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Cover Page Graphic: Real Choice Systems Change Grant Program: Initiatives of the FY2004 Mental Health Systems Transformation Grantees: Final Report, U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services Logos, June 2009

Initiatives of the FY2004
Mental Health Systems Transformation Grantees

Wayne L. Anderson, Ph.D.

Janet O'Keeffe, Dr.P.H., R.N.

Christine O'Keeffe, B.A.

CMS Project Officer: Cathy Cope

Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-14-26
Baltimore, MD 21244-1850

RTI International

Contract Number CMS-500-00-0044, TO #2

June 2009

This project was funded by the Centers for Medicare & Medicaid Services under contract no. CMS-500-00-0044, TO #2. The statements contained in this report are solely those of the authors and the Systems Change Grantees and they do not necessarily reflect the views or policies of the Centers for Medicare & Medicaid Services.

RTI International is a trade name of Research Triangle Institute.

Acknowledgments

The authors would like to thank the Mental Health Systems Transformation Grantees who provided information for this report. We would also like to thank Peggy Clark, April Forsythe, Ron Hendler, and Cathy Cope of CMS's Center for Medicaid and State Operations for helpful comments on an earlier draft of the paper.

Executive Summary

Mental illness is the leading cause of disability in the United States, and serious mental illnesses such as schizophrenia, bipolar disorder, and severe depressive disorders can be especially disabling if undiagnosed or untreated. Individuals with serious mental illnesses experience substantial limitations in major life activities, at home, at work, and in the community. Each year, approximately 6 percent of the U.S. population experiences a serious mental illness.

The delivery of publicly funded mental health services has evolved over the past decades from a system that consisted of large state-run mental institutions, funded solely with state funds, to a community support system (CSS) that strongly emphasizes support for individuals in the community rather than confining services to fixed-site clinics and offices. The CSS philosophy recognizes that individuals with serious mental illnesses frequently need supports beyond treatment and clinical services to help them live successfully in community settings. The CSS framework includes traditional mental health services, which have been enhanced by the development of a wider array of effective medications to treat mental disorders, improvements in medication management, and the identification of "evidence-based practices" (EBPs) that have demonstrated efficacy and cost-effectiveness in securing positive outcomes for individuals with serious mental illnesses.

An evidence-based practice is a method to address a condition, which meets scientific and stakeholder criteria for safety, effectiveness, and cost-effectiveness. EBPs translate research findings into practice. The deployment of EBPs is widely regarded as central to improving health care quality. There are now six recognized adult mental health EBPs: Assertive Community Treatment (ACT), Family Psychoeducation, Integrated Dual Disorders Treatment, Illness Management and Recovery Program, Medication Management Approaches in Psychiatry (MedMAP), and Supported Employment.

Several of these evidence-based practices have a strong recovery component. Recovery is a compelling paradigm for supporting individuals with serious mental illnesses. Recovery has its roots in the fundamental principles of the community support system concept and stresses how crucial it is for people with mental illnesses to assume responsibility for and control of their lives by making decisions about their services. Recovery shares many of the same philosophical underpinnings as those of the broader self-direction movement among people with disabilities of all types who are asserting greater authority over service provision and assuming personal responsibility for improving the quality of their lives.

Peer support is an essential component of a recovery-oriented service system. The term peer support refers to social and emotional support—frequently coupled with help to perform daily living tasks—that is mutually offered or provided by persons having a mental health condition to others with a similar or different condition, to bring about a desired social or personal change. Other examples of recovery-oriented services include Wellness Recovery Action Planning (WRAP), Pathways to Recovery, and Peer Bridgers.

The principles of recovery and the emergence of evidence-based practices are exerting a strong influence on the provision of publicly funded community mental health services. Beginning in 2000, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Robert Wood Johnson Foundation co-led a nationwide effort to promote the application of evidence-based practices. Many states have launched initiatives to introduce and expand the use of these practices in their community mental health systems. Several states, including Georgia and Michigan, have made progress in redesigning their coverage of Medicaid mental health services to incorporate the essential principles of recovery.

Mental Health Systems Transformation Grants

In September 2004 CMS provided $3.6 million to fund Mental Health Systems Transformation (MHST) grants to encourage states to develop mental health systems infrastructure to implement and sustain evidence-based and recovery-oriented practices. Grants were awarded to 12 states under the Systems Change grants program: Delaware, Maine, Massachusetts, Michigan, Minnesota, New Hampshire, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, and Virginia.

The primary purpose of the grants was to help states increase their capacity to deliver evidence-based practices and to adopt a recovery orientation in order to better serve individuals with mental illness receiving Medicaid-funded services. Another purpose was to help states to better align their Medicaid and mental health systems to collaborate with one another and with other stakeholders. States were permitted to use grant funding flexibly to achieve their goals.

This report describes the 12 MHST Grantees' initiatives, with a focus on implementation issues and challenges and how they addressed them. Four Grantees focused solely on evidence-based practices, six on recovery practices, and two on both.

Implementing Recovery-Oriented Initiatives

All of the eight Grantees with recovery initiatives focused their efforts on developing, implementing, and/or sustaining various methods for providing peer support—defined as supports and services provided by consumers on a volunteer or paid basis, whether in the traditional mental health system or through consumer-/peer-operated programs or activities.

Several Grantees developed curricula and trained individuals with mental illness to be employed in specific recovery-focused roles in the mental health system. States use different names for these roles (e.g., a recovery support specialist in Oklahoma, a certified intentional peer support specialist in Maine). States confronted some operational issues when providing training, such as provider reluctance to lose revenue when allowing peer support specialists to participate in training. With the exception of such operational issues, Grantees did not report any major challenges in conducting training. However, in some states, individuals who received training could not find employment because these states did not determine beforehand where trainees would work.

Grantees identified several major provider-related challenges that impede the overall adoption of a recovery orientation and the incorporation of peer support services, specifically, in the mental health services system. These challenges included a lack of knowledge of or interest in recovery concepts, practices, and skills; skepticism about the recovery concept; resistance to giving up control and working collaboratively with individuals they perceive as "clients"; negative views about individuals with mental illness; and reluctance to hire individuals with mental illness. Many of these challenges are interrelated, and all must be addressed if states want providers in their mental health systems to promote recovery. Grantees developed and conducted a wide range of education and training initiatives to address provider-related challenges. In addition to education and training on recovery-oriented practices, providers often need technical assistance to support the development of peer support and peer-operated services.

Peer support staff face challenges when working for traditional providers who have never encountered service users as staff members. These challenges can include the expression of negative attitudes and disrespectful comments from non-peer staff about peer support staff or consumers. Such challenges can create discomfort and workplace conflicts, and some organizations provided mentoring for peer support staff to address these conflicts or developed peer support staff networks.

Several Grantees worked to develop reimbursement policies for peer support services, but not all Grantees succeeded in securing Medicaid reimbursement for these services. Activities included developing a Medicaid State Plan amendment (Pennsylvania) or a service description and associated Medicaid billing codes for peer-operated drop-in centers (Oregon). Several Grantees mentioned inadequate funding—and a lack of Medicaid reimbursement in particular—as the reason their state could not offer or expand recovery services, particularly peer support. Several noted that because CMS no longer allows bundled billing for ACT services, they were less able to employ peer support staff on ACT teams. Several Grantees said that their state's plans to submit State Plan amendments to obtain Medicaid funding for peer support services have been put on hold until issues related to Medicaid coverage of services under the Rehabilitation and Targeted Case Management options are resolved.

Employing Medicaid to underwrite mental health services involves "finding the fit" between the services and supports that a state has identified as critical to meeting the needs of individuals with serious mental illnesses and Medicaid program requirements. Several states have done so successfully. For example, Michigan's grant staff noted that the Section (§) 1915(b) waiver authority affords considerable flexibility to fund a wide range of recovery-oriented services, including peer support specialists and peer-operated programs such as drop-in centers.

States and provider organizations sought to determine the extent of an organization's recovery orientation in order to identify areas for improvement. Several types of tools are available for this purpose, including the Recovery Enhancing Environment tool, the Recovery Oriented System Indicators tool, and the Fidelity Assessment Common Ingredient Tool. Several Grantees used one of these tools to help various entities in the mental health services system assess their recovery orientation and identify areas for improvement.

Several Grantees noted that both states and the federal government need to revise existing policies to facilitate and promote infrastructure development and bring about systems change to support a recovery orientation in the public mental health system. States can make some changes without federal approval, but others require action by CMS and SAMHSA.

Implementing Evidence-Based Practices

Several evidence-based practices are recognized by SAMHSA as having demonstrated efficacy and cost-effectiveness in securing positive outcomes for individuals with serious mental illnesses. Yet the practices validated by research are not widely offered in mental health practice settings. One possible explanation for this gap between knowledge and practice is that states need a robust infrastructure to support delivery of these practices, but developing this infrastructure is costly and challenging. Essential elements of infrastructure development include active stakeholder involvement; sustained provider training and follow-up clinical supervision; adequate funding for start-up and sufficient reimbursement for implementation; practical methods and funding to monitor implementation to improve quality; and alignment of federal, state, and provider policies and structures to support practice implementation.

The more elements of a service system that can be employed to support change and reduce resistance, the more likely that practice improvements will occur.

Six of the MHST Grantees had initiatives to implement evidence-based practices in their state's mental health system, focusing on provider training and supervision; developing reimbursement methods; and developing monitoring methods to ensure that evidence-based services are being provided with high fidelity (i.e., in accordance with implementation instructions).

Provider Training and Supervision

Changing how clinicians practice is a challenging task. Research has shown that education alone does not strongly influence their practice behaviors and that additional efforts are needed, including providing clinicians with supervision and feedback. Both North Carolina and Minnesota developed methods for providing ongoing consultation. Delaware developed a manual to facilitate the adoption of family psychoeducation by providing a visible reminder for therapists to use the evidence-based practice. As with training for peer support staff, providers were reluctant to have their clinicians participate in training because the time off led to revenue losses. New Hampshire and Minnesota developed additional funding to cover the cost of ongoing consultation and follow-up; New Hampshire is in the early stages of developing credentialing procedures and standards for providers of Illness Management and Recovery practices.

Ensuring Reimbursement for Evidence-Based Practices

To facilitate the adoption of new practices—and to track their delivery—some states developed separate billing codes for specific practices; for example, Delaware established a separate billing code for Family Psychoeducation. North Carolina explored the possibility of developing multiple billing codes and "pay for performance" initiatives.

Several grant staff noted that Medicaid's inability to reimburse all EBP components makes it difficult for providers to furnish the practices with high fidelity. Virtually all of the Grantees implementing evidence-based practices said that the SAMHSA tool kits for some practices include recovery-oriented components that frequently are not billable to Medicaid. However, several states recognize the need to find other funding sources to cover services that Medicaid will not reimburse. North Carolina developed multiple reimbursement codes to ensure that providers are able to bill for all service components of the Integrated Dual Diagnosis Treatment tool kit. Having to use multiple codes results in a complex billing structure, but it ensures coverage for all of the components of the practice.

Ensuring the Quality of Evidence-Based Practices

Research indicates that when mental health programs attempt to implement evidence-based practices, the quality of the implementation strongly influences outcomes (i.e., programs that have the higher fidelity to the defined practice tend to produce superior clinical results). This finding suggests that efforts to promote evidence-based practice must include fidelity measures and self-correcting feedback mechanisms.

Researchers have developed various measures and instruments to assess the fidelity of the implementation process. These include the tool kits from SAMHSA for each evidence-based practice and the General Organizational Index, which measures a set of general operating characteristics of an organization that are hypothesized to be related to its overall capacity to implement and sustain any evidence-based practice.

States recognize the need to ensure regular monitoring of provider practices. However, fidelity assessments are expensive, and providers cannot afford to conduct them on an ongoing basis. North Carolina and New Hampshire provided funding to support monitoring. Some Grantees also developed structured processes to support fidelity measurement. No Grantee was monitoring consumer outcomes as a quality measure.

Conclusions

Although SAMHSA has approved six evidence-based practices and encouraged their adoption, to date, science is far ahead of practice. Some states have taken the lead and made progress in the delivery of both evidence-based and recovery practices, but others are still in the very early stages of implementation. Although the 12 states that received MHST grants have unique service delivery systems and are at different stages in the systems transformation process, they faced similar challenges. Even with these challenges, all made significant progress in developing the infrastructure to support evidence-based and recovery practices.

Despite the availability of information about how to implement evidence-based practices, these 12 states varied in the degree to which they appeared to make use of it. Some states used their grants to implement one or more components of a clearly articulated, broad systems transformation strategy, whereas others implemented what seemed to be stand-alone initiatives. Still others had education initiatives that a cursory review of the research literature would have revealed as inadequate for achieving their goals.

Before planning systems change initiatives generally, and the implementation of evidence-based practices specifically, state staff need to review the relevant literature and to take advantage of available technical expertise to become more knowledgeable about implementation challenges and methods to address them. Understanding what other states have tried and the challenges they faced and resolved—or not—will also help staff to develop successful approaches.

Several Grantees mentioned federal Medicaid rules as a major impediment to the adoption of a recovery orientation, because the rules preclude coverage of many recovery-oriented practices. Many Grantees also said that lack of Medicaid reimbursement for all components of evidence-based practices made it difficult to implement the practices with high fidelity. However, Medicaid pays for services—not practices. Medicaid principally pays for medical services (including psychiatrist and some psychologist services), and the majority of mental health services are covered through optional benefit categories, such as rehabilitation and clinic services.

Because evidence-based practices include some components that Medicaid does not cover, states need to break down the practices into services to determine what Medicaid can cover under the State Plan and to identify other sources of funding for the components not covered. For example, North Carolina uses state funds for recovery-oriented services and Medicaid funds for services that meet State Plan requirements to seamlessly integrate evidence-based practices with recovery-oriented services such as housing, employment, social, and peer supports.

Although it is understandable that states with limited budgets look to Medicaid to fund recovery-oriented services, including peer support and all components of evidence-based practices, it is important for state staff and policy makers to recognize that the basic provisions of Medicaid law determine parameters for Medicaid services, which may not encompass all of the services and supports that beneficiaries with serious mental illnesses need to live successfully in the community.

Employing Medicaid to underwrite mental health services entails finding the fit between Medicaid program coverage and the services and supports that a state has identified as critical to meeting the needs of individuals with serious mental illnesses. Several states have done so successfully. Eight states support peer specialists through various Medicaid financing strategies, primarily by qualifying individuals with mental illness as providers under the Medicaid rehabilitation option. Georgia and South Carolina have also developed a distinct peer support service under the rehabilitation option. Michigan, Colorado, and New Mexico use §1915(b) waivers to cover peer support services.

States should consider investigating other Medicaid authorities for covering these services. For example, Michigan and Oregon use the §1915(b)(3) waiver authority to use savings obtained through managed care arrangements to cover additional services, including recovery-oriented services. Nevada and Iowa are using the new §1915(i) home and community-based services (HCBS) authority to provide services for individuals with mental illness. A major advantage of this authority is that it does not tie the provision of HCBS to a requirement that an individual need an institutional level of care.

Finally, states need to establish measurable goals to guide the transformation to an evidence-based, recovery-oriented mental health system and to identify desired individual, provider, and systems-level outcomes to measure progress toward those goals. However, fidelity assessments and other systems evaluation measures are very costly to implement, and states need to provide technical assistance and funding to providers to conduct fidelity reviews and measure progress.

Next Steps

The MHST grants provided much-needed funds for 12 states to implement initiatives to increase the use of evidence-based and recovery-oriented practices in their mental health systems. However, additional funding is needed to continue their efforts and sustain quality over time.

Given the very high cost of efforts to change clinicians' practice patterns, states should consider giving greater attention to working with professional licensing boards, colleges, and universities to ensure that students preparing for work in the mental health system—at all levels—receive training based on current evidence-based psychosocial intervention research and obtain clinical experience in the use of evidence-based practices. A SAMHSA-led national-level effort in this area could help to jump-start state-level initiatives as well as focus much-needed attention on the need to prepare mental health practitioners and clinicians at all levels to provide evidence-based and recovery-oriented services.

The proposed changes to services under Medicaid's rehabilitation and targeted case management options—and uncertainty about how, when, and whether the changes will be finalized—have led many states to put mental health systems improvement initiatives on hold. Many Grantees said that their states will be unable to move forward with their plans to increase the availability of evidence-based and recovery-oriented practices in their mental health systems until CMS releases final rules. However, CMS cannot act until the congressional moratorium ends, and Congress may extend it until the new administration decides how to handle the proposed changes.

Section 1. Introduction¹

Mental illness is the leading cause of disability in the United States, and serious mental illnesses such as schizophrenia, bipolar disorder, and severe depressive disorders, can be especially disabling if undiagnosed or untreated. Individuals with serious mental illnesses experience substantial limitations in major life activities, at home, at work, and in the community. Each year, approximately 6 percent of the U.S. population experiences a serious mental illness.²

Public funds account for almost $3 of every $5 spent on mental health services in the United States. The organization and management of public mental health systems is a state responsibility, and states and localities underwrite a substantial share of national mental health expenditures. Historically, public mental health systems revolved around the operation of large public institutions. Today these systems focus on assisting individuals in the community. Federal funding for mental health services comes from the Medicaid program and grants to states from the Substance Abuse and Mental Health Services Administration (SAMHSA).

The joint federal-state Medicaid program is the single largest source of funding for public mental health services. On average, over a 10-year period from 1991–2001, Medicaid accounted for 44 percent of public mental health spending.³ Approximately 11 percent of Medicaid beneficiaries use mental health and/or substance abuse services.⁴ Most state Medicaid programs cover mental health services that are frequently unavailable through private health insurance or Medicare.⁵

No single source of public funding—including Medicaid—is sufficient in its amount or purpose to fully support effective community mental health services. States must use multiple funding sources to support individuals. However, Medicaid can play a pivotal role in underwriting vital services and supports for low-income individuals with serious mental illnesses.

The delivery of publicly funded mental health services has evolved over the past decades from a system that consisted of large state-run mental institutions, funded solely with state funds, to a community support system (CSS) that strongly emphasizes support for individuals in the community rather than confining services to fixed-site clinics and offices. The CSS philosophy recognizes that individuals with serious mental illnesses frequently need supports beyond treatment and clinical services to help them live successfully in community settings. It also underscores the critical role that peers, families, friends, and other sources of community support outside the formal service delivery system can play in supporting individuals in community settings.

The CSS framework also includes traditional mental health services, which have been enhanced by the development of a wider array of effective medications to treat mental disorders, improvements in medication management, and the identification of "evidence-based practices" that have demonstrated efficacy and cost-effectiveness in securing positive outcomes for individuals with serious mental illnesses. The President's New Freedom Commission on Mental Health stressed the importance of increased use of evidence-based practices.⁶ (See Box 1 below.)

Box 1. Evidence-Based Mental Health Practices⁷

Several of these evidence-based practices have a strong recovery component. Recovery is a compelling paradigm for supporting individuals with serious mental illnesses (see Box 2). Recovery has its roots in the fundamental principles of the community support system concept and stresses how crucial it is for people with mental illnesses to assume responsibility for and control of their lives by making decisions about their services. Recovery shares many of the same philosophical underpinnings as those of the broader self-direction movement among people with disabilities of all types who are asserting greater authority over service provision and assuming personal responsibility for improving the quality of their lives.¹⁴

Box 2. Recovery-Oriented Services and Peer Support¹⁵

Over the past decade, prompted by advocates, the emerging research literature, and concurrent demands to improve the effectiveness of public mental health services, several states have introduced the recovery concept into their mental health systems. In many states, this introduction coincided with a shift toward a managed care approach to financing services and system accountability.¹⁷ Peer support is an essential component of a recovery-oriented service system. (See Box 2.)

