Through partnerships with state behavioral health agencies and Medicaid, state and territorial health agencies can promote the establishment of peer support services and ensure sustainability for the critical work they do.

Peer recovery coaches are particularly impactful in improving outcomes for pregnant and postpartum women with SUD. Initiatives like Project Nurture in Oregon have found that PRCs had significant impacts on women’ self-advocacy and adherence to treatment. Additional findings underscore how peer recovery services can provide role modeling of positive health behaviors for women, connect with women more effectively than clinical staff, and be a source of employment.

Definition and Role

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines a peer provider as a person who uses their lived experience of recovery from mental illness and/or addiction, plus skills learned in formal training, to deliver services in behavioral health settings to promote mind-body recovery and resiliency. ‘Peer provider’ is an umbrella term for various professionals who provide peer support, one of which includes peer recovery coaches. A peer recovery coach is defined as “a peer leader in stable recovery (who) provides social support services to a peer who is seeking help in establishing or maintaining their recovery.” These individuals are trained to provide informational, emotional, social, and/or practical support to individuals recovering from SUD and can be found in a variety of settings such as hospitals, outpatient clinics, and recovery community centers. Regardless of the level of formal training or certification, peer recovery coaches can effectively engage patients beyond the bounds of traditional clinical practice.

Peer Support Services in Federally Qualified Health Centers

Federally qualified health centers (FQHCs) play an especially critical role in delivering peer recovery support in the healthcare safety net. Primary care is a key entry point for new patients in need of SUD treatment and peer support services, and FQHCs have proven themselves to be capable of successfully integrating substance use services. FQHCs can also act as an entryway to peer support and SUD services for individuals receiving regular primary care who may otherwise avoid or delay seeking out SUD services due to stigma.

Financing

States and territories use various funding streams to finance peer recovery support services. While several federal agencies (such as SAMHSA) provide related grant funding, Medicaid is a major source of financing for peer support services. This is evidenced by the 37 state Medicaid programs which define, cover, and pay for peer support services. State Medicaid coverage of peer support varies in terms of eligible services, settings, and peer support specialist criteria. The Centers for Medicare and Medicaid Services (CMS) recently promoted the use of Medicaid Section 1115 waivers to address the opioid epidemic through SUD treatment demonstration opportunities, including peer support. For example, West Virginia’s Section 1115 waiver allows the state to reimburse peer recovery support services when provided by peer specialists certified by the state’s Department of Health and Human Services.

Training and Certification

CMS issued guidance in 2013, stating that peer support specialists must “complete training and certification as defined by the state” to provide billable services. Since then, states are increasingly formalizing the peer support profession by establishing training programs and certification pathways. For instance, Michigan’s certification training requires that applicants be employed as peer recovery coaches for a minimum of 10 hours per week, have received publicly-funded treatment and recovery services for addiction, and maintain continuing education requirements. In Pennsylvania, recovery specialists are vetted by the state’s certification board through a written examination.

Recruitment

Some of the strategies that have been used for recruiting peer support providers include using peer provider training lists to engage qualified providers who are ready for employment. Another strategy is recruiting from those who have a personal experience with recovery either currently or in the past. Other recruiting methods include getting referrals from state rehabilitation divisions and through contact with other peer organizations. Some states, such as Massachusetts, seek to recruit peer support providers in a manner that actively encourages participation of historically underrepresented communities in terms of accessing services.

Looking Ahead and Considerations

Leveraging the lived experience of PRCs can allow states to advance health equity by ensuring that individuals with SUD are supported by their peers, reducing stigma, and creating a sense of trust. Principles like mutuality and reciprocity are often at the heart of peer support services, both of which are powerful antidotes to the internalized stigma and shame that clients may experience. Peer support services that are tailored to the local circumstances and community that they serve can help address the health disparities that individuals and families struggling with substance use and mental health disorders may have. Federal organizations working on behavioral health issues, such as CDC and SAMHSA, also play a role in addressing substance use and promoting peer support services by providing clear guidelines and best practice recommendations on the use of peer support in health centers; supporting the development of research studies to build the evidence base on peer support services; and developing trainings and certifications for peer support providers.