The Pandemic, Peer Recovery Supports, & the Value of Care Coordination
Substance abuse and mental health treatment models continue to not only fail patients and their families but their workforce as well. Many sufferers have sought treatment in the past, with not even a glimpse that recovery was possible. Patient engagement in care is a reoccurring struggle for behavioral healthcare providers.
Emerging quality standards in behavioral healthcare are currently focusing on bridging the gap between behavioral health and physical medicine, within a recovery-oriented system of care. The emerging changes in standards and quality of care are in direct response to many treatment providers not offering a continuum of care, not coordinating care from additional specialties, and utilizing mutual aid groups alone for aftercare. These service gaps, in conjunction with the professionalism of substance abuse care, created the space in which peer recovery support services were born. Peer-based services within community-based programs, substance abuse treatment, and mental health care have continued to develop over time, despite being met with many barriers along the way. The roles of peer workers are many and diverse and exist within multiple care specialties and organizations. The current language, practice guidelines, and credentialing aspects may differ among peer providers, however, the value of the peer-based relationship to the consumers they serve remains recovery-oriented.
In 2001, ASAM defined recovery as, as “overcoming both physical and psychological dependence to a psychoactive drug while making a commitment to sobriety.” Today ASAM’s definition looks a bit different, “Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.” The changes made in ASAM’s new definition highlight the needed changes that are required to treat those who suffer from substance use from a whole-person perspective.
Formally licensed care providers, who used to define recovery from such a narrow-minded viewpoint, are now adopting the trauma-informed, strengths-based, and recovery-oriented frameworks of the peer-based workforce. However, these same formally licensed care providers are simultaneously remaining resistant in their adoption and acceptance of peer providers as valued members within multidisciplinary teams. This fragmentation continues to fuel treatment gaps and interruptions in utilization while creating barriers to continued care along a formal continuum. This fragmentation also exists within the current fee-for-service system overall. Providers and payers must move away from fee-for-service models that only reimburse based on volume, and move toward a system that holds providers accountable for the quality of care, patient outcomes, and allows for innovation. Value of care is determined by the consumers, not the policymakers and payers. The COVID-19 pandemic has created new challenges across the entire healthcare landscape, including behavioral health. The fear, isolation, and socioeconomic effects of COVID-19, have heightened many existing barriers to receiving care, such as financial weakness, food insecurity, substance abuse, and the inability to access community services.
For payers seeking to engage with their members who are not currently participating in appropriate care, they are often finding that the pandemic has stretched thin the existing behavioral health services and providers available. The provider workforce as a whole is significantly burnt out, and the pandemic is not backing down. The current pandemic also highlights the importance of social determinants of health, along with the relationship evident between those significantly impacted by the pandemic are often the same population that suffers from substance abuse or mental health. Providers are doing their best, but without active collaboration of care, many sufferers are left without their needs truly being met.
The current state of addiction and mental health treatment has left consumers, providers, and payers, with levels of care that do not adequately implement or report on the quality of care provided. All stakeholders involved are left with increasing costs of care, lack of treatment outcomes, and fragmented care delivery. Despite the seemingly impossible improvements necessary within each level of care, the development of peer providers with lived experience in recovery from substance abuse and/or mental health as valued members of the behavioral healthcare workforce will continue forward. Peer-based services meet the sufferer, right where they’re at, and can engage them in the services and supports they need. Peer providers, whether their role is a recovery specialist or coach, are recovery champions of strength and resiliency within their communities. They are visible examples of the opportunity that recovery has to offer those who continue to suffer from active substance use and/or active mental health symptoms. The industry growth and adaptation of recovery-oriented systems of care will continue to fuel the passion within every peer provider. The presence of these recovery champions in the community may be the key contagion that allows the concept of recovery capital to become commonplace and utilized within healthcare delivery and community support(s).
Peer providers will continue to unite and develop core training for staff within primary care settings and alternative reimbursement models that include primary care physicians. Once a set of standardized training and skill requirements are established within communities and service areas, they will allow for peer recovery coaching and supportive services to be adequately defined and embedded within a patient-centered continuum of care. Such as clinical settings, non-clinical settings, emergency departments, crisis-stabilization, mobile crisis teams, psychosocial rehabilitation programs, outpatient behavioral health programs, and peer-run programs.
William White was correct in 2013, when he predicted that recovery would be the organizing construct of the alcohol and drug problem landscape. Stakeholders in policy and treatment are acknowledging the benefits of peer support, as evidenced by their development of new funding streams. Common goals of peer support services are to provide a safe and supportive environment, acceptance and education, and utilizing their lived recovery experience disclosure when appropriate. Peer support providers continue to capture new ideas and experiences that have proven effective in the field, ensuring that the movement evolves over time to respond to ongoing research discoveries and to changes in society and culture. Peer recovery support services are a trauma-informed practice and aim to be culturally competent within their service markets.
Issues related to social determinants of health such as transportation, food insecurity, unemployment, and lack of supportive housing play a significant role in creating barriers to continued recovery. The linkage between treatment and recovery needs more attention by the healthcare system if there is ever to be a hope of providing true value of care. Recovery capital can be synonymous with social determinants of health within substance use treatment. Assessing recovery capital includes the assessment of personal capital, social capital, community capital, and cultural capital. Personal capital includes the resources an individual has to meet their basic needs such as transportation, housing, and nutrition. It also includes an individual’s abilities, skills, and knowledge associated with navigating life. Social capital refers to resources such as interpersonal relationships, and recovery supports. Community capital includes resources available to an individual such as treatment services, advocacy groups, and peer recovery support. Cultural capital includes resources available to an individual based on their specific cultural and faith-based beliefs. Essentially, assessing recovery capital mirrors domains that should be addressed during a full biopsychosocial assessment and highlights any social determinants of health that may impose barriers on an individual’s continued recovery. To combat the chronic nature of fragmented services and failed linkage between levels of care, a team-based approach is necessary. Assessing social determinants of health will not improve patient care if collaboration among providers does not exist.
Value-based care reimbursement models are the industry and policy response to fragmented care delivery. These models aim to bring all aspects of patient care together with a shared outcome, improved quality of life. This will require providers to collaborate in patient care through coordination efforts. ASAM believes that those who suffer from chronic medical conditions like addiction can achieve recovery when high quality, coordinated whole-person care is attainable. Peer providers are uniquely qualified to engage with patients as they access every necessary provider, and can help in said coordination of whole-person care while also assessing recovery capital outcomes along the way. With the pandemic resurging, what is the substance use treatment industry waiting for? Changes need to be made to how care is delivered, otherwise, those who suffer from substance use will continue to struggle within a system that is not built for their success.