The terminology used to describe the many types of peer support—and its components—varies in the research, policy, and mental health literature, as well as in states' mental health systems. The term is used both to designate a broad concept and specific services. Some states may not even use the term "peer" in the title of a service provided by peers (e.g., recovery specialist). To eliminate confusion, this report uses the generic term "peer support" as the umbrella term for all peer-provided supports and services, whether on a volunteer or paid basis, and whether provided in the traditional mental health system or through consumer-/peer-operated programs or activities. Other terms will be used only when needed to make distinctions between different types of peer support.

Box 3. Examples of Recovery-Oriented Peer Support Practices

Although the level of evidence for the efficacy of peer support practices is not strong, individuals with mental illness report that these practices help them to achieve the recovery goals in their person-centered plans.²⁰ Rigorous research on peer support practices is under way to begin to identify the potential effects of some of these practices on various measures, including personal outcomes important to consumers and systems outcomes such as hospitalization rates and use of community-based services.²¹ Until research demonstrates their efficacy, recovery-oriented peer support practices may be viewed as promising practices or emerging best practices.²²

The principles of recovery and the emergence of evidence-based practices are exerting a strong influence on the provision of publicly funded community mental health services. Beginning in 2000, SAMHSA and the Robert Wood Johnson Foundation co-led a nationwide effort to promote the application of evidence-based practices. Many states have launched initiatives to introduce and expand the use of evidence-based practices in their community mental health systems. Several states, including Georgia and Michigan, have made progress in redesigning their coverage of Medicaid mental health services to incorporate the essential principles of recovery.

Challenges Faced When Implementing Evidence-Based Practices

Despite states' interest in incorporating evidence-based practices into their mental health systems, they face many challenges in their efforts to do so. First, many mental health practitioners lack knowledge about evidence-based practices because their education and training did not cover them. Information about evidence-based practices has only recently begun to be widely disseminated, so this challenge still exists.²³

Second, mental health practice varies widely, and professionals do not always agree on which practices lead to the best outcomes. Thus, many practitioners are reluctant or resistant to change their practice modalities, particularly if they have been using them for many years or even decades. Even when they are convinced of a practice's efficacy, change is very difficult without extensive education and training and consistent reinforcement. Reinforcement is needed from the research and clinical fields, but practitioners also need support from the mental health infrastructure that supports their work.

Third, evidence-based practices may not be supported by key stakeholders in a state's mental health system. A state's organizational culture, a lack of leadership and teamwork, statutory and regulatory policies, and reimbursement policies can all impede the adoption of both evidence-based practices and of a recovery orientation.²⁴ For example, Medicaid does not cover all the components of some evidence-based practices, and states face numerous challenges in developing effective strategies for combining federal, state, and local funding to cover them.

Fourth, individuals with mental illness and their families may also not know about these practices or be convinced of their utility. Consumers and their advocates may be more interested in encouraging the adoption of a recovery orientation and specific recovery-oriented practices, both within the traditional mental health system and through an alternative or parallel system, than they are in supporting adoption of evidence-based practices. Some view these practices as more medically oriented than recovery oriented; however, this view may be based solely on their names (e.g., "Illness Management" rather than "Maintaining Wellness").

Fifth, implementing evidence-based practices is a costly undertaking. States and provider agencies often lack the necessary funds to change the existing infrastructure to support widespread implementation of evidence-based practices.

Challenges Faced When Adopting a Recovery Orientation²⁵

Consumers and professionals who view recovery as synonymous with cure may dismiss it as an unrealistic expectation, particularly for persons with very serious illnesses such as schizophrenia and those experiencing psychotic symptoms. Thus, a major challenge for a state seeking to incorporate a recovery orientation into its mental health system is the need for extensive education and training about the recovery concept. Recovery is more aptly conceived of as a healing process with two main components: (1) defining a self apart from the illness, and (2) finding ways to relieve the symptoms of the illness or reduce the social and psychological effects of stress.

For providers to incorporate a recovery orientation into their practice, they must make a fundamental shift from being "in charge" to sharing both power and responsibility. Such a change in roles and relationships can be very challenging because it requires that providers change their fundamental concepts about the course of mental illness and the way they practice, focusing on individuals' strength and goals rather than solely on their illness. They must also abandon the hierarchical relationships they are comfortable with and develop collaborative relationships with the individuals they serve. Collaboration allows individuals with mental illness to work with providers to plan, negotiate, and make decisions about the services and activities they will use to support their recovery. To make all these changes, providers need extensive education, training, and ongoing supervision, as well as a mental health system infrastructure that not only supports these changes but also encourages them.

Efforts to encourage and support the employment of individuals with mental illness in the traditional mental health system face two specific sets of challenges. The first set arises from the stigma associated with mental illness and negative views about the capabilities of persons with mental illness. The second arises from mental health providers' ethical and professional concerns about dual relationships (i.e., interacting with a client in both a client and a co-worker role) and about confidentiality. These are valid concerns that states need to address.

Peer support staff can also experience difficulty in redefining their roles and boundaries as employees, particularly if they are hired by the agency where they are also a client. Clients may also have difficulty accepting a friend and/or peer in a paid provider role.²⁶ States need to address these and other human resources issues before peer support staff can be successfully integrated into the mental health services delivery system.

Finally, finding funding for peer services can be a challenge if they are not defined in a manner consistent with Medicaid reimbursement requirements.

Mental Health Systems Transformation Grants

Given the challenges and barriers enumerated above, in September 2004 CMS provided $3.6 million to fund Mental Health Systems Transformation (MHST) grants to encourage states to develop the infrastructure to implement and sustain evidence-based and recovery-oriented practices. Grants were awarded to 12 states under the Systems Change grants program: Delaware, Maine, Massachusetts, Michigan, Minnesota, New Hampshire, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, and Virginia.

Seven Grantees finished their grants in September 2007, and four finished in September 2008. Because Michigan did not receive its grant until May 2005, the time frame for its completion was extended to April 2009. Detailed information about each Grantee's initiative can be found in the individual state summaries in Appendix A.

This report describes the 12 MHST Grantees' projects, with a focus on implementation issues and challenges and how they were addressed.

Study Methods

To gather initial information about the Grantees' initiatives, we reviewed summaries of their goals and activities and their annual reports submitted to CMS. We also sought input from the CMS project officer and other staff. We prepared discussion guides tailored to grant activities and conducted in-depth telephone interviews during fall 2008 with all the grant project directors and associated staff, such as grant contractors. Based on these discussions and other source materials, including grant-funded reports, we prepared written summaries of grant activities and sent them to each project director for review to confirm their accuracy. We obtained clarification and additional information through follow-up calls and e mail. These summaries were the primary source of information for the main report and are included in Appendix A. To ensure accuracy, we also sent Section 2—Overview of Grantees' Initiatives—to all of the project directors for their final review.

Limitations

The descriptions of the initiatives in this report are not intended to be comprehensive or exhaustive but to provide sufficient context for understanding the discussion of policy and implementation issues.

Organization of This Report

Section 2 presents an overview of the Grantees' initiatives. Section 3 discusses Grantees' initiatives with a focus on their challenges and how they addressed them. Section 4 presents our conclusions.

Appendix A provides a summary of each of the 12 Grantees' goals and initiatives and the policy-related issues and challenges they faced. Appendix B contains the August 15, 2007, State Medicaid Director's Letter pertaining to CMS policy regarding peer support services.

Section 2: Overview of Grantees' Initiatives

This section highlights the major features of the 12 Grantees' initiatives. Table 2-1 provides an overview of the Grantees' overall goals and their primary approach for achieving them. Two Grantees had initiatives that focused on both evidence-based and recovery-oriented practices (Virginia, Oklahoma). Four Grantees had initiatives that focused solely on evidence-based practices (Delaware, Minnesota, New Hampshire, and North Carolina). Although Delaware's overall goal was to provide a stronger recovery orientation in the mental health system, its primary approach was to develop and pilot family psychoeducation: an evidence-based practice.

Six Grantees focused on recovery practices only (Maine, Massachusetts, Michigan, Ohio, Oregon, and Pennsylvania). All of the eight Grantees whose primary goal was to promote recovery had at least one initiative to develop, expand, or sustain peer support services or programs; all but one of these Grantees had peer support initiatives as their main focus. In addition to developing new and expanding existing peer-operated programs and services, a major goal for Oregon was to promote these services as evidence-based practices.

Most of the Grantees had several different initiatives to help them achieve their goals, which are described in the individual descriptions of each grant in Appendix A.

Target Populations

Grantees targeted improvements in their mental health systems to benefit specific populations.

Maine, Michigan, North Carolina, Ohio, Oregon, and Virginia targeted adults with mental illness.
Oklahoma targeted adults with mental illness and/or substance abuse disorders.
New Hampshire and Pennsylvania targeted adults with mental illness and children with serious emotional disturbance.
Massachusetts targeted adults with mental illness and children with serious emotional disturbance, including those with co-occurring substance abuse disorders; it also targeted young adults transitioning out of the children's mental health system.
Delaware targeted children with behavioral health problems and their families.
Minnesota targeted children with serious emotional disturbance and their families.

Table 2-1. Overview of MHST Grantees' Initiatives
Lead Agency	Overall Goal	Primary Approach
Delaware Department of Services for Children, Youth and Their Families	Enhance the mental health services delivery system by providing a stronger orientation toward recovery, with families as key agents for support during relapse and in the recovery process.	Develop and pilot a family psychoeducation program to educate parents/caregivers, providers, school psychologists, and guidance counselors on social, emotional, and behavioral health problems in children and youth.
Maine Department of Health and Human Services	Increase the State's ability to offer recovery-oriented services to Medicaid-eligible individuals with mental illness.	Design and implement a peer support specialist training and certification program.
Massachusetts University of Massachusetts Medical School	Promote a recovery orientation throughout the State's mental health system with a particular focus on strengthening the role of peer specialists.	Design and implement a peer support specialist training and certification program, and establish a state-level, consumer-operated Recovery Center of Excellence.
Michigan Department of Community Health	Establish recovery-oriented practices as the foundation of Michigan's adult mental health system.	Develop infrastructure to support recovery-oriented mental health services, including peer supports and a consumer-operated Recovery Center of Excellence.
Minnesota Department of Human Services	Improve the quality of children's mental health services and their treatment outcomes, and reduce out-of-home placements.	Develop an EBP database, educational materials, and training for clinicians and families to enable the provision of effective treatment strategies based on scientific research.
New Hampshire Bureau of Behavioral Health	Implement illness management and recovery (IMR) as an evidence-based practice in behavioral health services for individuals with severe mental illness.	Develop an organizational structure supporting IMR clinicians in each community mental health center region, and revise reimbursement regulations to cover IMR services.
North Carolina Division of Mental Health, Developmental Disabilities, & Substance Abuse Services	Achieve greater incorporation of evidence-based practices into the local mental health system.	Develop infrastructure to support EBPs in four pilot areas, and disseminate EBP tool kits statewide to help other local areas replicate the infrastructure-building process.
Ohio Department of Mental Health	Ensure that peer support specialists are included as part of Assertive Community Treatment (ACT) services offered by community mental health centers throughout the State.	Develop a curriculum to train individuals as peer support specialists in order to serve on ACT teams, and provide training, consultation, and technical assistance to traditional mental health providers.
Oklahoma Department of Mental Health & Substance Abuse Services	Provide quality mental health and substance abuse services focused on recovery, and involve consumers in treatment decisions.	Develop a policy and program framework for evidence-based practices, and a network of recovery support specialists.
Oregon Addictions and Mental Health Division	Develop new—and expand existing—peer-operated programs and services, and promote their acceptance statewide as evidence-based practices.	Improve peer-operated program structure and services by identifying collaboration strategies, funding mechanisms, and policy changes needed to sustain peer-operated programs.
Pennsylvania Department of Public Welfare, Office of Mental Health & Substance Abuse Services	Integrate recovery-oriented practices in the State's mental health services delivery system.	Train and certify peer support staff and develop a Medicaid reimbursement methodology for their services; provide training and technical assistance to counties to meet the requirements for the new peer support service.
Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services	Introduce and sustain the provision of recovery-oriented evidence-based practices and peer support services to adults with serious mental illness.	Develop infrastructure to align Medicaid Mental Health Rehabilitation option services with three EBPs: ACT, IMR, and Supported Employment; and train and certify consumers as peer specialists.

Specific Practices Selected by Grantees

As shown in Table 2-2, six Grantees chose to develop the infrastructure for or implement one SAMHSA-recognized evidence-based practice. Minnesota developed a database of evidence-based practices for children with serious emotional disturbance (SED). Four of the Grantees selected the evidence-based practice of Illness Management and Recovery. North Carolina selected four practices, and Virginia selected three. Eight Grantees chose to work on recovery-oriented practices, with peer supports selected by eight.

Table 2-2a. Evidence-Based and Recovery-Oriented Practices Selected by Grantees
Evidence-Based Practices	DE	MA	ME	MI	MN	NC	NH	OH	OK	OR	PA	VA	Total
Illness Management and Recovery	–	–	–	–	–	•	•	–	•	–	–	•	4
Assertive Community Treatment	–	–	–	–	–	–	–	–	–	–	–	•	1
Family Psychoeducation	•	–	–	–	–	•	–	–	–	–	–	–	2
Supported Employment	–	–	–	–	–	•	–	–	–	–	–	•	2
Integrated Mental Health and Substance Abuse Treatment	–	–	–	–	–	•	–	–	–	–	–	–	1
Practices for Children with SED	–	–	–	–	•	–	–	–	–	–	–	–	1

Table 2-2b. Evidence-Based and Recovery-Oriented Practices Selected by Grantees
Recovery-Oriented Practices	DE	MA	ME	MI	MN	NC	NH	OH	OK	OR	PA	VA	Total
Peer Support	–	•	•	•	–	–	–	•	•	•	•	•	8
Consumer-Operated Services and Supports	–	•	–	–	–	–	–	•	–	•	–	–	3
Wellness Recovery Action Planning	–	–	–	•	–	–	–	•	–	–	–	–	2
Peer Bridgers	–	–	–	–	–	–	–	•	–	•	–	–	2

Section 3: Implementation of Grant Initiatives

This section of the report focuses on the challenges Grantees faced during implementation of the initiatives and how they addressed them. The first part looks at initiatives to incorporate a recovery orientation in the mental health services systems—primarily through the provision of peer support. The second part focuses on initiatives to develop the necessary infrastructure for or to implement evidence-based practices.

Implementing Recovery-Oriented Initiatives

Because peer support is an essential component of a recovery-oriented service system, all of the eight Grantees with recovery initiatives focused their efforts on developing, implementing, sustaining, and/or expanding various methods for providing peer support.

Training Individuals with Mental Illness to Provide Peer Support in Traditional Mental Health Settings

As noted in Section 1, this report uses the generic term peer support as the umbrella term for all peer-provided supports and services, whether on a volunteer or paid basis, and whether provided in the traditional mental health system or through consumer-/peer-operated programs or activities. When referring to individuals with mental illness who provide paid services, we use the general term peer support staff unless referring to the specific terms the states use.

For example, Maine developed a peer support specialist certification process, which required completion of two courses; quarterly co-supervision with staff in the Office of Adult Mental Health Services, Office of Consumer Affairs; two continuing education classes per year; and 75 hours of work per year on a paid or volunteer basis. Certification is issued upon completion of all requirements, which must be met within 1 year of completing the training program. To maintain certification, the requirements for continuing education, co-supervision, and 75 hours of peer support work must be met annually.

Michigan developed continuing education courses to help peer support specialists keep their newly learned skills current by working with community colleges to develop a curriculum offering three elective credit hours; this course can also be used to complete requirements for certification.

States confronted a few operational issues related to training. For example, in some states, individuals who were interested in receiving newly available training were already working in a peer support capacity, and their employers were reluctant to grant them time away from their jobs to participate because of the lost revenue. To address this concern, Ohio revised its peer support specialist training to be provided in half-day rather than full-day segments.

In Maine, the State lacks trained peer facilitators needed to provide Wellness Recovery Action Planning (WRAP). One of Maine's grant goals was to increase the number of consumers who could be WRAP facilitators by having them attend a train-the-trainer curriculum offered by an advocacy organization that provides WRAP technical assistance. However, the organization increased its participation requirements, and very few interested individuals were able to meet them.

With the exception of such operational issues, Grantees did not report any major challenges in conducting training. However, in some states, individuals who received training could not find employment. (These states did not require applicants to either have a current peer support position or a commitment from an employer to hire them once training was completed.)

Provider-Related Challenges and How They Were Addressed

Grantees identified several major provider-related challenges that impeded the overall adoption of a recovery orientation and the incorporation of peer support services, specifically, in the mental health services system. Challenges related to mental health services providers included the following:

a lack of knowledge about recovery concepts, practices, and skills, and/or a lack of interest in obtaining such knowledge and skills;
skepticism about the recovery concept, particularly for individuals with serious illnesses such as bipolar disorder and schizophrenia, individuals who experience psychotic symptoms, and persons whose providers have been unable to find effective medications;
resistance to recovery practices that entail giving up control and working collaboratively with individuals they perceive as "clients";
negative views about individuals with mental illness, particularly in regard to their ability to reliably provide valuable and useful services; and
reluctance to hire individuals with mental illness based on valid concerns about professional ethics and boundary issues, maintaining confidentiality, and various human resources issues.

Many of these challenges are interrelated, and all of them must be addressed if states want providers in their mental health systems to promote recovery.

The extent to which Grantees grappled with these challenges varied, but all did so to some degree. Oklahoma's experience provides an example of provider resistance to hiring peer support staff. Oklahoma mandates that ACT providers have a Recovery Support Specialist (a peer provider) on their team in order to be certified. To circumvent this requirement, some Oklahoma ACT teams have hired professionals who have experienced mental illness in the past, calling them Recovery Support Specialists in addition to their professional title, even though they do not function as Recovery Support Specialists.

Other Oklahoma ACT providers have "borrowed" a Recovery Support Specialist from another section of their treatment facility (e.g., the outpatient division) when undergoing recertification. Once recertified, the Recovery Support Specialist returns to the original position. Oklahoma grant staff noted that some ACT teams do not want to hire Recovery Support Specialists because they are unconvinced that individuals with mental illness have the ability to fully recover and provide effective services (despite the practice, noted above, of hiring some professionals who have a mental health history). They also noted that some providers are less inclined to hire individuals who are receiving SSI or SSDI, preferring those with current work experience.

Grantees developed and conducted a wide range of education and training initiatives to address provider-related challenges. For example, the Ohio Coordinating Center for ACT now includes a 1-day training on peer support specialists as part of its technical assistance and training package for individual ACT teams. The Center also provides training about supervising and supporting peer support specialists as part of an ethics course for traditional providers, many of whom attend the course to meet professional licensure requirements.

Michigan grant staff and members of its Recovery Council—established by grant staff to direct and support grant activities—found it very challenging to work with large numbers of providers with multiple clinical perspectives. Grant staff reported that differences in perspectives regarding recovery-oriented principles and practices required much discussion and interaction to develop a shared perspective and to make decisions. At the same time, such discussion strengthened the Council's capacity to provide direction and oversight of the State's recovery activities.

As noted above, many providers voiced valid concerns about confidentiality, human resources issues, professional ethics, and boundary issues when peer support staff are hired (e.g., concerns about dual relationships and the potential for violating professional boundaries required in psychotherapy). A dual relationship is created when a person receiving services from a provider is also employed by that provider.

To protect clients, the professional ethics codes for nurses, social workers, psychiatrists, and psychologists discourage dual relationships because of the power imbalance between provider and client, which raises questions for providers about how to deal with issues that arise when employees/co-workers are also clients.

Ohio grant staff and partners addressed concerns about dual relationships by clarifying hiring and supervision practices for peer support specialists designed to avoid dual relationships (e.g., by requiring that supervisors not be involved in peer support specialists' clinical care).²⁷ Grant staff also had positive discussions with licensing boards, which helped to reduce concerns about dual relationships. Other Grantees provided training for supervisors of peer support staff to address similar concerns.

