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Research Highlight

Potential Role of Peer Support in Care Management

The intersection between peer support and care management is of increasing interest to mental health services researchers, leaders, and policymakers. Care management is a key part of team-based mental health care, including mental health care that is delivered in specialty settings or in primary care. Collaborative care, an evidence-based model of primary care, emphasizes ongoing care management for persons with mental health conditions treated in primary care.

Peer support programs are also becoming more widely disseminated. Certified peer specialists, persons who have "lived" mental health treatment experience, and those who have completed a certification program are becoming more commonly employed in the Department of Veterans Affairs and other public mental health systems to support persons receiving mental health care. Peer support is considered a key element of recovery-oriented mental health care, supporting patients in their non-linear recovery journeys by providing social connections, and transferring skills and knowledge. However, to date, potential intersections or synergies between peer support and care management have received only limited attention.

Traditional Peer and Care Manager Roles

Care management programs include activities that assist patients and their informal supporters or caregivers in better managing their medical and mental health conditions. Guided by a care plan developed by team members in conjunction with the patient, care managers might coordinate specialist or auxiliary appointments that support a patient's health, remind patients about their appointments or accompany them to appointments, and help patients both establish and meet self-identified goals. Care managers also work with patients to improve their self-care for ongoing health and mental health conditions.

Peers working with patients may complete tasks similar to those outlined above for care managers, although peer roles are often broader and less specified than care manager roles. Peer activities may vary in both content and structure (i.e., they may primarily provide emotional support or share their recovery story, deliver structured curriculum, or provide care managementtype services). Peers may also model community living skills and provide key information to patients about community and social resources. By modeling life skills and recovery, peers are thought to promote hope, activation, and support the self-efficacy of the patients with whom they are working.

Peers may be more or less integrated into formal mental health treatment teams. Peers who participate in mutual self-help groups (e.g., Alcoholic Anonymous) have often functioned outside of formal treatment settings. However, certified peer specialists are increasingly functioning as full members of formal treatment teams. In general, only peers who are certified and full members of treatment teams take on care manager tasks and assist in implementing a care plan.

The Evidence for Peer Support in Different Roles, Including Care Manager Roles

Potentially, because of the variety of roles and activities that peers might assume when supporting others with mental health conditions, several recent systematic reviews have reported mixed evidence for the effectiveness of peer support in improving patients' outcomes.1, 2, 3 Several trials of peer support within VA have also reported little benefit compared to usual or enhanced usual care, except for increases in patient activation. A systematic review by Chinman et al. reported that studies that assessed the impact of peers added to usual care services and peers who delivered structured curricula reported improvements in measures of recovery, empowerment, and hope. In contrast, Pitt et al. found that "add on" peer staff provided little benefit. A systematic review by Llyod-Evans et al. reported low-grade evidence for a reduction in psychiatric symptoms and hospitalizations but more positive, albeit inconsistent, evidence for improvements in hope and empowerment. However, both Lloyd-Evans et al. and Pitt et al., reported no differential effect for peer staff delivering traditional care management services compared to professional staff.

Thus, while the evidence is mixed and limited, peers may do as well as professionals in providing care management type services and may produce improvements in recoveryoriented outcomes, such as activation, hope and empowerment.

Peer support has wide acceptance in the mental health community, and these programs are being further disseminated and expanded within VA and other public sector settings. Currently, over 35 state Medicaid programs reimburse for peer services.

While peer support literature gives preliminary indications that peers who act as care managers might produce patient outcomes similar to professional care managers, additional research on peers in these roles appears warranted. Further defining the types of care management activities where peers function best or where they might even be preferable to professional staff is key to developing an efficient approach to providing these patient-centered services. Identifying synergies between these popular and expanding programs stands to improve patient outcomes.

References

1. Chinman M, George P, Dougherty RH, et al. "Peer Support Services for Individuals with Serious Mental Illnesses: Assessing the Evidence," Psychiatric Services 2014; 65(4):429-41.
2. Pitt V, Lowe D, Hill S, et al. "Consumer-Providers of Care for Adult Clients of Statutory Mental Health Services [Internet]," Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd, 2013. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858. CD004807.pub2/abstract
3. Lloyd-Evans B, Mayo-Wilson E, Harrison B, et al. "A Systematic Review and Meta-analysis of Randomised Controlled Trials of Peer Support for People with Severe Mental Illness," BMC Psychiatry 2014; 14:39.