To ensure that providers understand consumers' perspectives on recovery, Michigan tries to ensure that consumers constitute a large proportion of those attending mental health trainings (i.e., more than the usual 51 percent representation requirement). Michigan's grant staff pointed out that consumers need to have a "critical mass" to get their point across. The presence of such a large group creates a different learning dynamic and gives consumers confidence that their views on what helps and hinders recovery will be heard. To encourage large numbers of consumers to attend training sessions, the State invites them to attend at no charge; it also tries to place consumers on training teams in order to improve clinicians' views about recovery. Peer support specialists also attend psychiatrists' training sessions, and their presence and contributions help inform psychiatrists' recovery perspective. (See Box 4.)

In addition to education and training on recovery-oriented practices, providers often need technical assistance to support the development of peer support and peer-operated services. To meet this need, Massachusetts developed a peer-operated training and technical assistance center (the Transformation Center) to support, improve, and expand recovery-oriented and peer-operated programs. The Center not only provides technical assistance to other peer-operated organizations and a training program for certified peer specialists, it also conducts training about recovery practices for providers.

Challenges for Peer Support Staff and How They Were Addressed

Ohio's grant staff reported that peer support staff face challenges when working for traditional providers who have never encountered clients as staff members. These challenges can include the expression of negative attitudes and disrespectful comments by non-peer staff about peer support staff and clients.

Box 4. Promoting Recovery Throughout the Mental Health System

Such challenges can create discomfort and workplace conflicts. To help peer support specialists cope with these challenges and learn advocacy skills to increase their ability to get what they need from their work environment, Ohio Advocates provides mentoring for peer support specialists who are employed by community mental health centers. Mentoring can also be provided by other peer support staff or by professionals who also use mental health services.

Another method to help peer support staff deal with workplace challenges is the development of a peer support staff network. One of Pennsylvania's grant goals was to support and expand the activities of certified peer specialists (CPS) by establishing a self-help network for CPS graduates. To achieve this, grant staff conducted two conferences as networking opportunities for CPS staff, which 70 people attended. Attendees recommended that the State develop a consumer-run statewide peer support association and continuing education opportunities. The Peer Support Association was subsequently formed and was scheduled to conduct its first meeting in January 2009. Continuing education programs have been developed, including one focused on working with older adults and individuals involved in the justice system.

Not all individuals who receive training to provide peer support find employment. Many of Ohio's peer support specialists had expected to find a job in the mental health system when they completed their training and were disappointed when they did not. One year after training, only 56 percent were working in the mental health system in some capacity, with just 26 percent employed as peer support specialists (including four individuals who had worked as peer support specialists prior to the training).

The failure to find employment raises questions about the advisability of using scarce resources to train individuals for positions in which employment is not ensured. To address this problem, the Project Director and Ohio Advocates staff recommended to the Ohio Department of Mental Health that individuals not be accepted for training until after they have been hired to provide peer support services or until an employer has committed to hiring them once trained.

It is also important to recognize that in states that do not have a Medicaid buy-in program, the risk of losing Medicaid benefits because of increased income is a potential work disincentive.

Reimbursement Issues for Peer Support and Other Recovery-Oriented Services

CMS issued guidance on how to secure Medicaid reimbursement for peer support services in a letter to State Medicaid Directors on August 15, 2007. (See Box 5 for a summary of Medicaid reimbursement criteria for peer support services.)

Box 5. Medicaid Provisions for Reimbursement of Peer Support Services

Several Grantees worked to develop reimbursement policies for peer support services, but not all Grantees succeeded in securing Medicaid reimbursement for these services. In 2005, Pennsylvania developed and submitted an application for a State Plan amendment to include peer support services as a component of rehabilitation services, and at the same time developed the coding and billing mechanisms for reimbursement. After CMS approved the amendment in 2007, grant staff developed a 17-point checklist to help providers meet requirements for furnishing the new service. They also provided technical assistance and training to all of the State's 67 counties to ensure implementation of Medicaid-funded peer support services.

Oregon's grant staff developed a compendium of research on peer-delivered services (Peer-Run/Peer-Driven Programs, Services, and Organizations: A Review of the Evidence) to help mental health organizations and consumer/survivor organizations identify evidence-based and promising peer-delivered services used elsewhere in the United States. Oregon's established EBP hierarchy has six evidence categories, with Category 1 denoting practices with the highest level of evidence. The Oregon Addictions and Mental Health Division designated the socialization aspect of peer-operated drop-in centers as a Category 3 practice and also approved a service description and associated Medicaid billing code for peer-operated drop-in centers to provide this service.

However, to be able to bill for this service, a peer-operated organization in Oregon must be either a certified mental health provider agency able to offer all mental health services, or must subcontract to another certified mental health provider agency to provide drop-in center and other peer-operated services. Because very few consumer-operated organizations can meet the certification requirements or enter into subcontracts to furnish these services, only one peer-operated organization in the State is currently billing for the newly approved service.

Because New Hampshire has a peer support service system that is separate from and complementary to its community mental health center services system, the State has chosen to forego Medicaid reimbursement for peer support services in order to ensure the system's flexibility and stability. Instead, the State uses federal block grant funds to reimburse these services supplemented by state funds.

Several Grantees mentioned inadequate funding—and a lack of Medicaid reimbursement in particular—as the reason their state could not offer or expand recovery services, particularly peer support. In particular, they noted that the change in CMS policy to no longer allow bundled billing for ACT services had hampered their ability to employ peer support staff on ACT teams. For example, in Ohio, ACT teams can hire mental health service users to provide Community Psychiatric Supportive Treatment services—which are Medicaid reimbursable; however, WRAP training and support and other peer support services are not Medicaid reimbursable. Grant staff said that having separate billing procedures for Medicaid and non-Medicaid services impedes the continuity of care provided by peer support specialists.

Ohio grant staff also noted that non-Medicaid funding for peer support is limited by severe constraints on the State's budget. In addition, many of Ohio's county mental health boards are running out of funds to provide the local required match for federal financial participation (FFP; i.e., the federal portion of Medicaid reimbursement). Currently, the Ohio Department of Mental Health is working with the Ohio Department of Job and Family Services (the state Medicaid agency) and CMS to change the match method so that the State, rather than county boards, will be responsible for the entire required FFP match.

Several Grantees said that their respective state's plans to submit State Plan amendments (SPA) to obtain Medicaid funding for peer support services have been put on hold until issues related to Medicaid coverage of services under the rehabilitation and targeted case management options are resolved. These issues were raised in a proposed rule for changes in the rehabilitation option (Federal Register notice dated August 13, 2007) and targeted case management (Federal Register notice dated August 13, 2007). Because of widespread opposition to the proposed regulation by states, service providers, and advocacy groups, Congress placed a moratorium on the implementation of the targeted case management regulation until July 2009 and does not want the Department of Health and Human Services to finalize the rehabilitation regulation until the new administration obtains more information and decides how to proceed.

Many of the Grantees said that their states were reluctant to make any changes in their Medicaid State Plans until policy regarding service coverage under the two regulations is finalized. Some said their states were reluctant to submit a State Plan amendment because during the review, CMS looks at all services and language on the submitted pages, which may lead to questions about services in the State Plan that may not currently be reimbursable.

Determining the Extent of Organizations' Recovery Orientation

To determine whether an organization is improving its recovery orientation, baseline and follow-up measures are needed. Recovery-oriented measures assess the basic content of services, how they are provided, and the views of individuals who receive the services. Assessing the extent of an organization's recovery orientation on various measures can identify areas for improvement.

Several types of tools are available for determining the degree of any organization's recovery orientation, including the Recovery Enhancing Environment (REE) tool, the Recovery Oriented System Indicators (ROSI) tool, and the Fidelity Assessment Common Ingredient Tool (FACIT). (See Box 6.) Several Grantees used one of these tools to help various entities in the mental health services system assess their recovery orientation and identify areas for improvement.

Virginia's Department of Mental Health, Mental Retardation, and Substance Abuse Services encouraged Community Service Boards to use the ROSI scale to help determine the extent to which their services were recovery oriented. Although the ROSI survey tool includes a consumer assessment and an organization assessment, grant funds were sufficient only to conduct a consumer assessment.

Box 6. Tools for Assessing Recovery Orientation or the Quality of Recovery Services

Virginia's grant staff and contractors surveyed consumers in 2005 using the ROSI tool at 43 sites in 11 local Community Service Board areas. Grant funds were used to train and pay mental health peers to conduct the survey. The peer surveyors interviewed 600 consumers and also disseminated 400 Roadmap to Recovery pamphlets at mental health centers across Virginia. The Department has encouraged Community Service Boards to continue to use the instrument, and, in 2008, 496 consumers were surveyed with the ROSI tool in one of the State's seven planning regions.

The Michigan Department of Community Health and its Recovery Council adopted the REE tool as a quality improvement measure for recovery-oriented practices. Grant staff began data collection with grant funds in November 2008, and the Department plans to use SAMHSA Mental Health Block Grant funds to support long-term REE data collection statewide.

Oregon's grant staff modified an existing fidelity assessment protocol used in the peer-operated services field—the FACIT—and shared it with eight peer-operated organizations. All of the organizations implemented the protocol and used the findings to identify areas of peer-operated services in need of improvement.

Remaining Recovery-Orientation Challenges & Recommendations to Address Them

Grantees' recommendations for expanding the provision of recovery-oriented services include the following:

Federal and state policy regarding Medicaid provider requirements should be modified to permit consumer-operated programs to become providers of reimbursable recovery-oriented peer services.
SAMHSA should combine the block grants for mental health and substance abuse. For youth, the co-morbidity rate for these disorders is high, and requiring a diagnosis for only one of these conditions to receive services discourages the development and adoption of integrated mental health and substance abuse treatment interventions.
The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) mandate is the foundation for many of a state's mental health services for children and their families, and it needs to be retained to ensure that these services continue to be provided.
CMS should consider funding another grant initiative to help states implement and sustain major mental health systems improvements.
The proposed changes in the definition of rehabilitation services and targeted case management will create many serious problems for states' mental health systems if implemented. Many of these proposed changes need to be dropped. The final rules need to be published as soon as is practically feasible because States cannot move forward with their plans to increase the recovery orientation of their mental health systems until they know whether funding for current services is ensured.
The Federal External Quality Review requirements for managed care providers of mental health services should be amended to include a strong focus on recovery-oriented practices.

Implementing Evidence-Based Practices

Several SAMHSA-recognized evidence-based practices have demonstrated efficacy and cost-effectiveness in securing positive outcomes for individuals with serious mental illnesses. Yet the practices validated by research are not widely offered in mental health practice settings.³⁶ One possible explanation for this gap between knowledge and practice is that states need a robust infrastructure to support delivery of these practices, but developing this infrastructure is costly and challenging. Essential elements of infrastructure development include

active involvement from state staff, providers, consumers, and families;
sustained provider training and follow-up clinical supervision;
adequate initial funding for start-up and sufficient reimbursement for implementation;
practical methods and funding to monitor implementation to improve quality; and
alignment of federal, state, and provider policies and structures to support practice implementation.

The more elements of a service system that can be employed to support change and reduce resistance, the more likely that practice improvements will occur.³⁷

Six of the MHST Grantees had initiatives to implement evidence-based practices in their states' mental health systems, focused primarily on provider training and supervision; developing reimbursement methods; and developing monitoring methods to ensure that evidence-based services are being provided with high fidelity (i.e., in accordance with implementation instructions).

Provider Training and Supervision

Changing how clinicians practice is a major undertaking. The challenges include (1) a lack of provider knowledge of and/or interest in evidence-based practices; (2) a lack of professional consensus about which practices lead to the best outcomes; (3) provider reluctance or resistance to changing long-standing practice modalities; (4) the high cost of education, training, follow-up consultation, and consistent reinforcement over the long term; (5) a lack of support and leadership within the mental health system; and (6) the cost of developing the mental health infrastructure to support clinicians.

Research has shown that education alone does not strongly influence the practice behaviors of health care providers and that additional efforts are needed, including providing clinicians with supervision and feedback on practices.³⁸ Resources spent on education and training will be wasted in the absence of ongoing clinical supervision on how to implement evidence-based practices (see Box 7). Such supervision is important to reinforce learning from an initial training course and to provide information to help clinicians grapple with various issues that may arise when implementing a new practice.

Box 7. Aligning Policy and System Infrastructure to Support Practice Implementation

When introducing North Carolina's new evidence-based practices, grant staff suggested to service providers that they designate staff "champions" to ensure that their practitioners receive training and feedback about implementing EBPs. North Carolina also addressed the need for ongoing supervision by setting reimbursement rates high enough to cover its cost. The State also often pays for additional supervision and coaching through grants and contracts.

In Minnesota, after an orientation to a new Family Psychoeducation EBP database failed to change clinicians' clinical practice, the Grantee developed a new curriculum requiring in-person attendance for 5 days, followed by weekly phone consultation with clinical EBP experts over a 6- to 9-month period. During these calls, the clinical EBP experts train the clinician to use a specially designed form—called a clinical dashboard—to monitor treatment patterns and measure client outcomes on a weekly basis, as well as client progress over time.

The dashboards provide a graphic representation of the treatment strategies that have been used during each session with the client and the client's progress toward treatment goals. This training approach allows clinicians time to use the new practice with one or two clients at a time and provides assistance from clinical experts. After 6 to 9 months of training and consultation, each supervisor was expected to be part of a team to train a new cohort of clinicians, because teaching others both reinforces the training and strengthens an agency's clinical infrastructure by improving the skills of a greater number of staff.

Delaware developed a manual to facilitate the adoption of family psychoeducation by providing a visible reminder for therapists to use the evidence-based practice. The manual has proved to be a useful tool, providing everyone who serves children in the mental health system with a common framework for discussing treatment goals and approaches. Therapists noted that family psychoeducation provides a common philosophical basis for treatment among different entities; for example, school staff and mental health providers.

As with training for peer support staff, providers were reluctant to have their clinicians participate in training because time off for training meant lost revenue. To offset this loss, New Hampshire gave its 10 provider agencies a total of $375,000 over a 2-year period. In 2007, Minnesota's legislative appropriation included a new funding category to cover the cost of clinicians' participating in the 5-day training course as well as the 6 to 9 months of ongoing consultation and follow-up.

New Hampshire is in the early stages of developing credentialing procedures and standards for IMR providers to facilitate long-term Medicaid reimbursement. To minimize the administrative burden on community mental health centers, the State's Illness Management and Recovery Steering Committee decided to develop a mechanism to credential agencies rather than individual practitioners, and chose five measures for credentialing: (1) overall IMR fidelity score, (2) the proportion of workers completing annual training, (3) the proportion of workers receiving regular supervision on IMR practice, (4) the proportion of eligible consumers receiving IMR services, and (5) the number of consumers who complete all 10 modules of the IMR treatment program.

Another challenge some Grantees had to address was high staff turnover in community mental health centers, on average 20 percent across the provider system (one agency had a 60 percent turnover rate on its adult treatment team). High staff turnover substantially increases training costs, as evidenced in New Hampshire. To help ensure that high staff turnover would not impede IMR implementation efforts, the New Hampshire Bureau of Behavioral Health committed to providing IMR training for new CMHC hires, which includes weekly supervision for a period of 4 months by a trainer from the Dartmouth Psychiatric Research Center.

Ensuring Reimbursement for Evidence-Based Practices

To facilitate the adoption of new practices—and to track their delivery—some states developed separate billing codes for specific practices. For example, Delaware established a separate billing code for Family Psychoeducation, which is billed in 1-hour increments. However, rather than use this code, providers have been incorporating Family Psychoeducation in their Individual and Family Mental Health Intervention sessions (e.g., counseling) and using the billing code for this service. As a result, the State cannot accurately assess the extent to which the new practice is being provided.

During the grant period, North Carolina was in the midst of a major effort to reform its mental health care system, which included revisions to the service definitions used for determining Medicaid reimbursement. The State also implemented initiatives to educate administrators, providers, and consumers about how the new evidence-based practices fit within the revised service definitions.

Medicaid Reimbursement Issues

Implementing evidence-based practices with high fidelity to achieve the best client outcomes is dependent on implementing SAMHSA's EBP tool kits, which are sets of detailed instructions guiding practice implementation. Fidelity is the term used for the degree to which a practice is implemented according to these instructions. Virtually all of the Grantees implementing evidence-based practices said that the toolkits for some practices include recovery-oriented components that frequently are not billable to Medicaid.

Several grant staff noted that Medicaid's inability to reimburse for all EBP components makes it difficult for providers to furnish the practices with high fidelity. However, several States recognize the need to find other funding sources to cover services that Medicaid will not reimburse. For example, Ohio providers can bill portions of the evidence-based practices of Assertive Community Treatment, Integrated Dual Diagnosis Treatment, Multi-Systemic Therapy, Illness Management and Recovery, and Supported Employment using existing Medicaid codes for Community Psychiatric Supportive Treatment, behavioral health counseling, and other Medicaid-billable services. The components of these practices that do not meet Medicaid criteria for inclusion in the State Plan, particularly supported employment, are covered by a combination of state general revenue funds, levies, client fees, and a few foundation grants.

North Carolina developed multiple reimbursement codes to ensure that providers are able to bill for all services components of the Integrated Dual Diagnosis Treatment tool kit. Using multiple codes results in a complex billing structure, but it ensures coverage for all of the components of the practice.

Ensuring the Quality of Evidence-Based Practices

Research indicates that when mental health programs attempt to implement evidence-based practices, the quality of the implementation strongly influences outcomes (i.e., programs that have higher fidelity to the defined practice tend to produce superior clinical results). This finding suggests that efforts to promote evidence-based practice must include fidelity measures and self-correcting feedback mechanisms.⁴⁰ Researchers have developed several measures and instruments to assess the fidelity of the implementation process. (See Box 8.)

Box 8. Fidelity Measures

States recognize the need to ensure regular monitoring of provider practices. However, fidelity assessments are expensive, and providers cannot afford to conduct them on an ongoing basis. To address this issue, North Carolina analyzed the cost of fidelity monitoring conducted under the grant to determine the amount of additional state funds to add to the payment rate for Local Management Entities (LMEs) to support the State's new monitoring requirement.

Some Grantees developed structured processes to support fidelity measurement. For example, New Hampshire's IMR Steering Committee developed a quality assurance process that includes consumer outcome measures, SAMHSA IMR fidelity measures, and General Organizational Index measures. Fidelity assessment teams—consisting of Bureau staff, a consumer, a CMHC quality improvement staff member, and occasionally a family member conducted fidelity reviews of all community mental health centers in the State. The State reviewed fidelity scores to identify areas needing technical assistance as well as the IMR implementation process to identify areas for improvement. The State mandated the annual fidelity review process and will continue to fund it.

New Hampshire also decided to have its IMR implementation process evaluated by expert external evaluators using an objective methodology—the State Health Authority Yardstick (SHAY), which was developed by SAMHSA and Dartmouth Medical School to measure how a state authority is implementing and supporting evidence-based practices. Overall, the New Hampshire CMHC scores were similar to those in the National Evidence-Based Practices Implementation Project, on both the aggregate CMHC fidelity score and by the individual measures.

North Carolina began developing procedures and instruments for ensuring the quality of evidence-based practices by adopting the fidelity assessment instruments in the SAMHSA EBP tool kits. Local Management Entities or external evaluators will conduct the fidelity assessments. Two of the four LMEs conducted fidelity assessments during the grant period. Ohio's data collection effort demonstrated that the State's 37 ACT teams serving 1,560 service users were meeting Dartmouth Assertive Community Treatment fidelity criteria, recognized by SAMHSA.

Although attention to process outcomes through fidelity monitoring is an important component of quality assurance, consumer outcomes are the most important quality measure; but only New Hampshire grant staff mentioned the need to evaluate these outcomes.

Remaining EBP Challenges and Recommendations to Address Them

Most of the challenges mentioned throughout this section remain. One of the Grantees noted that the MHST grant was very helpful in establishing illness management and recovery as a service but that significant state funding was needed to implement the practice: about triple the amount of the grant. Obtaining continued funding for training and ongoing fidelity reviews is always a challenge, and given the states' current budget situation, future funding is uncertain.

Recommendations from Grantees on how CMS might address continuing challenges are as follows:

Facilitate the provision of evidence-based practices by providing a specific Medicaid reimbursement code for each SAMHSA-approved evidence-based practice, and reimburse all of the component services of each practice.
Consider funding more systems change grants to help states continue developing the infrastructure needed to implement evidence-based practices and to sustain their use.

Section 4: Conclusions

Although SAMHSA has approved six evidence-based practices and encouraged their adoption, science remains far ahead of practice. Some states have taken the lead and made progress in the delivery of both evidence-based and recovery practices, but others are still in the very early stages of implementation. The 12 states that received MHST grants have unique service delivery systems and are at different stages in the systems transformation process, yet they faced similar challenges. Despite these challenges, all of them made significant progress in developing the infrastructure to support evidence-based and recovery practices.

Using Research to Help Ensure Successful Initiatives

Despite the availability of information about how to implement evidence-based practices, the 12 states that received MHST grants varied in the degree to which they appeared to make use of it. When introducing new evidence-based practices, ideally, initiatives will be part of a broad and integrated approach to develop the infrastructure to support the new practice. Some states used their grants to implement one or more components of a clearly articulated, broad systems transformation strategy, and others implemented what seemed to be stand-alone initiatives.

Similarly, it has been well known for decades that providing information does not change behavior and that training without regular ongoing consultation and continuing education will not lead to changes in clinicians' practice. Yet one state used its grant initially to implement a stand-alone education initiative about evidence-based practices. When grant staff found that the initiative did not lead to changes in clinicians' behavior, they conducted interviews and focus groups to discover what a cursory review of the research literature would have told them: clinicians need both training to learn how to implement practices and ongoing supervision to ensure their consistent use.

Before planning systems change initiatives generally, and the implementation of evidence-based practices specifically, state staff need to review the relevant literature and make use of available technical expertise to become more knowledgeable about implementation challenges and how to address them. Understanding what other states have tried and the challenges they faced and resolved—or not—will also help staff to develop successful approaches.

Understanding Medicaid's Reimbursement Options and Limits

Many Grantees noted that lack of reimbursement of all components of evidence-based practices made it difficult to implement the practices with high fidelity. However, Medicaid pays for services—not practices. Medicaid principally pays for medical services (including psychiatrist and some psychologist services), and the majority of mental health services are covered through the optional benefit categories, such as rehabilitation and clinic services.

Because evidence-based practices include some components that Medicaid does not cover, states need to break down the practices into services to determine what Medicaid can cover under the State Plan and to identify other sources of funding for the components not covered. For example, North Carolina uses state funds for recovery-oriented services and Medicaid funds for services coverable under the State Plan to seamlessly integrate evidence-based practices with recovery-oriented services such as housing, employment, social, and peer supports.

Employing Medicaid to underwrite mental health services involves "finding the fit" between Medicaid program coverage and the services and supports that a state has identified as critical to meeting the needs of individuals with serious mental illnesses.⁴³ Several states have done so successfully; for example, eight states support peer specialists through various Medicaid financing strategies, primarily by qualifying individuals with mental illness as providers under the Medicaid rehabilitation option.⁴⁴ Georgia and South Carolina have also developed a distinct peer support service under the rehabilitation option. Michigan, Colorado, and New Mexico use §1915(b) waivers to cover peer support services.

States should consider investigating other Medicaid authorities for covering these services. For example, Michigan and Oregon use the §1915(b)(3) waiver authority to use savings obtained through managed care arrangements to cover additional services, including recovery-oriented services. Michigan's grant staff noted that its §1915(b) waiver has enabled them to fund a wide range of recovery-oriented services, including peer support specialists and peer-operated programs such as drop-in centers. They believe that the reason other states have been unable to fund peer support services under Medicaid is that they have not made use of available Medicaid authorities.

Another option for providing services to individuals with mental illness is the new §1915(i) authority.⁴⁵ The §1915(i) authority gives states the ability to provide home and community-based services to adults with disabilities without requiring an HCBS waiver or demonstrating cost neutrality (i.e., services do not have to cost less than institutional alternatives). States are limited to offering services to participants whose income does not exceed 150 percent of the federal poverty level.⁴⁶

Unlike the HCBS waiver authority, the §1915(i) authority does not tie the provision of HCBS to a requirement that an individual need an institutional level of care. This is an important difference between the two authorities that may prove especially beneficial for states that want to provide services to individuals with mental illnesses who currently cannot qualify for HCBS waiver services because they do not meet institutional level-of-care criteria.⁴⁷ Only two states to date—Nevada and Iowa—have made use of this option to offer services for individuals with mental illness.

Measuring Progress

States need to establish measurable goals to guide the transformation to an evidence-based, recovery-oriented system and identify desired individual, service, and systems-level outcomes to measure progress toward those goals. Fortunately, the states and provider agencies use a small number of common measures: SAMHSA's fidelity instruments to assess EBP implementation and a few different instruments to determine the recovery orientation of provider agencies.

Although widespread use of common instruments will help to promote their broad acceptance and enable comparisons to be made within and among states, fidelity assessments and other systems evaluation measures are very costly to implement. Procedures for using these instruments recommend outside assessors, which can help to ensure acceptance of results and uniformity of reviewing procedures across provider agencies, but which also increase costs.

To ensure that systems transformation efforts lead to improved outcomes for persons with mental illness, states need to provide technical assistance and funding to providers so they will be able to conduct fidelity reviews and measure progress.

Next Steps

One Grantee recommended that CMS provide free technical assistance to states for implementing recovery practices in both State Plan and waiver services as it does for improving quality in HCBS waiver programs. In fact, CMS already provides free technical assistance when requested by states and also has a contractor who can provide technical assistance regarding quality assurance and improvement.

The proposed changes to services under Medicaid's rehabilitation and targeted case management options—and the uncertainty about how, when, and whether the changes will be finalized—has caused many states to put mental health systems improvement initiatives on hold. Many Grantees said that their states will be unable to proceed with their plans to increase the availability of evidence-based and recovery-oriented practices in their mental health systems until CMS releases final rules. However, CMS cannot act until the congressional moratorium ends, and Congress may extend it until the new administration decides how to handle the proposed changes.

Only one Grantee noted the need to determine how to work with professional licensing boards, colleges, and universities to ensure that students preparing for work in the mental health system—at all levels—receive training based on current evidence-based psychosocial intervention research and obtain clinical experience in the use of evidence-based practices. Given the very high cost of efforts to change clinicians' practice patterns, states should consider devoting greater attention to working with these entities.

A SAMHSA-led national-level effort in this area could help to jump-start state-level initiatives as well as focus much-needed attention on the need to prepare mental health practitioners and clinicians at all levels to provide evidence-based and recovery-oriented services.

Endnotes

¹ Unless otherwise cited, the information in the first four pages of the Introduction is condensed from the discussion in Smith, G., Kennedy, C., Knipper, S., and O'Brien, J. (January 2005). Using Medicaid to Support Working Age Adults with Serious Mental Illnesses in the Community: A Handbook. Office of Disability, Aging, and Long-Term Care Policy. Available at http://aspe.hhs.gov/daltcp/reports/handbook.pdf.

² National Institute of Mental Health. Available at http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml. Accessed on January 2, 2008.

³ U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2005). National Expenditures for Mental Health Services and Substance Abuse Treatment 1991–2001. DHHS Publication Number SMA 05-3999.

⁴ Buck, J., Teich, J. L., and Miller, K. (2003). Use of Mental Health and Substance Abuse Services Among High-Cost Medicaid Enrollees. Administration and Policy in Mental Health, 31(1).

⁵ The Kaiser Commission on Medicaid and the Uninsured. (March 2007). Medicaid: A Primer. Key Information on the Health Program for Low-Income Americans. Available at http://www.kff.org/medicaid/upload/Medicaid-A-Primer-pdf.pdf.

⁶ President's New Freedom Commission on Mental Health. (2003). Final Report of the New Freedom Commission on Mental Health. Rockville, MD. Available at http://www.mentalhealthcommission.gov/reports/reports.htm.

⁷ Smith, G., et al., op. cit, note 1.

⁸ Evidence-Based practices are identified by reviewing research findings on treatment interventions to determine how well they improve mental health conditions. Practices evaluated through several randomized controlled trials or other well-designed experiments showing positive outcomes with no harmful effects are ranked the most evidence based.

The evidence base decreases accordingly as the number or quality of well-designed studies decreases. Practices for which the evidence shows harmful effects or a lack of research are ranked as the least evidence based. Once identified, policy makers promote the adoption of practices having the highest level of evidence by supporting training and technical assistance for mental health providers.

⁹ The fundamental precepts of EBP in health emerged roughly a decade ago. In the United States, the Institute of Medicine has been a central force in promoting the development and implementation of EBPs (see, especially, Committee on Quality of Health Care in America [2002]. Crossing the Quality Chasm. Institute of Medicine). The Agency for Health Care Policy and Research at the U.S. Department of Health and Human Services has lead responsibility for promoting evidence-based practice in health care.

¹⁰ Unless otherwise specified, all the descriptions of evidence-based practices summarize materials included in the following: the 2002 draft resource kits, materials disseminated by the New York State Office of Mental Health via its website, and the 1999 Surgeon General's Report on Mental Health.

These practices were identified by a consensus panel sponsored by the Robert Wood Johnson Foundation (RWJF). This panel was composed of researchers, families, individuals with mental illnesses, and mental health administrators. Funding from RWJF, SAMHSA, and other sources is underwriting the preparation of materials by the New Hampshire-Dartmouth Psychiatric Research Center in collaboration with several other organizations to facilitate and accelerate the implementation of EBPs by agencies and mental health systems. Implementation resource kits have been prepared for each practice for use by administrators, program directors, practitioners, individuals with mental illnesses, and families. These "tool kits" are designed to promote interest in the use of these practices, facilitate their adoption, and provide tools (fidelity measures) to assess whether the practice is being used consistently. These kits are located at http://www.mentalhealth.org/cmhs/communitysupport/toolkits.

¹¹ Extensive materials concerning ACT are available from the National Alliance for the Mentally Ill (NAMI), which has been a leading advocate for the expanded availability of ACT nationwide. NAMI employs the acronym PACT (Program for Assertive Community Treatment). NAMI also has exercised leadership in the development of standards for ACT. For more information, go to http://www.nami.org/about/pact.htm.

¹² This term is occasionally used in practice by provider organizations.

¹³ NAMI Issue Spotlight: Employment and Income http://www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay.cfm&ContentID=13158.

¹⁴ This description of recovery is from Smith, G., et al., note 1.

¹⁵ Text condensed from Jacobson, N., and Greenley, D. (April 2001). What Is Recovery? A Conceptual Model and Explication. Psychiatric Services, 52, 482-485. © 2001 American Psychiatric Association. Adapted with permission.

¹⁶ Solomon, P. (2004). Peer Support/Peer Provided Services Underlying Processes, Benefits, and Critical Ingredients. Psychiatric Rehabilitation Journal, 27(4), 392-401.

¹⁷ Jacobson, N. (2000). Recovery as Policy in Mental Health Services: Strategies Emerging from the States. Psychiatric Rehabilitation Journal, 23(4), 333-341. The author notes that in the managed care framework, recovery is envisioned as a set of guiding principles whose application can result in cost-effective behavioral health care and which suggest measurable treatment outcomes.

¹⁸ Doughty, C., Tse, S., Duncan, N., and McIntyre, L. (2008). The Wellness Recovery Plan (WRAP): Workshop Evaluation. Australasian Psychiatry, 16(6), 450-456.

¹⁹ The study is being conducted by Judith Cook at the National Research and Training Center on Psychiatric Disability at the University of Illinois–Chicago.

²⁰ A review of research on peer-delivered services compared with other services (case management, supported employment, supported housing, skills training, and integrated dual diagnosis treatment for mental illness and addiction) found that the evidence base for peer-delivered services was the weakest among all of the services. Solomon, P. (2004). Ibid.

²¹ A few randomized controlled trials and research efforts using quasi-experimental designs have been conducted, and more research projects using randomized controlled trials and quasi-experimental research projects are currently under way. Cook, J. A. (2005). "Patient-Centered" and "Consumer-Directed" Mental Health Services. Prepared for the Institute of Medicine, Committee on Crossing the Quality Chasm—Adaptation to Mental Health and Addictive Disorders. Available at http://www.cmhsrp.uic.edu/download/IOMreport.pdf.

²² Stotland, N. L., Mattson, M. G., and Bergeson, S. (2008). The Recovery Concept: Clinician and Consumer Perspectives. Journal of Psychiatric Practice, 14(Supplement 2), 45-54.

²³ Additionally, many academic and research centers tend to focus on theory and not on preparing clinicians to work in actual practice settings. Stuart, G. W., Burland, J., Ganju, V., Levounis, P., and Kiosk, S. (January 2002). Educational Best Practices. Working paper developed under grant number HS10965 from the Agency for Healthcare Research and Quality. Available through http://commerce.metapress.com/content/t0475161q9232685/.

²⁴ Corrigan, P. W., Steiner, L., McCracken, S. G., Blaser, B., and Barr, M. (2001). Strategies for Disseminating Evidence-Based Practices to Staff Who Treat People with Serious Mental Illness. Psychiatric Services, 52, 1598-1606; Rosenheck, R. A., Organizational Process: A Missing Link Between Research and Practice, 1607-1612; Goldman, H. H., Ganju, V., Drake, R., Gorman, P., Hogan, M., Hyde, P., and Morgan, O., Policy Implications for Implementing Evidence-Based Practices, 1591-1597; Torrey, W. C., Drake, R. E., Dixon, L., Burns, B. J., Rush, A. J., Clark, R. E., and Klatzker, D., Implementing Evidence-Based Practices for Persons with Severe Mental Illnesses, 45-50. © 2001 American Psychiatric Association. Adapted with permission.

²⁵ Unless otherwise cited, this section is condensed from the discussion in Jacobson, N., and Greenley, D. (April 2001). What Is Recovery? A Conceptual Model and Explication. Psychiatric Services, 52, 482-485. © 2001 American Psychiatric Association. Adapted with permission.

²⁶ O'Brien, J., White Tiegreen, W., and Campbell, J. (July 2008). Policy Issue #2: Introducing and Supporting Peer Providers in Traditional Mental Health Provider Networks. Second in a series of three policy briefs on peer supports in mental health delivery systems. Independent Living Research Utilization in collaboration with the Human Services Research Institute.

²⁷ In urban areas, dual relationships can often be circumvented because there are several settings in which peer support specialists can work, reducing the likelihood that they will receive their services from the same agency that employs them. But this is not always possible in rural or other areas with few providers.

²⁸ Smith, G., Kennedy, C., Knipper, S., and O'Brien, J. (January 2005). Using Medicaid to Support Working Age Adults with Serious Mental Illnesses in the Community: A Handbook. Office of Disability, Aging, and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.

²⁹ The REE was developed by Priscilla Ridgway with the Yale University Program for Recovery and Community Health in 1999.

³⁰ Ridgway, P., and Press, A. (2004). Assessing the Recovery-orientation of Your Mental Health Program: A User's Guide for the Recovery-Enhancing Environment Scale (REE). Version 1. Lawrence, Kansas: University of Kansas, School of Social Welfare, Office of Mental Health Training and Research.

³¹ The ROSI was developed in part by Steve Onken, Ph.D., and Jeanne Dumont, Ph.D.

³² Questionnaire can be found at http://www.power2u.org/downloads/ROSI-Recovery%20Oriented%20Systems%20Indicators.pdf.

³³ Taken from Campbell-Orde, T., Chamberlin, J., Carpenter, J., and Leff, H. S. (Eds.). Measuring the Promise: A Compendium of Recovery Measures. Cambridge, MA: The Evaluation Center @ Human Services Research Institute.

³⁴ The FACIT was developed by Jean Campbell, Ph.D.

³⁵ Detailed information on implementing the FACIT can be found at http://www.cstprogram.org/consumer%20op/Multi-Site%20Activities/FACIT%20Protocol/FACIT%20Protocol.pdf.

³⁶ Torrey, W. C., Drake, R. E., Dixon, L., Burns, B. J., Rush, A. J., Clark, R. E., and Klatzker, D. (2001). Implementing Evidence-Based Practices for Persons with Severe Mental Illnesses. Psychiatric Services, 52, 45-50.

³⁷ Ibid.

³⁸ Ibid.

³⁹ Stuart, G. W., Burland, J., Ganju, V., Levounis, P., and Kiosk, S. (January 2002). Educational Best Practices. Working paper developed under grant number HS10965 from the Agency for Healthcare Research and Quality. Available through http://commerce.metapress.com/content/t0475161q9232685/.

⁴⁰ Torrey, W. C., et al., op cit.

⁴¹ SAMHSA Health Information Network. http://mentalhealth.samhsa.gov/cmhs/CommunitySupport/toolkits/illness/IMR_FidelityScale3.asp.

⁴² The items on the GOI were derived from clinical experience, although the research literature also supports the importance of many of these factors. It contains broad principles regarding elements such as program philosophy, training, supervision, and program monitoring. The GOI contains simple-to-understand face-valid items that are rated on a 5-point response format, ranging from 1 equals no implementation to 5 equals full implementation, with intermediate numbers representing progressively greater degrees of implementation. Typical sources of information include interviews with staff, observation of team meetings, review of charts, and observation of interventions. See http://download.ncadi.samhsa.gov/ken/pdf/toolkits/employment/14.SE_GOI.pdf for detailed information about the index.

⁴³ This discussion of Medicaid reimbursement is based on the discussion in Smith, G., et al., op cit., note 28.

⁴⁴ Campbell, J., and Eiken, S. (August 2005). Promising Practices in Using Medicaid for Peer-Delivered Mental Health Services. Prepared for the U.S. Department of Health and Human Services.

⁴⁵ The §1915(i) authority was established under Section 6086 of the Deficit Reduction Act of 2005, effective January 2007, now P.L. 109-171.

⁴⁶ Under the HCBS waiver authority, a state may offer waiver services to persons with incomes up to approximately 225 percent of the federal poverty level (by covering individuals with incomes up to 300 percent of the Federal Benefit Rate for SSI payments.) Although §1915(i) permits states to cover persons with incomes up to 150 percent of the federal poverty level, a state may offer HCBS only to persons who are financially eligible for Medicaid in eligibility groups that the state already has included in its Medicaid State Plan.

⁴⁷ Federal law does not permit states to claim federal financial participation in the costs of services furnished to adults between the ages of 22 and 64 with mental illnesses in an "Institution for Mental Disease" (IMD). An IMD is a hospital, nursing facility, or other institution of more than 16 beds that primarily engages in the diagnosis and treatment of mental disease. The "IMD exclusion" has proven to be a barrier to states in operating HCBS waivers for these adults. Because adult IMD services are not Medicaid reimbursable, an HCBS waiver cannot operate to furnish alternatives to such services. Three states (CO, MT, and WI) operate HCBS waivers that specifically target adults with serious mental illnesses. These waivers are structured to furnish HCBS as alternatives to a nursing facility rather than IMD services. Many other states operate HCBS waivers for people with disabilities that accommodate adults with serious mental illnesses. More information about this topic is contained in Smith et al., op. cit, note 28 (available at http://aspe.hhs.gov/daltcp/reports/handbook.htm).

Appendix A: Description of MHST Grant Initiatives

Delaware

The grant's primary purpose was to develop practices to support and facilitate full partnerships between families and mental health professionals in decision making about children's mental health services; and to enhance the existing delivery system by providing a stronger orientation toward recovery, with families as key agents for support during relapse and in the recovery process. The target population included families and children served by the State's Section (§) 1115 Medicaid waiver's public/private partnership for managed children's behavioral health care. The grant was awarded to the Delaware Division of Child Mental Health Services, which partnered with the Delaware Federation of Families for Children's Mental Health and the state Medicaid office, and contracted with the University of Delaware Center for Disabilities Studies to conduct many grant activities.

Description of Grant Initiative

The Delaware Federation of Families for Children's Mental Health identified the absence of effective, comprehensive, and system-wide family psychoeducation as a critical gap in Delaware's statewide public system of children's behavioral health care. The grant project's goals were to develop, pilot, and disseminate a psychoeducation program relating to children's mental illnesses and severe emotional and behavioral disturbance.

To assess the need for the evidence-based practice of family psychoeducation for children and families in Delaware, and to determine what psychoeducation therapeutic models and resources are available, contractor staff conducted a mail survey and several focus groups with family members, caregivers, and children from all areas of the State to identify their education needs for managing behavioral issues. They also conducted an informal survey with school personnel, members of the Division of Child Mental Health Services Advisory and Advocacy Councils, Interagency Council members, and attendees of the Delaware Life Conference on Medicaid Reform. Finally, contractor staff conducted a literature review on available educational materials and promising practices in family psychoeducation.

Contractor staff, with input from service users and providers, designed and produced a family psychoeducation intervention, which uses a web-based curriculum that is also available as a manual (Family Education and Support) to educate parents/caregivers, providers, school psychologists, and guidance counselors on social, emotional, and behavioral health problems in children and youth and strategies for addressing them. The intervention is designed to complement other services clients are receiving, and consists of educational materials on 12 topics (6 for family members/caregivers and 6 for children/youth) to be presented in group or individual sessions. The curriculum can be accessed and used online, and all program handouts may be downloaded and printed from the website. The full manual can also be downloaded.

The intervention was piloted by the largest mental health outpatient provider for children's services in the State in three public mental health provider settings. Grant funds were used to pay a stipend to service users and family members to develop and pilot test the intervention and encourage their active involvement in critical phases of grant activities. An evaluation of the pilot found that among individuals receiving treatment, those who had participated in the psychoeducation intervention improved more quickly than those who did not. This finding is consistent with those of other research in this area. In addition to documenting the intervention's cost-effectiveness, the pilot also found that offering the intervention was a way of making services available to clients who otherwise would not have been receiving any services at all while on a waiting list.

After participating in the family psychoeducation sessions while on a waiting list for outpatient services, pilot participants entered outpatient treatment with the same provider. After the grant ended, outpatient providers continue to have access to the manual for family psychoeducation. Providers report that they are not billing separately for psychoeducation with children and families but are incorporating it in their individual and/or family therapy sessions, which are billed as such.

The grant contractor produced 900 hard copies of the Family Education and Support manual and distributed them throughout the State in response to consumer and mental health provider agency requests. Contractor staff provided training on using the manual to staff from the Division of Child Mental Health Services and its contracted service providers, as well as to outpatient mental health providers and providers of other levels of care (e.g., intensive outpatient home-based, day treatment, and residential treatment). About 150 providers, including school counselors and psychologists, received training on how to use the manual to provide family psychoeducation.

Systems-level Challenges

Grant staff noted that enrolling service users in evidence-based practices or recovery-oriented practices could be difficult, particularly in the rural, southern part of the State, which lacks public transportation. It is hard to get people to appointments, and families have many competing demands. Some providers offer a dinner to make it easier for families to participate, and grant staff suggested that it would be helpful to run multifamily groups with adequate transportation.

Education and Training

Therapists using the manual during the pilot were generally enthusiastic about family psychoeducation; their input on the manual was used to improve it. The manual has facilitated the adoption of family psychoeducation by therapists because it is a visible reminder and a useful tool for providing the evidence-based practice. Therapists noted that family psychoeducation provides a common philosophical basis for treatment among different entities; for example, school staff and mental health providers. The psychoeducation manual provides everyone who serves children in the mental health system with a common framework within which they can discuss treatment goals and approaches.

Reimbursement Issues

Although the State established a separate billing code for family psychoeducation—designed to be billed in 1-hour increments—providers statewide billed only 183 units of family psychoeducation. Grant staff had hoped that providers would make more extensive use of the psychoeducation billing code. Instead, they continue to use a billing code for individual and family mental health treatment sessions, during which they incorporate family psychoeducation concepts and use the materials in the manual. As a result, the State cannot accurately assess the extent to which the new service is being provided.

The separate billing code allows providers to furnish family psychoeducation as an individual or group intervention in addition to their usual services—thereby increasing revenues. However, providers have not yet adopted this service approach.

Quality Assurance

Although fidelity was not measured as part of the pilot, feedback from experts in child trauma treatment indicate that the materials are highly consistent with psychoeducation concepts used in trauma-based cognitive behavior therapy. The pilot did not provide quantitative or qualitative data, but therapists' anecdotal reports on outcomes noted that families were much better prepared to participate in treatment after having received the family psychoeducation intervention.

The availability of a carefully crafted family psychoeducation manual, which has been designed with extensive consumer input, can increase the quality of family psychoeducation services. Mental health service providers and parents/caregivers found the written information to be understandable and the visual materials and graphics very useful for understanding key concepts; the materials for children were also age appropriate and understandable.

Grant Outcomes

The provision of psychoeducation with children and their families was a new service in Delaware. The materials developed under the grant have enabled therapists to routinely provide family psychoeducation as part of comprehensive mental health services for children/youth and their families. The family psychoeducation curriculum and the full manual are available at http://www.udel.edu/cds/familyeducation/ and in hard copy format for use by therapists. The State now reimburses providers for the provision of family psychoeducation and has established a separate billing code for this service.

In addition, the Delaware Department of Education has requested that the project director provide training for its school psychologists, counselors, and health staff on use of the curriculum as well as hard copies of the materials. Additional partnering agencies have requested and are being included in outreach and training activities, including the Division of Family Services (child welfare), the Office of Prevention and Early Intervention, and managed care organizations with which Medicaid contracts to provide health care to Medicaid eligibles.

Finally, the University of Delaware's Center for Disabilities Studies is considering using the manual with persons who have suffered traumatic brain injury, and possibly trauma-focused cognitive behavior therapy. If possible, the Center will try to incorporate new training into existing programs.

Remaining Federal/State Issues

Grant staff recommended that the Substance Abuse and Mental Health Services Administration stop using separate block grants for mental health and substance abuse. For children and youth, the co-morbidity rate for these disorders is high. Forcing labeling or diagnosis of youth for only one of these conditions discourages the development and adoption of integrated mental health and substance abuse treatment interventions.
The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) mandate is the foundation for many of the State's mental health services for children and their families, and grant staff recommend that it be retained to ensure that these services continue to be provided.

Maine

The grant's primary purpose was to increase the State's ability to offer recovery-oriented services to Medicaid-eligible individuals with mental illness. The grant was awarded to the Maine Department of Health and Human Services, Office of Adult Mental Health Services. The University of Southern Maine's Center for Learning, Institute for Public Sector Innovation, was contracted to provide training and logistical support for the project's training and education component.

Description of Grant Initiative

The main focus of grant activities was the design and implementation of a Certified Intentional Peer Support Specialist (CIPSS) training and certification program comprising three courses. Grant staff, consultants, and the grant Advisory Committee developed three training curricula for the CIPSS program. Grant staff produced a brochure describing the program and conducted the trainings. Several state-supported consumer-operated programs recruited participants for the program.

The first course (Peer Support 101) is a 3-hour class that serves as an introduction and provides an opportunity for (1) service users to discover the many types of peer support that are available in Maine and qualify for participation in the certification training; (2) providers to learn about peer support, and decide if they would like to offer it as part of their agency services; and (3) family and community members to find out about peer support services options for their friends and relatives who require mental health services. During the grant period, 32 classes were conducted for 304 individuals.

The second course (Healthy Connections: Moving Towards What We Want) was developed as an intermediate-level training course for individuals wanting to learn more about peer support but not necessarily interested in becoming certified as peer support specialists. This course provides an opportunity for individuals, programs, and community-based organizations (e.g., a social club or residential program) to work together to identify shared goals and methods to achieve them. The class begins with a half-day session, where participants discuss and plan what they want to learn. The following three day-long sessions focus on the interests of the entity hosting the program. For example, a local program might want to focus on conflict resolution while another might want to focus on dealing with crisis situations; 67 individuals attended this course.

The third course (Certified Intentional Peer Support Specialist Training Program) is required for certification as a peer support specialist and is discussed in detail below.

Peer Support Education and Training

Requirements for peer support specialist certification include completion of Peer Support 101 and the CIPSS training program; quarterly co-supervision with staff in the Office of Adult Mental Health Services, Office of Consumer Affairs; two continuing education classes per year; and 75 hours of work per year. Applicants to the certification course must also demonstrate their individual recovery commitment and experience, and their community engagement and ability, which are assessed using their application and by contacting references.

Certification is issued on completion of all requirements, which must be met within 1 year of completion of the CIPPS training program. Co-supervision, continuing education, and the 75 hours of peer support work—paid or on a volunteer basis—must be met each year to maintain yearly certification.

The certification training takes 9 days. A consultant was paid to develop the curriculum with state funds so that the State would own it. The grant was used to fund training for 80 persons. The State has developed a tracking database to determine whether individuals have completed all of the certification requirements.

The State lacks trained peer facilitators to provide Wellness Recovery Action Planning (WRAP). One of the grant goals was to increase the number of service users who could be WRAP facilitators by having them attend a train-the-trainer curriculum offered by The Copeland Center, an advocacy organization that provides WRAP technical assistance. However, the Center increased its participation requirements, and as a result, very few interested individuals were able to meet them.

Reimbursement Issues

The State reimburses CIPSS services on two Assertive Community Treatment (ACT) teams that work with clients in forensic settings but needs to amend the Medicaid State Plan to obtain funding to pay for CIPSS services on all of the State's ACT teams. However, Maine has bundled ACT service reimbursement, and if CMS requires Maine to unbundle ACT services, those provided by peer support specialists on ACT teams would need to be billed separately from the rest of the team, which could jeopardize continuity of care.

Quality Assurance

Grant funding was insufficient to assess the quality and outcomes of service provided by peer support specialists.

Grant Outcomes

The Office of MaineCare Services (the state Medicaid agency) amended a Medicaid rule to include the definition of certified intentional peer support specialist, and to require that all ACT teams hire one full-time equivalent peer support specialist. However, the rule change is conditional on CMS approval of a proposed State Plan Amendment that will allow reimbursement for their services. If CMS does not approve the amendment, the Department will seek state funding to pay for certified intentional peer support specialists on all ACT teams, but obtaining funds is unlikely in the current economic climate.

Because the State Plan amendment is on hold (see Federal/State Issues below), the Office of Adult Mental Health Services is providing state funds for the two ACT teams that are specially trained to deal with clients' forensic issues and required to hire a certified intentional peer support specialist. (This requirement is separate from that mentioned above.)

The CIPSS training and certification program has increased access to peer support services by increasing their availability in several settings, including general hospital emergency departments, state mental health hospitals, and peer "warm lines." Warm lines offer telephone support for non-crisis situations, including, but not limited to (1) dealing with grief, sadness, discouragement, or loneliness; (2) developing effective strategies for the future; (3) providing assistance with referrals to community resources; and (4) providing information about recovery programs. These CIPSS services are reimbursed with state general revenue funds.

Remaining Federal/State Issues

Some mental health provider groups are reluctant to contract with trained peers, such as WRAP facilitators or certified intentional peer support specialists, because they are afraid they will have no control over their work and could be liable for any negative outcomes resulting from the peers' performance. Also, some ACT providers and peer service users still have difficulty conceptualizing how peer support should be incorporated into the ACT model because Medicaid definitions of medical necessity are deficit based rather that strength based. However, treatment focused on addressing deficits is not totally incompatible with a strength-based, recovery-oriented approach; thus, ongoing provider education is needed on the role of peer support specialists on ACT teams.
CMS required the Office of MaineCare Services to submit a State Plan Amendment to include certified intentional peer support specialists on ACT teams. However, during the grant period, the U.S. Congress enacted changes to the rules governing the rehabilitation option and the targeted case management option. Because of opposition to the changes from many states, Congress declared a moratorium until 2009. Until policy regarding these two options is finalized, the State will not submit a State Plan amendment for the stated purpose.

Massachusetts

The grant's primary purpose was to promote a recovery orientation throughout the State's mental health system with a particular focus on strengthening the infrastructure to support mental health consumer-operated programs and activities (COPAs). Although the State's long-term goal is to transform the overall system, the grant project focused on adult Medicaid-eligible mental health service users, including those with co-occurring substance abuse problems. The grant was awarded to the University of Massachusetts Medical School, Center for Health Policy and Research, in partnership with the Massachusetts Department of Mental Health and the Office of Medicaid. The state agencies for Medicaid, mental health, substance abuse, and rehabilitation, along with consumer-operated and provider organizations, formed the Transformation Committee that met monthly to lead grant activities.

Description of Grant Initiative

One of the grant goals was to establish a formal network across the State of all consumer-operated programs that provide recovery-oriented activities. The network's purpose was to encourage these programs to share lessons learned and to strengthen the voice of mental health consumers around the State to inform mental health policy. As a first step, a subcommittee of the Transformation Committee developed a survey to collect information on existing, free-standing consumer-operated programs and activities statewide. The survey was distributed widely and 47 COPAs responded. The results were published in the COPA in Massachusetts Directory, and hard copies of the directory were distributed to service users, providers, and consumer-operated organizations. The report is available on the web for access by other stakeholders and the general public, and a consumer-operated organization—The Transformation Center—plans to keep the directory current. After the directory was released, the consumer-operated programs began meeting regularly in statewide meetings.

The information from the survey is being used to (1) identify areas in the State that have few or no COPAs in order to target development of new programs, (2) develop a database that service users and providers can search to identify COPAs in their communities, (3) inform training and technical assistance activities for COPAs and for those service users who want to develop similar activities in their communities, and (4) identify promising practices and build evidence for the value and contributions of COPAs to the larger mental health system.

The Transformation Committee also conducted a conference that was attended by 250 providers, service users, and state agency staff. In addition to regional networking sessions, the conference included talks and workshops on Supporting Recovery and Person-Centered Transformation Initiatives, Emerging Trends in Recovery Practice and System Organization, and Peer-Operated Programs and Activities: History and New Developments.

To assess gaps in recovery-oriented services statewide, grant staff and two mental health consumer interviewers conducted interviews with staff and service users at six traditional mental health provider service organizations to document examples of recovery-oriented practices and services, and the opportunities for and barriers to providing these services. A report summarizing results from the interviews (Snapshot of Recovery Oriented Practices) was used to generate discussion at the Department of Mental Health and provider agencies about how to identify and implement recovery-oriented practices.

Grant staff also developed a position paper (Developing a Mental Health Peer Specialist Workforce in Massachusetts) on the value of peer specialists in providing mental health services, and the growing evidence base supporting the use of peer specialists. The paper was disseminated to state agencies, consumer-operated organizations, and provider organizations. It helped to advance discussions with the Department of Mental Health and the Office of Medicaid about the value of integrating peer specialists into the public mental health system, although the specifics of a Medicaid financing strategy for doing so are still under discussion.

The Transformation Committee helped to establish a state-level, consumer-operated training and technical assistance center—known as The Transformation Center—to support, improve, and expand recovery-oriented and consumer-operated programs, and to inform and influence state mental health services policy. During the grant period, the Transformation Center provided information and referral services and training and technical assistance on recovery, empowerment, and cultural change to more than 625 individuals from both consumer-operated programs and traditional mental health providers. In addition, the Center's website received about 200 hits per month.

Peer Specialist Training and Certification Program

A subcommittee of the Transformation Committee and staff from the Transformation Center collaborated to adapt Georgia's peer specialist training and certification program for use in Massachusetts. Grant funds supported the activities undertaken to develop the Massachusetts peer specialist training program and also funded the first training in August 2006; the November 2006 and March 2007 trainings were funded by the Department of Mental Health. Certification is not currently a requirement to work as a peer specialist in mental health service agencies, although most mental health employers in the State place high value on certification when hiring peer specialists, so those who are certified are more likely to be employed.

The 34-module curriculum covers the foundation and stages of the recovery process and the role peer specialists can play in that process; in particular, how to use their own recovery story so they can serve as role models for others. The curriculum, which focuses on helping the trainee to develop competencies and skills in the peer specialist role, is provided over 8 days in a retreat-like setting where participants attend classes during the day and stay overnight on the training site (generally, a hotel/conference center), interacting with classmates over meals and other social activities. This approach provides participants with an opportunity to build relationships with other peer specialists whom they can turn to for support and ideas after they return to work, or take new positions, as peer specialists.

The certification exam is offered approximately a month after the training is completed and consists of a written and oral exam, with a minimum passing score of 75 percent. Once an individual completes the training and passes the certification test, that individual is considered a certified peer specialist and is assumed to possess the skills and expertise required to successfully fill peer specialist roles throughout the Massachusetts mental health service system. Certified peer specialists are required to participate in continuing education activities conducted by the Transformation Center and Recovery Learning Communities to ensure that their knowledge and skills are kept up to date.

Of the 87 participants who completed the peer specialist trainings in 2006–2007, 68 took the certification test, 54 of whom passed. The goal of future peer specialist trainings is to have all participants take the test. In fact, for the 2008 peer specialist trainings, a considerably higher proportion of trainees (greater than 90 percent) took the certification test, indicating that achieving certification is becoming increasingly more valuable in the state.

It has been challenging to meet the high demand for training from service users and mental health providers who are eager to employ certified peer specialists in their service programs. For the first training class, priority was given to individuals already working in peer support roles. The rationale behind this targeted selection was to build an experienced cadre of certified peer specialists that would be able to apply their new skills and knowledge immediately in their peer positions, helping to illustrate the value and importance of their roles throughout the service system.

For the second and third trainings, recruitment targeted certain geographic areas to increase numbers of certified peer specialist services where demand for their services was high. The ongoing goal for class selection is to accept two-thirds of individuals with experience working or volunteering in peer roles, and one-third of individuals with recovery experience who have not yet worked in a peer role.

In regard to measuring the outcomes of the three peer specialist trainings conducted during the grant period, a consumer-operated quality improvement organization, Consumer Quality Initiatives (CQI), conducted pre- and post-test assessments to determine whether changes in participants' knowledge were occurring as a result of the training. CQI adapted a test instrument developed by the University of Illinois at Chicago that has been used to evaluate knowledge changes resulting from the Georgia peer specialist training. Fifty-five participants across the three trainings completed the pre- and post-test, and demonstrated measurable and statistically significant gains in their knowledge. Although increases in knowledge are a positive outcome, the broader goal is for training participants to secure jobs as peer specialists throughout the mental health system and to apply their new skills to move the system toward a stronger recovery orientation.

The Transformation Center staff have informally assessed work outcomes as a result of the peer specialist training through phone and in-person interviews with certified peer specialists. Forty-six of the 54 individuals who were certified in 2006–2007 are currently working in peer specialist roles; 32 already had paid peer specialist work before the training, and several of this group increased the number of hours they were working in their positions; 14 obtained new peer specialist positions after the training.

The Center for Health Policy and Research is in the process of evaluating the peer specialist training program with a final report expected in July 2009. The evaluation is examining the impact of the training on a trainee's employment in peer specialist roles and on the individual's skills for working in these roles.

Reimbursement Issues

The State has been funding consumer-operated programs such as drop-in centers, advocacy organizations, and peer support groups for many years, but there is no specific reimbursement category for peer specialists who work in traditional provider settings. Traditional providers may elect to hire peer specialists using their existing budgets. Providers often hire peer specialists to run groups, work in residential settings, and work on benefits and vocational issues with their peers.

According to providers who serve on the Transformation Committee, most of the provider community feels that peer specialists are very valuable in helping service users achieve their recovery goals, and as a result, providers are committed to hiring them, even when it is challenging for their budgets. But this environment often results in peer specialists being hired for limited part-time positions and thus not truly being integrated into provider programs.

Although the Department of Mental Health is interested in exploring a separate reimbursement code for peer specialist services, discussions with the Office of Medicaid would first be required to determine how this could be done.

Quality Assurance

Feedback from service users attests to the value of peer specialists, who change the service culture to one that is more supportive and recovery oriented. Also, as a result of their training, many peer specialists see their own recovery in a different light because they have a new sense of empowerment. As mentioned above, the Center for Health Policy and Research is currently evaluating the impact of the peer specialist training program on its trainees. The evaluation will also include interviews with service users who receive supports from certified peer specialists to begin exploring their service outcomes and impact on the mental health service system.

Grant Outcomes

The Department of Mental Health considers the promotion of a recovery orientation throughout the State's mental health system to be a strategic priority, and the initiatives funded under this grant, including the Transformation Center and ongoing certified peer specialist trainings, have been sustained with state agency funds and other grants since the grant ended.

During the grant period, the Transformation Committee became a respected leader in the ongoing dialogue about mental health system transformation in Massachusetts. Committee members have stimulated the development of infrastructure to support and sustain consumer-operated and recovery-oriented mental health services in Massachusetts. The Committee is now a permanent subcommittee of the State's Mental Health Planning Council. The Council's role is to guide the Department of Mental Health in its planning processes and to determine how federal block grant money is to be used.

The concepts of recovery and peer-provided services are becoming more accepted across the Massachusetts mental health system, and more providers are hiring certified peer specialists. However, the newly hired sometimes face challenges working in settings that are not supportive of mental health clients' assuming professional roles in which they use their experience as a client to help their peers. This may be due in part to the stigma surrounding mental illness that results in staff uncertainty about the value of peer specialists working in mental health programs.

To help promote a more accepting mental health system, a small group of individuals from the Transformation Committee took the lead in developing a Culture of Respect Statement on why responsible disclosure within the mental health workforce is valuable and should be supported. The statement endorses a system that views voluntary, personal disclosure within the context of helping relationships as a positive action that supports recovery, and encourages providers to support and respect such disclosure. The Statement has been distributed to state agencies and mental health provider organizations.

Remaining Federal/State Issues

The need for additional funding—be it state or federal—to support the peer specialist workforce is hindering expanded use of peer specialist services in the traditional mental health system. The State's Office of Medicaid and the Department of Mental Health have not yet decided to pursue Medicaid funding for peer specialist services because of uncertainties about the best approach for doing so. However, conversations about securing Medicaid reimbursement are continuing. It would be helpful for CMS to provide more technical assistance to states about the reimbursement options for peer specialists.

Michigan

The grant's primary purpose was to make recovery-oriented practices the foundation of Michigan's adult mental health system. Grant staff worked to encourage a recovery orientation among consumers, professionals, service system managers, and state mental health policy leaders. The grant was awarded to the Michigan Department of Community Health (MDCH).

Description of Grant Initiative

Grant staff created a 48-member Recovery Council of Michigan to direct and support grant activities. MDCH and the Recovery Council worked to ensure the adoption of recovery-oriented practices throughout the Michigan mental health system. Michigan has 46 county-based community mental health services programs (CMHSPs), which contract with 18 regional prepaid inpatient health plans (PIHPs) under the State's concurrent Section (§) 1915(b)/(c) waiver for Medicaid Specialty Mental Health and Substance Abuse Services.

Peer specialists play an important role in providing a recovery-oriented focus. Medicaid funding for peer specialist services is available under the §1915(b)(3) waiver authority. More than 550 certified peer support specialists provide services through community mental health services programs. They work in various settings (e.g., Assertive Community Treatment teams, crisis settings, and consumer-run organizations) and provide services in a wide range of service areas, including assistance with housing, jail diversion, psychosocial rehabilitation, employment, and other areas as defined in the §1915(b) waiver.

To support the transition to recovery-oriented practices, the Recovery Council (which included MDCH staff) developed a strategic plan to develop the infrastructure needed to bring about systems change. The Council also produced several documents including (1) one describing the Recovery Council's vision and the values of a transformed system, (2) one supporting the Recovery Enhancing Environment (REE) tool designed to measure consumers' and organizations' recovery orientation, and (3) one clarifying MDCH's vision and values for recovery and the role of certified peer support specialists in the mental health system.

MDCH and the Recovery Council collaborated with three local community colleges to host town hall meetings with consumers, family members, advocates, providers, and community college staff and students. The purpose of the meetings was to (1) provide information on Council activities, recovery initiatives, and the REE tool; (2) describe the new Certified Peer Support Specialists and virtual Michigan Recovery Center of Excellence initiatives, and (3) obtain input on these topics from those attending.

MDCH—in partnership with the Appalachian Consulting Group—developed a curriculum on systems transformation training, which includes principles and practices of recovery, and provided training to consumers, providers, community organizations, and board members and executive staff of managed care plans. MDCH also collaborated with Lansing Community College to develop a curriculum for recovery-oriented trainings on health and wellness and recovery-oriented practices such as trauma-informed care, person-centered planning, self-determination, consumer leadership, and Wellness Recovery Action Planning. (For information on trauma-informed care, see http://mentalhealth.samhsa.gov/nctic/)

One of the Recovery Council's goals is to have persons in recovery involved in all relevant MDCH activities. Grant staff said that although MDCH is committed to a recovery orientation, some settings and providers whose work is based on traditional practice models are not as welcoming; additional effort is needed to promote recovery practices in these settings. Grant staff reported that involving peer support specialists who model hope and recovery in all initiatives helps promote this focus.

For example, MDCH implemented Dialectical Behavior Therapy (DBT) training statewide.¹ To achieve its goal of having a peer support specialist on every DBT team, MDCH worked with community mental health services programs to involve peer support specialists in providing this therapy. As a result, peer specialists in Michigan are now an integrated part of DBT teams statewide.

In the mental health trainings it offers, MDCH tries to ensure that service users constitute 30 percent of attendees to give their voices a critical mass. They also try to place service users on training teams to improve clinicians' view of recovery. Peer support specialists have attended training sessions for psychiatrists, and their presence and contributions during the training inform psychiatrists' recovery perspective.

Development of Michigan Recovery Center of Excellence

MDCH and the Recovery Council created a virtual Michigan Recovery Center of Excellence using grant funds and SAMHSA block grant funds. The Recovery Center developed a website (http://www.mirecovery.org) with state, national, and international information related to recovery-oriented practices; the Center will provide technical assistance through the website and to providers and service users on how to implement the Recovery Enhancing Environment tool designed to measure the recovery orientation of consumers and organizations.

MDCH and consumer leaders established the statewide Recovery Council with the goal of consumers' composing more than 75 percent of its members. Such a Council can oversee state, regional, and local recovery-oriented initiatives and work in partnership with educational institutions to bring about systems change. Grant staff reflected that the phrase "nothing about us (service users) without us" means having "enough of us" to form a critical mass to get the consumers' point across. This critical mass needs to be higher than the usual 51 percent service user representation requirement to give service users confidence that they will be heard and to create a different learning dynamic.

Service users challenge MDCH staff about undesirable policies and practices, enabling staff to understand their perspectives. Grant staff suggested that states encourage service users—including peer support specialists—to provide their perspective on what helps and hinders recovery. States can help service users do so by allowing them to attend any training session at no charge, which will also help to achieve the goal of increasing their representation in the trainings.

Systems-level Challenges

Grant staff stated that although recovery principles are frequently mentioned in brochures and publications, unless they are codified in state and federal guidelines—including Mental Health Code requirements, rules, and regulations—their application is not guaranteed. Many state and federal services and supports for persons with mental illness are provided by multiple departments, including health services, human services, vocational rehabilitation, and others. Unless state-level administrators continue their commitment to recovery-oriented practices and continue to provide policies and guidance to support and sustain these practices, they will not be implemented in all of these departments.

The Department continues to face another challenge in that Michigan lacks sufficient HUD Section 8 vouchers and other housing resources to promote independent living. Because they do not have their own residence, individuals are often placed in foster care with several other consumers. Being able to live in a place of their own with support would help promote recovery.

Adoption of a Recovery-Orientation by Mental Health Providers

Many provider agencies generally lack a recovery-oriented perspective. Nationally, provider education in community colleges and universities does not include course work on recovery-oriented practices. In addition, providers have extensive ongoing job responsibilities, and learning about recovery-oriented practices is often not their priority. On the other hand, grant staff believe that all service users—regardless of their degree of illness—have better outcomes when they receive person-centered planning and community support, which are both important components of recovery.

Grant staff and the Recovery Council found it challenging to work with a large number of providers with different clinical perspectives (i.e., both traditional and recovery-oriented). A considerable amount of discussion and time was needed to develop a shared perspective and make decisions. The end result, however, made the Council a stronger body, better able to carry out oversight and provide direction.

Grant staff suggested that states develop and support a well-trained, highly qualified, peer support specialist workforce to help strengthen recovery-oriented practices. Based on the experience of Michigan's mental health system, peer support specialists need to be given a reasonable salary and a benefit package to ensure their retention.

Reimbursement Issues

The §1915(b)(3) waiver authority affords considerable flexibility to fund recovery-oriented initiatives. MDCH uses the §1915(b)(3) authority to operate a managed care service delivery system, which allows savings to be used to fund additional services. Michigan's program uses savings to fund peer support specialists and peer-operated programs such as consumer-run drop-in centers. States can also use the Medicaid rehabilitation option to fund peer support specialists, as does Georgia. Grant staff thought that the reason many states do not cover peer support services is because they are not making use of all the available Medicaid options to do so.

Quality Assurance

MDCH and the Recovery Council adopted the Recovery Enhancing Environment (REE) tool as a quality improvement measure for recovery-oriented practices. Data collection with grant funds began in November 2008. MDCH will use SAMHSA Mental Health Block Grant funds to support long-term REE data collection statewide.

The REE was developed by Priscilla Ridgway at the Yale University Program for Recovery and Community Health to collect information on personal recovery, organizational climate factors that support resilience, and programs and services that influence recovery. The REE has a total of 166 questions organized into eight domains: Demographics, Stage of Recovery, Importance Ratings on Elements of Recovery, Program Performance Indicators, Special Needs, Organizational Climate, Recovery Markers, and Consumer Feedback.

The REE can be used in strategic-planning processes as well as organizational change or systems transformation efforts. Ideally, such activities would require a wide variety of stakeholders, particularly service users.

Along with improving recovery-oriented practices through use of the REE tool, MDCH is working to improve the quality of currently practiced EBPs—ACT, Integrated Dual Disorder Treatment, DBT, and Supported Employment. MDCH required the State's 18 regional prepaid inpatient health plans (PIHPs) to set up Improving Practices Leadership Teams (IPLT) across the PIHP to participate in statewide practice improvement. The IPLTs foster development of a learning organization within the State's mental health system so that promising and evidence-based practices are supported. A committee is working to identify common outcome measures to be used for all EBPs offered in the State.

Grant Outcomes

MDCH will fund the Recovery Council's ongoing activities, ongoing statewide implementation of the REE, and the development and fielding of individual recovery markers such as "having hope is important to my recovery," "having my rights respected and upheld," and "having a sense of meaning in life." Consumers can use these individual markers to identify their goals during the person-centered planning process. MDCH will also develop site review indicators, which will inform consumers, providers, and MDCH staff about provider progress toward full implementation of recovery-oriented practices.

MDCH worked with community colleges to develop a curriculum that will offer three elective credit hours for peer support specialists who complete certification requirements. In addition to the three elective credit hours, MDCH and Lansing Community College are currently working together to offer continuing education opportunities to peer support specialists in multiple areas centered on the principle and practices of recovery.

Remaining Federal/State Issues

Grant staff made four recommendations for CMS's consideration to improve the use of recovery-oriented practices. First, CMS policy needs to support a comprehensive range of recovery-oriented practices. Second, CMS should provide free technical assistance to states for implementing recovery practices in both State Plan and waiver services as it does for improving quality in HCBS waiver programs. Third, CMS should consider another grant initiative to help states implement major mental health systems transformations. Fourth, The Federal External Quality Review requirements for managed care providers of mental health services should be amended to include a strong focus on recovery-oriented practices.

Minnesota

The grant's primary purpose was to improve the quality of children's mental health services and their treatment outcomes, and to reduce out-of-home placements. The target population was Medicaid-eligible children with serious emotional disturbance (SED). The grant was awarded to the Minnesota Department of Human Services, Children's Mental Health Division (hereafter, the Division). Grant staff partnered with the National Alliance for the Mentally Ill (NAMI)-Minnesota to implement several grant activities.

Description of Grant Initiative

A major grant goal was to identify evidence-based practices (EBPs) for children with SED and facilitate their implementation statewide. As a first step, a grant contractor developed an innovative system to help providers and families plan more effective treatment for children with SED. The system uses an EBP database that is built on rigorous review of the scientific literature. Based on one developed originally in Hawaii, the database can be used to guide decisions about child and adolescent care; there is no similar database for adult mental health disorders.

The grant contractor updated and expanded Hawaii's database to include current evidence on treatment for seven mental disorders (Depression, Anxiety, Attention Problems, Disruptive Behavior, Substance Use, Trauma, and Autism). The contractor (1) screened more than 4,000 studies for inclusion, (2) conducted a rigorous review of the scientific literature on a range of psychosocial treatments, (3) analyzed the components in each of the treatment protocols, and (4) coded the information for inclusion in the database as evidence for the effective treatment of specific disorders. The database includes summaries of each study as well as aggregate results for each specific disorder.

Information about negative outcomes and side effects was not readily apparent in the original database developed in Hawaii. For example, some studies found that children got worse with some treatments, results that Minnesota considers to indicate a treatment risk. To address this problem, the format for presenting study results was modified so that information about risks and side effects documented in the research are clearly presented.

The Minnesota database incorporates data from approximately 322 randomized trials, representing 40 years of research with more than 25,000 children and youth. Contractors added research findings that were not available to the original Hawaiian project and continue to add studies as they are published. Based on practice elements and client variables furnished by users, the database system provides profiles of promising strategies to inform treatment planning throughout the service system. In practical terms, the new system provides a "map" of the treatment strategies most likely to succeed for a specific disorder given a child's demographic characteristics.

Because the coded data are considered the intellectual property of PracticeWise, the database is proprietary; the State pays an annual license fee to use the data and has an ongoing contract with PracticeWise to update the database annually. Other states have expressed interest in the database, and they can also pay an annual fee to PracticeWise to access it.

A second contractor developed a web-based application to enable providers and families statewide to use the database to develop more effective treatment plans for children with SED. The application was piloted, and provider staff and families were trained to use the database to guide treatment decisions.

When families found the application difficult to use, grant staff decided to partner with NAMI-Minnesota to develop a series of fact sheets for parents and families describing specific mental health disorders in children and adolescents and suggested EBP treatment strategies. They also developed a curriculum (called What Works? What Helps? Treatment Options in Children's Mental Health) to train parents and family members about the use of evidence-based practices in providing more effective treatment plans for children's mental health disorders.

The grant funded NAMI-Minnesota staff to present this curriculum in 16 training sessions for families statewide. A major training goal was to help families better understand their potential role in improving treatment outcomes for their children. The trainings were open only to family members (not to clinicians) so they would not feel constrained in voicing their views and concerns, and in asking questions about treatment.

Mental Health Provider Education and Training

The Division's initial plan was to implement a pilot in which clinicians would be trained to use the database to inform practice, and then compare outcomes of their treatment group with those of a matched control group. Two major problems arose relatively early in this process. The first was related to sample size: of the 40 families referred, 27 were enrolled in the study; at the first 30-day review, 19 subjects remained; and at the 90-day review point only 9 subjects remained. Although a few new referrals were received, it became clear that the pilot would not have a large enough sample to conduct the evaluation.

The second problem was that the clinicians involved in the pilot were not implementing the practices with any regularity or fidelity. Division staff learned that simply providing access to EBP research did not lead to the adoption of evidence-based practices by clinicians who, after exposure to the information, continued to practice using methods with which they were familiar, based on their original education and training and consensus in the field about effectiveness.

To better understand the issues involved in having clinicians adopt new practices, Division staff conducted chart reviews of the children enrolled in the experimental clinic and held focus groups and individual interviews with clinicians who participated in the pilot. Clinicians indicated that just knowing the information was insufficient: they felt they needed specific training on how to implement the practices. In response, Division staff worked with the grant contractor to develop an in-depth curriculum to help clinicians adopt evidence-based practices consistently in their daily practice.

The curriculum requires in-person attendance for 5 days, followed by weekly phone consultation with the contractor's and the Division's clinical EBP experts over a 6- to 9-month period. During these calls, the clinical EBP experts train the clinician to use a specially designed form—called a clinical dashboard—to monitor treatment patterns and measure client outcomes on a weekly basis, as well as progress over time. The dashboards provide a graphic representation of the treatment strategies that have been used during each session with the child and the progress the child has made toward treatment goals. This training approach allows clinicians time to use the new practice with one or two clients at a time and provides assistance from clinical experts.

This in-depth curriculum model has been used to train a core group of 53 clinical supervisors from 23 mental health agencies, including the supervisor from the experimental clinic, using the intensive week-long training and in-depth curriculum that had been developed. After 6 to 9 months of training and consultation, each supervisor was expected to be part of a team to train a new cohort of clinicians. Teaching others both reinforces the training and strengthens an agency's clinical infrastructure by improving the skills of a greater number of staff.

At the same time, when it became clear that it would not be possible to evaluate the pilot, grant staff decided to provide an overall introduction to clinicians across the State about the database and the EBP models the State wanted to implement in the mental health system. This introduction was not intended to change clinicians' practice but to give them a clear understanding about the direction the State was taking in the mental health system. More than 150 clinicians (psychologists or licensed clinical social workers) from across the State were educated about the general EBP model and trained to use the database.

A continuing challenge for the Division now is to ascertain how to work with professional licensing boards and pre-service university training entities to ensure that mental health professionals receive training on current evidence-based psychosocial intervention research, and receive clinical experience in the use of evidence-based practices.

Quality Assurance

The Division does not use fidelity scores or other indicators to determine how well a given treatment has been implemented. Instead, it identifies specific practice elements included in the treatment and determines how often they were used with an individual client. The clinical dashboard tracks treatment strategies used during each session, and also tracks how often sessions were held and how effective the treatment was. The dashboard uses both standardized and non-standardized measures to track outcomes, and measures can be combined as appropriate for each client. It can be easily discerned from a dashboard printout whether clinicians are following EBP protocols in treating individual clients.

Because the evidence-based practices were not implemented in the pilot clinic as intended (for the reasons described above), the Grantee was unable to evaluate the system with an experimental design as had been planned. However, the Division is using funds from a CMS Systems Transformation grant to develop a web-based quality improvement system that all providers were to begin using early in 2009. The new system will allow the Division to track the progress of each child served in the mental health system on a number of standardized measures. Outcomes can then be compared across provider agencies—those that have implemented evidence-based practices and those that have not.

Grant Outcomes

The EBP database, educational materials, and training for clinicians and families have laid the foundation for more effective treatment strategies based on scientific research rather than on consensus in the field about "what works." About 80 percent of clinicians who have been trained to date are implementing the new evidence-based practices, which has increased the number of agencies providing EBP services from 0 to 23. The Division continues to train new cohorts of clinicians each year, and is also training parents and families so they can actively participate in treatment planning and be informed about the strategies most likely to be effective for their children.

In 2007, the State's legislative appropriation included a new funding category in the Division's budget to develop and support evidence-based practices. The Division is currently using this funding category to provide grants to providers across the State to help them develop the clinical capacity to provide more evidence-based services. This has enabled agencies to cover the cost of having their clinicians participate in the 5-day training as well as the 6 to 9 months of ongoing consultation and follow-up. In the future, these funds may be used in other ways to support evidence-based practices.

Remaining Federal/State Issues

Federal policy makes it very difficult for states to provide some components of evidence-based practices—specifically, Multi-systemic Therapy, Functional Family Therapy, and Multidimensional Treatment Foster Care—because some of their components are not billable under Medicaid. It is also problematic to bill for Parent Management Training that requires training of groups of parents without the children present.
The Division would like SAMHSA to fund PracticeWise to continue maintaining and updating the database based on new research. SAMHSA's sponsorship would enable other states to access the database without each having to pay for a separate contract with PracticeWise.

Some SAMHSA staff are aware of the database, but SAMHSA maintains its own list of treatments through its agency review process. However, most of the practices being promoted by SAMHSA are appropriate only for disruptive behavior, and candidate treatments enter the review process through a nomination process rather than the rigorous review for "evidence" used in the Minnesota model.
Although the database provides valuable information about effective treatments, evidence-based practices are difficult to implement, and ongoing support and follow-up consultation are needed to sustain their use. States need funding for the training and consultation infrastructure to support EBP implementation.
Because of the shortage of licensed mental health professionals in the State, Minnesota allows the psychotherapy benefit to be supplemented with skills training. This service is provided by bachelor's degree-level mental health workers who help clients to practice specific skills. The State is still working out the specifics to determine which components of the EBP treatment strategies can be provided as part of skills training and which must be provided as part of psychotherapy.

New Hampshire

The grant's primary purpose was to implement illness management and recovery (IMR) as an evidence-based practice in behavioral health services for individuals with severe mental illness. The grant was awarded to the New Hampshire Bureau of Behavioral Health (hereafter, the Bureau.) The Dartmouth Psychiatric Research Center was contracted to provide training and ongoing technical assistance to community mental health center (CMHC) staff in the provision of IMR services.

Description of Grant Initiative

Illness management and recovery includes psychoeducation, strategies for improving medication adherence, developing a relapse prevention plan, and enhancing skills for coping with persistent symptoms. Implementation analyses of the IMR program (conducted in New Hampshire and nationally) have identified barriers to accessing IMR services, including (1) lack of a coherent service structure and involvement of service providers, (2) a mismatch between Medicaid-reimbursable procedures and some key components of IMR interventions, and (3) the need for ongoing mechanisms to ensure access to training and to sustain high-quality services. The grant was used to address these barriers to IMR provision in New Hampshire.

One of the grant goals was to develop an organizational structure supporting IMR clinicians in each CMHC region. To achieve this, community mental health centers developed IMR implementation teams and designated IMR coordinators to oversee implementation. Each center also established an IMR implementation committee comprising various stakeholders, including service users, who work with the IMR coordinator to implement and sustain the IMR practice. Grant staff provided consultation to the IMR teams regarding CMHC policies and procedures that support illness management and recovery, and Medicaid reimbursement of IMR services.

Because the State receives many calls about mental health services from families and friends of individuals with mental illness, public education about the mental health system is critical for improving access to services. The Bureau and the Dartmouth Psychiatric Research Center developed and conducted IMR informational meetings for service users, families, and the general public, including state legislators. Also, each community mental health center developed posters and brochures that were displayed in CMHC waiting rooms and distributed by staff during intake and appointments.

The Dartmouth Psychiatric Research Center also developed training in IMR-related topics, such as stages of change, motivational interviewing, cognitive behavioral therapy, working with families, and mental illness; and worked with Bureau staff to develop an IMR manual and a train-the-trainer curriculum called IMR, Teach New IMR Practitioners. The Dartmouth Psychiatric Research Center provided IMR training—along with weekly supervision—to staff in the single state psychiatric hospital, the transitional housing services program, and the secure psychiatric unit at the state prison, and will continue to conduct trainings and fidelity assessments on an annual basis.

Another grant goal was to develop recommendations for modifying Medicaid reimbursement guidelines to support provision of IMR services. Grant staff rewrote the administrative rule that governs the provision of mental health services to include illness management and recovery, and helped gain its approval by a legislative committee. They also revised reimbursement regulations to ensure coverage of IMR services, and implemented the new regulations after passage by a legislative committee.

Mental Health Provider Education and Training

The Bureau planned to implement a statewide training initiative and to apply the IMR practice broadly across each community mental health center by training a majority of clinical staff members who could potentially offer the service, as opposed to training only one or two persons in each center. The Bureau engaged all 10 community mental health centers to participate, and from the beginning made statewide implementation of illness management and recovery a mandate. Because the time taken for training would directly affect provider revenue, the State provided $375,000 to the centers to make up for that revenue loss over a 2-year period of time.

It was difficult to implement the IMR practice because of high CMHC staff turnover, on average 20 percent across the provider system (one agency had a 60 percent turnover rate on their adult treatment team) and the need to continually train new staff. The Bureau assisted by providing IMR training for new CMHC hires, including weekly supervision for a period of 4 months with a trainer from the Dartmouth Psychiatric Research Center.

The Bureau also planned to develop credentialing procedures and standards for IMR providers, including staff at community mental health centers, the state psychiatric hospital, and the secure psychiatric unit at the state prison. The purpose of the credentialing process was to facilitate long-term Medicaid reimbursement capability. To minimize the administrative burden on community mental health centers, the IMR Steering Committee (established through the grant) decided to develop a mechanism to credential agencies rather than individuals, and chose five measures for credentialing: (1) overall IMR fidelity score, (2) the proportion of workers completing annual training, (3) the proportion of workers receiving regular supervision on IMR practice, (4) the proportion of eligible consumers receiving IMR services, and (5) the number of consumers who complete all 10 modules of the IMR treatment program.

The credentialing process was not fully implemented during the grant period because there was insufficient time to obtain the second round of CMHC fidelity scores for the IMR indicators. The process will be completed by the end of 2009.

Reimbursement Issues

The State had difficulty identifying a funding mechanism for IMR services prior to receiving the grant, but after reviewing guidance from CMS and having further discussions with CMS on the topic, the State decided to obtain reimbursement through Medicaid's rehabilitation option.

Quality Assurance

Grant staff created an IMR Steering Committee, comprising staff from the state Medicaid, mental health, corrections, and housing agencies; CMHC and peer support agency staff; consumer and advocacy organizations; and Dartmouth Psychiatric Research Center. The Steering Committee developed a quality assurance process for illness management and recovery, which includes consumer outcome measures, SAMHSA IMR fidelity measures, and General Organizational Index (GOI) measures (characteristics believed to be related to an organization's overall capacity to implement and sustain evidence-based practices).

Fidelity assessment teams consisting of Bureau staff, a service user, a CMHC quality improvement staff member, and occasionally a family member conducted fidelity reviews of all community mental health centers. The Steering Committee reviewed fidelity scores to identify areas that needed technical assistance, and reviewed the IMR implementation process to identify areas for improvement. Overall, the State's community mental health center scores were similar to scores in the National Evidence-Based Practices Implementation Project, on both the aggregate CMHC fidelity score and on the individual measures.

The State mandated the annual fidelity review process and will continue to fund it. Community mental health centers are required to implement the IMR practice in accordance with specified standards and benchmarks. Beginning in FY 2010, the Bureau will give a small monetary award annually to three CMHCs that demonstrate high IMR fidelity. The criteria for the award are currently being developed.

The Bureau also decided to have its IMR implementation process evaluated by expert external evaluators using an objective methodology: the State Health Authority Yardstick (SHAY), which was developed by SAMHSA and Dartmouth Medical School to measure how a state authority is implementing and supporting evidence-based practices to ensure their sustainability. (The SHAY is used to evaluate the Bureau, and the Bureau evaluates the provider system using the annual fidelity and GOI reviews.)

The SHAY evaluation provided an enlightening and critical report and helped to promote the IMR initiative's sustainability. The evaluation's results and action plan developed by the Bureau of Behavioral Health in response to its findings were shared with senior leadership within the Bureau and the Department of Health and Human Services, the Steering Committee, and all of the community mental health providers.

Grant Outcomes

The Bureau implemented illness management and recovery in all 10 community mental health centers, the State's inpatient psychiatric hospital, and the State's transitional housing service, thus ensuring access to this program on a statewide basis. Grant staff and the Steering Committee considered different approaches for the Bureau to provide oversight of IMR training and the fidelity of IMR practices, and to provide information about IMR to practitioners, service users, and the public. The Bureau decided to use existing resources and has contracted with the Dartmouth Evidence Based Practice Center (a Center in the Dartmouth Psychiatric Research Center) to conduct trainings and fidelity assessments on an annual basis.

A Center of Excellence was established as a state resource with the purpose of sustaining the IMR practice across state systems through training, fidelity reviews, and public promotion of IMR services. The Center is overseen by the Steering Committee, which is continuing its work with Bureau funding. The Committee also oversees the implementation and sustainability of other evidence-based practices, such as Supported Employment, which the State has implemented statewide using the lessons learned and implementation plan developed as a result of the grant.

The State's 10 peer support centers (funded through the SAMHSA block grant and state funds) did not initially buy into illness management and recovery because they thought it was too medically oriented, preferring instead Wellness Recovery Action Planning, another recovery-oriented practice. Nonetheless, the peer support centers provide information about the practice—as one of a range of available services—to services users who express an interest.

After the first IMR fidelity assessment, Bureau staff and the Dartmouth Psychiatric Research Center provided the community mental health centers with technical assistance to enable them to analyze the assessment report and develop an action plan for improvement. During the second round of assessments, it was noted that scores had improved at all the centers that had completed a second fidelity assessment by the end of the grant period; in particular, one center's GOI score improved considerably.

Remaining Federal/State Issues

CMS should consider funding grants to help states sustain the use of evidence-based practices in the mental health system. The grant was very helpful in establishing illness management and recovery as a service, but significant state funding was needed to implement the practice—about triple the amount of the grant. Obtaining continued funding for training and ongoing fidelity reviews is always a challenge, and given the current budget situation future funding is uncertain.
To accomplish the State's objective of creating a new recovery-oriented culture of service provision in New Hampshire, a workforce trained in state-of-the art treatment practices is critical. Much work remains to build a workforce trained in illness management and recovery. Grant staff noted that SAMHSA did not go far enough with its workforce development initiative to train clinicians to adopt evidence-based practices. Also, because of high turnover among CMHC staff who provide IMR services, it is difficult to sustain provider capacity to deliver these services.
States wanting to implement illness management and recovery as a service need to provide training and consistent supervision, and to understand that the fidelity and GOI scores will be a matter of public record (i.e., available for examination by services users and providers).

North Carolina

The grant's primary purpose was to develop the local mental health system infrastructure needed to offer evidence-based practices (EBPs) for adults with mental illness. The State developed the infrastructure for four new EBPs and developed a plan to disseminate grant toolkits statewide to help other local areas develop similar infrastructure. The grant was awarded to the North Carolina Department of Health and Human Services.

Description of Grant Initiative

Grant staff worked with 4 of the State's 25 Local Management Entities (LMEs) to develop the infrastructure for selected EBPs. LMEs are community-level management organizations charged by the State with managing and coordinating local delivery of mental health services. The 4 EBPs for which infrastructure was developed during the grant were Family Psycho Education (FPE), Integrated Dual Disorders Treatment (IDDT), Illness Management and Recovery (renamed Wellness Management and Recovery, or WMR), and Supported Employment (SE).

The directors of the four participating LMEs formed local work groups to develop infrastructure in their respective geographic areas. Over the grant period, these work groups trained staff; marketed EBPs to consumers and providers and educated them about EBPs; managed delivery of EBP services; monitored and evaluated outcomes; and developed business management practices to support EBP implementation, such as securing records and data; billing; complying with HIPAA privacy requirements; and developing a reimbursement strategy.

Each LME identified priority areas for which to develop infrastructure. Three considered it realistic to focus on only one EBP, given current statewide reform activities and other agency priorities. The Durham LME already had experience with Assertive Community Treatment (ACT) and thought it could implement the four new EBPs named above: Family Psycho Education, Integrated Dual Disorders Treatment, Wellness Management and Recovery, and Supported Employment. Because the other three LMEs had not previously implemented EBPs, the Durham LME helped them to anticipate challenges and to identify effective strategies for addressing them.

Each LME work group developed a strategic plan to develop the infrastructure for its EBP; developed technical resources such as cost analyses and data collection protocols to support implementation and sustainability; and developed outreach and education materials about the EBP for providers and consumers. Consultants provided technical assistance and training about the EBPs selected by each LME. Each LME conducted a field test of its selected EBP in collaboration with one or more of its provider agencies to determine strengths and potential challenges. Only one of the LMEs conducted fidelity assessments.

LMEs educated consumers and their families about EBPs and worked with them to identify and eliminate barriers to obtaining EBP services, such as not knowing how to identify competent providers or obtain services. They also provided information about reimbursement policies that could affect access, such as eligibility requirements, location, hours of operation, and information about the evidence-based practice itself.

Two of the LMEs developed toolkits that contain policies, procedures, manuals, and data collection forms for implementing and monitoring EBPs. The State will combine the information into a single tool kit and send it to all of the LMEs in the State to use when implementing EBPs.

Providers will continue to bill the new EBP services after the grant period, but fidelity monitoring will require additional reimbursement if it is to be maintained, so the State will fund LMEs to conduct regular fidelity reviews. The State used grant funds to conduct and analyze the cost of fidelity reviews to determine the amount of additional funds to add to LME payment rates to support fidelity monitoring. Funds to support monitoring are now built into the LME cost model. Some LMEs will conduct fidelity reviews as part of provider contracts.

The State's 10-year-old Practice Improvement Collaborative (http://www.ncpic.net) has a long tradition of improving practice statewide by encouraging researchers, practitioners, and consumers to improve mental health services and sustain EBPs. The Collaborative will continue to serve as a resource to the State's LMEs and providers as well as other states attempting to develop infrastructure for EBPs and implement them with high fidelity. Some services that are frequently provided in the mental health system do not have a strong evidence base, such as regular outpatient therapy for persons who meet the state's criteria for severe and persistent mental illness, so the State continually reviews research to identify potential EBPs to ensure that consumers have access to them.

Systems-level Challenges

The State identified three systems-level challenges in developing the infrastructure to support the provision of EBPs. First, the current infrastructure did not support adoption and new infrastructure needed to be developed to help providers incorporate EBPs into their current business practices. For example, staff need to be trained on EBP principles, billing issues need to be resolved, and methods for obtaining referrals and coordinating with other agencies need to be developed. The State recognized that EBP infrastructure needs to be in place before implementing EBPs in a local area. The EBP tool kits developed under the grant will help the State's remaining LMEs to develop and implement over time the policies and procedures needed to support EBP implementation.

Second, it was difficult for LMEs to develop the infrastructure for EBPs because they were already having trouble adjusting to the State's transformation of the overall mental health services system, which had instituted new service definitions and billing processes. Because the implementation date for the new service definitions was delayed, LMEs had to ensure that providers were billing correctly as the definitions were introduced. The State also moved responsibility for Medicaid enrollment and service authorization from LMEs to a utilization management company working for the State in order to ensure statewide standardization and efficiency, which initially affected the authorization process for EBPs without time limits, such as ACT and IDDT, authorization for which was being denied.

Third, integrating a recovery-oriented system of care with Medicaid medical necessity requirements is a major challenge. Recovery-oriented services may not meet the requirement for medical necessity but are highly desired by consumers to help keep them motivated to achieve goals in their person-centered plans. The State used state funds for recovery-oriented services and Medicaid funds for services that met the medical necessity requirement to seamlessly integrate EBPs with recovery-oriented services such as housing, employment, social, and peer supports. Providers were encouraged to use as many natural supports as possible in person-centered plans.

Operationalizing a recovery-oriented system of care through such integration is important to help consumers receiving EBPs to live in the community and find meaningful friends. Recovery, though not yet an EBP, is valued in that it promotes retention, adherence, and engagement.

The State and grant staff recommend developing the infrastructure for EBPs and slowly implementing them one at a time, in a few areas, to be sure that the financial costs are understood and can be supported by the State. Apart from the grant, the State develops infrastructure for and implements one or two EBPs each year, taking a strong role in sustaining EBPs by contributing staff time and funding for developing infrastructure.

Mental Health Provider Education and Training

Many grant activities focused on educating mental health providers. LMEs had to identify the types of staff needed to implement EBPs and find resources to train them; they also had to help providers change their clinical mindset and practice patterns. These activities required a concerted effort by both LMEs and providers. LMEs worked with nonprofit provider organizations such as community health centers to develop the infrastructure needed for implementing the new EBP they had selected. Providers in one of the four LMEs had experience in implementing ACT, but providers in the other LMEs had no experience implementing the EBP they selected. Generally, practitioners do not receive academic or other training in implementing EBPs. Grant staff suggested that providers designate staff champions to ensure that their practitioners receive training and feedback about implementing EBPs.

The State also required a shift from clinic-based to person-centered services. Grant staff noted that provider agencies need to move from a medical model to a person-centered model of care to implement EBPs, but practitioners experience difficulty changing their practice patterns to be customer friendly, to be open when consumers can conveniently receive services (e.g., weekend appointments), and to allow consumers to have some control over their services. Such changes are important because many EBPs have a self-direction component that encourages consumers to assume some responsibility for the services received.

Training practitioners on new EBPs is an important but expensive infrastructure development task. Provider agencies participating in this grant estimated training costs of approximately $60,000 per EBP adopted. Provider resources are limited and training is expensive both in terms of course enrollment and in lost revenue while providers attend a 4-day training course. Providers also have difficulty finding staff to cover for those who attend the courses. Because the State believes that provider training improves consumer outcomes, it underwrites EBP training costs and ongoing supervision by reimbursing provider agencies for course costs and lost revenue.

The need for training extends beyond completion of the 4-day initial training course on any SAMHSA tool kit, which may be adequate for experienced practitioners but not for inexperienced ones. Training courses may require that practitioners be competent in several other EBPs or therapies such as motivational interviewing, cognitive behavioral therapies, and psycho-educational techniques. However, practitioners may not have learned how to perform these activities as part of their academic preparation and, therefore, are unlikely to continue to perform them without additional instruction or encouragement.

The lack of ongoing clinical supervision to help providers implement EBPs in daily practice may be an impediment to implementing EBPs. Some supervision is included in reimbursement rates, but the State often pays for additional supervision and coaching through grants and contracts. Clinical supervision is important in reinforcing learning from the initial training course and in providing feedback on issues faced in implementing EBPs. Although SAMHSA told the Grantee that many different staff could implement EBPs, including peers, grant staff indicated that excellent clinical supervision is needed for non-clinicians to implement them.

The State is modifying its service definitions to enhance the delivery of EBPs and clinically appropriate care by increasing staff qualifications. Subsequently, the State will increase the service rate it pays providers for affected services. Some providers see the State's modifications as excessive, but the State considers them important to improve the quality of care and if providers choose to participate in the Medicaid program, they must meet these requirements.

Reimbursement Issues

CMS will reimburse providers through the North Carolina State Plan only for providing services that conform to specific Medicaid service definitions. During the grant period, the State was in the midst of a major effort to reform its mental health care system and the service definitions used for determining reimbursement. Thus, the State provided support to LMEs, providers, and consumers regarding the relationship between EBPs and the changing service definitions.

Identifying how EBPs fit within the State Plan service definitions was complicated. In North Carolina some EBPs (e.g., Multisystemic Therapy and ACT) have stand-alone state and Medicaid definitions with defined fidelity that mirrors the SAMHSA EBP. On the other hand, the State did not choose to have specific stand-alone definitions for other EBPs, instead expecting providers to deliver them as part of their menu of services offered to consumers in a person-centered plan. These broad, existing state service definitions offer a flexible platform from which clinicians can shape their own EBP, which has to be negotiated with and approved by CMS. The State is conducting a crosswalk between provider-created EBPs and the State's service definitions to determine under which definition they fall.

The State and provider agencies had difficulty in billing Medicaid for all aspects of certain EBP models. For example, in Integrated Dual Diagnosis Treatment, providers are not able to bill for Community Support Team group sessions indicated in the EBP. Consequently, they are required to use multiple reimbursement codes to provide the necessary services spanning the EBP to the consumer, which requires receiving authorization for multiple services. This process results in a complex billing structure to get coverage for all aspects of some EBPs.

Quality Assurance

During the grant period the State began developing the procedures and instruments for ensuring EBP quality. For example, the State included some fidelity elements in the Medicaid provider qualifications requirements. In addition, the State will ensure quality through fidelity assessments conducted by LMEs or outside parties. Before fidelity assessment begins, EBP implementation needs to be stable and robust.

To develop provider monitoring procedures, the LMEs adopted the fidelity assessment instruments in the SAMHSA EBP tool kits and acquired training from the Southeast Area Health Education Center for Excellence on how to implement fidelity assessments. They also participated in external fidelity monitoring conducted by staff from the Center for Excellence.

Two of the four LMEs conducted fidelity assessments during the grant period. Only the Durham LME had previous experience conducting fidelity assessments of its own programs. Prior to the grant, the Durham LME had not conducted fidelity monitoring of provider EBPs because of the expense. The State analyzed the cost of fidelity monitoring conducted under the grant to determine the amount of additional state funds to add to the LME payment rate to support the new monitoring requirement going forward. Some LMEs are incorporating LME-conducted fidelity assessments in provider contracts to meet the monitoring requirement.

One LME used grant funds to pay for fidelity assessments of four EBPs (IDDT, Supported Employment, WMR, and ACT) that were implemented at two provider agencies. All of the EBPs were rated at a high level of fidelity to the model. Both ACT teams showed improvement from the previous year's scores, and the Supported Employment program showed substantial growth in fidelity. The provider agencies had used the previous year's assessment to make improvements in their EBPs, reflecting the usefulness of continuing fidelity reviews.

The fidelity assessments also noted several recurring barriers across all EBPs assessed at the two provider agencies. First, securing specialty staff, particularly nurses or physicians, was difficult because of a national shortage of these professionals. Second, limited availability of EBP training, training program cost, as well as the difficulty in pulling staff "off line" to attend because of the associated revenue loss, remain barriers. Finally, providers experienced difficulty in securing authorization from the State's behavioral managed health care organization for services considered to be time unlimited, such as ACT and IDDT. The State addressed these problems with its vendor in order to support these new EBPs.

Providers are required to conduct fidelity assessments. The State reviews LME performance as to whether providers receive fidelity reviews. Although providers may conduct reviews without an external reviewer as long as they possess the needed staff expertise, some providers use outside reviewers. The Southeastern AHEC Center of Excellence conducts fidelity reviews on request.

Providers are attempting to develop an array of EBPs as a selling point to LMEs. The State plans to develop a report card that will list a provider's EBPs. Consumers can also call the customer service section of the State or the LME to find information about particular providers and practices.

Grant Outcomes

All four LMEs developed the infrastructure to support and sustain implementation of their selected EBPs. Each LME developed tool kits to implement its selected EBP and to monitor implementation. The NC Department of Health and Human Services developed a plan to disseminate these products statewide so that other LMEs can replicate the infrastructure-building process.

Although the grant was designed primarily to build infrastructure within the four LMEs for providing their selected EBPs, some consumers in each of the four LMEs received EBPs during the grant period. The LMEs are emphasizing the need for the EBPs to have high fidelity to ensure improved functional outcomes. Consequently, stable infrastructure needed for providing EBPs must be in place to ensure high fidelity and desired functional outcomes.

Remaining Federal/State Issues

North Carolina provides EBPs under the current service definitions in its Medicaid State Plan. The State educated providers about the appropriate billing codes to use when billing for specific EBPs within these existing definitions. The State does not want to amend its State Plan's service definitions for providing the new EBPs because it believes that the current definitions offer adequate flexibility for all of the new EBPs. The State, the LMEs, provider agencies, and consumers need time to learn to implement the new EBPs using the current service definitions.

Ohio

The grant's primary purpose was to ensure that peer support specialists are included as part of Assertive Community Treatment (ACT) services offered by community mental health centers (CMHC) throughout the State. The grant was also used to disseminate lessons learned about delivering peer support in traditional community mental health settings, and to exchange information about peer support with Ohio ACT providers and with Grantees in other states.

The grant was awarded to the Ohio Department of Mental Health (ODMH). Ohio Advocates for Mental Health (Ohio Advocates), a statewide consumer-operated advocacy organization for people with mental illness, and Ohio Coordinating Center for ACT, a nonprofit organization, provided training and technical assistance to stakeholders in order to facilitate provider acceptance of the role of peer support specialists on ACT teams.

Description of Grant Initiative

Ohio Advocates developed a 2-week curriculum called Peer Support Training to train individuals to become peer support specialists in order to serve on ACT teams. Peer support specialists must meet specific criteria: (1) be a mental health service user aged 18 years or older, (2) have very good communication skills, (3) be able to work with people with all kinds of disabilities, and (4) be able to serve as a role model for other service users. Individuals also need to be good team players who are comfortable working with peers and professionals. Work experience, voluntary or paid, is an advantage.

Ohio Advocates trained 90 mental health service users to be peer support specialists and ACT team members. (Four were already working as peer support specialists, and most had some prior training and/or experience providing peer support in one of Ohio's 70 local consumer-operated services.) Many had participated in nationally recognized training in peer education, including BRIDGES (Building Recovery & Individual Dreams & Goals through Education & Support), WRAP (Wellness Recovery Action Plan), or other nationally recognized peer support programs.

Peer Support Training provides information about the concepts of recovery, peer support, consumer advocacy organizations, and psychiatric advanced directives. It emphasizes attitudes, ethics, and communication skills. Topics include listening, message-giving, empathy, problem-solving, limit-setting, self-care, assertiveness, reciprocal empathy, dealing with emergencies, developing local resources, and advocacy. The training also includes information about WRAP and BRIDGES.² The ODMH Office of Research and Evaluation evaluated the Peer Support Training as part of the grant project's summative evaluation.

Ohio has flexible rules that allow a range of individuals to supply Community Psychiatric Supportive Treatment (CPST) services, including service users. Peer support specialists spend some of their time providing CPST services, which are reimbursed on a fee-for-service basis. Grant staff learned that training for peer support specialists should be offered in time segments shorter than 2 weeks because CPST providers are concerned about the loss of billable hours. To address this problem, Ohio Advocates is revising the peer support specialist training to be in 10 half-day segments, and the Ohio Coordinating Center for ACT will offer 1-day trainings for peer support specialists and 1-day trainings for supervisory staff.

Peer support specialists can encounter challenges when working for traditional providers who have never before had clients as staff members. These challenges can include negative attitudes among other staff toward peer specialist staff and disrespectful comments by other staff about clients. These and similar challenges can create discomfort and workplace conflicts. Mentoring and a support network can help peer support specialists cope with such challenges and to learn advocacy skills that increase their ability to get what they need from their work environment. Mentoring can be provided by other peer support staff or by professionals who are also mental health service users. Ohio Advocates provides mentoring for peer support specialists who are employed by community mental health centers.

ACT Teams

Including peer support specialists on an ACT team is a change that requires organizational action in addition to simply hiring new staff. Providers need to define roles, competencies, and job duties for peer support specialists, and develop appropriate human resources policies, such as policies related to medical leave for mental health treatment.

Ohio Coordinating Center for ACT trained traditional provider staff and peer support staff in the responsibilities of ACT team peer support specialists, and also provided technical assistance to traditional mental health provider organizations, such as community mental health centers, that wanted to offer peer support services. Trainings included group exercises that provide insight into the challenges that peer support specialists may experience while providing services, and helped provider organizations make the needed changes in human resources and supervisory policies to accommodate the use of peer support specialists.

Ohio Coordinating Center for ACT also produced a white paper (You Don't Have to ACT Alone: Using Peer Support to Enhance ACT Teams) that explains how peer support enhances ACT services and describes personnel policies and resources available to help incorporate peer support specialists into ACT teams. The paper also addresses professional ethics issues, which often surface when the topic of peer support services is discussed with traditional providers (see below).

Addressing Providers' Concerns

Major challenges in hiring service users as peer support staff within the mental health system are providers' (1) resistance to sharing power with individuals they perceive as clients and (2) concerns about dual relationships and the potential for violating the professional boundaries required in psychotherapy. To protect clients' interests, the professional ethics of nurses, social workers, psychiatrists, and psychologists discourages dual relationships because of the power imbalance between provider and client; by definition, a dual relationship is created when a person who is receiving services from an agency is also employed by that agency.

Because professional boundaries need to be adjusted when peer services are delivered in community mental health settings, Ohio Coordinating Center for ACT (OCCA), Ohio Advocates, and ODMH used the grant to address providers' concerns: specifically, how peer support specialists would be hired and supervised and how to avoid dual relationships. In urban areas, dual relationships can often be circumvented because there are several settings in which peer support specialists can work, reducing the likelihood that they will receive their services from the same agency that employs them. But this is not always possible in rural areas or those with few providers. Some rural areas have hired service users but minimize potential conflicts by requiring that their work supervisors not be involved in their clinical care. Grant staff had positive discussions with licensing boards and were successful in reducing concerns about dual relationships.

Although some providers' concerns are based on valid professional ethics issues, others are based on stigma, professional cultural issues, and the desire to maintain power and control. To address these issues, the Ohio Coordinating Center for ACT includes a 1-day training on peer support specialists as part of its technical assistance and training package to individual ACT teams, including the six new ACT teams in Franklin and Montgomery counties. Additionally, as part of an ethics course for traditional providers, OCCA provides training about supervising as well as being support colleagues to peer support specialists. Many traditional providers attend the ethics course to meet professional licensure requirements.

Reimbursement Issues

Ohio has a state-supervised, county-operated mental health system, which bills portions of the evidence-based practices of ACT, IDDT, Multi-Systemic Therapy, and Supported Employment using existing Medicaid codes for Community Psychiatric Supportive Treatment, behavioral health counseling, and other Medicaid-billable services. However, some of the components of these practices, particularly Supported Employment, do not meet Medicaid criteria for medical necessity.

For example, ACT teams can hire mental health service users to provide CPST services—which are Medicaid reimbursable—but providing nationally recognized peer education (e.g., WRAP training and support, supportive listening without "intervention," transportation, and attendance at meetings of a support group) is not Medicaid reimbursable. Additionally, peer support staff are not reimbursed for their time when they try to visit clients and find they are not at home or will not open the door, which happens often when staff provide outreach to individuals who are becoming psychotic or severely depressed.

In 2005, Ohio's legislative rules committee approved an ACT certification standard that required the inclusion of peer support staff on ACT teams for continued ACT certification. To obtain Medicaid funding for services required by the certification standards, the Ohio Department of Jobs and Families (the state Medicaid agency) worked with ODMH to prepare an amendment to the Ohio Medicaid State Plan that would allow Medicaid reimbursement of Assertive Community Treatment as a bundled service incorporating peer support. However, CMS changed its policies and stopped approving bundled mental health services, including ACT services, which resulted in the rejection of Ohio's proposed State Plan amendment in 2007. Many other states that had Medicaid-reimbursable bundled ACT services had to un-bundle those services. The lack of Medicaid reimbursement for peer support specialists on ACT teams is a major barrier to their employment in this capacity.

As stated earlier, Ohio's Community Psychiatric Supportive Treatment service is reimbursed by Medicaid, and ODMH has encouraged ACT teams to employ mental health service users to provide CPST services and to fund additional peer support specialist activities by using non-Medicaid funds. Many of Ohio's 50 community mental health boards use local tax revenues, state General Revenue funds, client fees, and a few foundation grants to pay for peer support services and other components of evidence-based practices that are not Medicaid reimbursable.

However, because Ohio's state budget faces severe constraints, non-Medicaid funding for peer support has been limited. In addition, many of the county mental health boards are running out of funds to provide the local required match to federal financial participation (FFP): the federal portion of Medicaid reimbursement. Currently, the Ohio Department of Mental Health is working with the Ohio Department of Job and Family Services (the state Medicaid agency) and CMS to change the match method so that the State, rather than county boards, would be responsible for providing the required FFP match.

Quality Assurance

Ohio collected data demonstrating that the State's 37 ACT teams serving 1,560 service users were meeting Dartmouth Assertive Community Treatment fidelity criteria, recognized by SAMHSA.

Grant Outcomes

During the grant period, 90 service users received 2 weeks of training as peer support specialists. One year after training, 56 percent of the trainees were employed in the mental health system in some capacity, with 26 percent employed as peer support specialists (including four individuals who had worked as peer support specialists prior to the training). Twelve of Ohio's 37 ACT teams hired peer support specialists, and additional teams were considering hiring them. Those who did not get jobs on ACT teams secured other jobs at provider organizations, such as residential specialist and receptionist.

ODMH has an in-house research and evaluation group that surveyed peer support specialists trained during the grant period to learn about their experience and views on a range of topics. They were surveyed at three different points—on the last day of their training and at 6 and 12 months post-training; 59 of the 90 who were trained responded at the first contact, but only 23 responded at the third contact.

The survey showed a consistent decline across the 12-month period in participants' perceptions of their ability to help others with recovery and to help professionals understand consumer perspectives. However, the six respondents who were employed as peer support specialists had more positive perceptions. The survey results raised questions about the advisability of training individuals for a position with little or no employment opportunity. Many of the peer support specialists expected to get a job in the mental health systems when they completed their training and were disappointed when they did not. To address this problem, the Project Director and Ohio Advocates staff recommended to the Ohio Department of Mental Health that training not be provided until service users have been hired to provide peer support services or an employer commits to hiring them once trained.

Despite the lack of Medicaid reimbursement for peer support specialists on ACT teams, grant staff were able to increase provider acceptance of peer support staff on the teams. Additionally, grant staff were successful in developing resources to support inclusion of peer support in the mental health system and the employment of service users. Resources include provider training about peer support/ACT services and guarding against dual relationships, an Ohio ACT provider list, the provider white paper You Don't Have to ACT Alone: Using Peer Support to Enhance ACT Teams, and ACT peer specialist job descriptions.

Peer support and other recovery-oriented concepts are now permanently incorporated into the trainings, consultation, and technical assistance provided by Ohio Coordinating Center for ACT to traditional mental health providers. Funding from the SAMHSA Mental Health Block Grant will ensure that the Coordinating Center continues its work. Also, Ohio Advocates developed additional training for peer support specialists, which is being used by ODMH to enhance peer support services not provided as part of ACT.

Remaining Federal/State Issues

Some interventions that support recovery from mental illness are educational and supportive in nature and do not meet Medicaid's "medical necessity" criteria for reimbursement. ODMH recommends that CMS modify its current reimbursement requirements, which are based on a traditional medical model, to include a rehabilitative model that includes some educational approaches for treatment of mental illness. Such a change would better support evidence-based and recovery-oriented practices such as peer support.

CMS should allow states to be reimbursed for all components of nationally recognized practices such as ACT, Multi-Systemic Therapy (for youth), Supported Employment, IDDT, and Illness Management and Recovery. By reimbursing these practices, CMS will increase the efficacy and efficient provision of mental health services.

Additionally, CMS and SAMHSA should coordinate data and policy requirements for mental health and substance abuse evidence-based and recovery-oriented practices. For example, those practices that have sufficient evidence to have SAMHSA-approved tool kits should have service codes that are reimbursable by Medicaid. For a list of these practices, their fidelity standards, and references to the published articles in refereed professional journals, see SAMHSA's website at http://mentalhealth.samhsa.gov/cmhs/CommunitySupport/toolkits/.

Oklahoma

The grant's primary purpose was to develop the evidence-based practice of Illness Management and Recovery (IMR) and to incorporate Recovery Support Specialist (RSS) services throughout the State's mental health service delivery systems. The grant was awarded to the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS; hereafter, the Department).

The grant project was an extension of the Recovery Collaborative of Oklahoma, which implements modifications to the State's adult outpatient behavioral health delivery system that focuses on recovery. The Collaborative is sponsored jointly by the Department and the Oklahoma Health Care Authority (OHCA): the state Medicaid agency. OHCA was a key partner and collaborated with the Department to develop and implement the services of Recovery Support and Illness Management and Recovery.

Description of Grant Initiative

As a first step toward achieving its goals, grant staff developed a policy and program framework to support Illness Management and Recovery and Recovery Support Specialists, the title Oklahoma uses for peer support providers. Using SAMHSA Implementation Toolkits, grant staff identified clinical policies and operational procedures for Recovery Support Specialists and then developed policies to support the development and delivery of Recovery Support and IMR services, including the establishment of a specific billing code for IMR group services.

These policies also addressed job descriptions for Recovery Support Specialists and RSS training, credentialing, and continuing education requirements. Grant staff submitted these policies to the Department and the State Medicaid Agency for approval. The Medicaid Agency approved rules for the Recovery Support service and a reimbursement rate for Recovery Support Specialists, and included them in an amendment to add RSS services to the Medicaid State Plan under the Rehabilitation option, which was submitted to CMS and approved July 2008.

To provide outreach and education about Illness Management and Recovery and Recovery Support, grant staff conducted program development forums with service users, advocates, and providers, and made presentations around the State at conferences and other venues. These forums were attended by consumers, family members, providers, state staff, and interested community members. The presentations focused on the grant project's goals, the role and responsibilities of Recovery Support Specialists, and methods to make RSS services more widely available in the State's mental health service delivery system. When attendance at these forums required payment of a registration fee, the Department provided scholarships to support consumers' attendance. Fees for individuals already working as Recovery Support Specialists were paid by their employers.

Recovery Support Specialist Training

The Department's grant staff and the director of the Office of Consumer Affairs initially developed an RSS training and credentialing curriculum based in part on the Georgia certified peer specialist project as well as on modules developed by the director of the Office of Consumer Affairs and the grant's RSS coordinator. The training curriculum was later modified to include content developed by the National Association of Peer Specialists, a private, nonprofit organization that seeks to improve the effectiveness of the mental health system through the hiring of peer specialists.

Grant staff developed a database of individuals already employed in a peer support role who might be interested in becoming Recovery Support Specialists and recruited them. (Employment in a peer support role was a criterion for participation in the training.) Grant staff trained 78 individuals, 56 of whom have been credentialed. Anecdotal feedback from supervisors reported that individuals greatly benefited from the training and that they were more confident about their abilities and more comfortable in stating an opinion and advocating for change. They were also more likely to offer creative solutions to address clients' issues.

The grant's RSS coordinator conducted more than 40 visits statewide to community mental health centers, crisis centers, and advocacy organizations where Recovery Support Specialists are employed, to provide technical assistance to them and their supervising clinicians.

Barriers to Employment for Recovery Support Specialists

Many mental health service providers have negative attitudes about hiring service users as staff, and grant staff found it very challenging to convince some providers of the value of incorporating Recovery Support Specialists into the mental health workforce. Some Assertive Community Treatment (ACT) teams are also reluctant to hire service users as Recovery Support Specialists because they are not convinced that individuals with mental illness have the ability to fully recover and provide effective services.

ACT providers are required to have a Recovery Support Specialist on their team, and some try to circumvent this requirement by hiring professional providers who have experienced mental illness in the past and calling them Recovery Support Specialists in addition to their role as clinicians; but in practice they do not function as a Recovery Support Specialist. Other ACT providers "borrow" (i.e., temporarily hire) a Recovery Support Specialist from another section of their treatment facility (e.g., the outpatient division) when they are undergoing recertification as an ACT provider to satisfy the requirement. Once recertified, the Recovery Support Specialist returns to the original position.

Some providers have concerns related to confidentiality and dual roles when an individual who is hired as a Recovery Support Specialist is also receiving mental health services from the employer, as has happened with some individuals. Providers are also more inclined to hire individuals with current or recent work experience rather than those eligible for Supplemental Security Income and Medicaid on the basis of disability, because providers think the individuals will have difficulty maintaining employment status because of their illness. When a Recovery Support Specialist needs to take sick leave—even if unrelated to mental illness—employers tend to view the incident as evidence that the individual is unable to handle the job.

To address these issues and concerns, the Department, the RSS coordinator, and occasionally OHCA staff conducted trainings for and provided technical assistance to provider agency staff.

Mental Health Provider Education and Training

Grant staff and a consultant conducted training on Illness Management and Recovery with about 25 to 30 providers statewide during the grant's first year. However, follow-up with the providers revealed that after making an initial effort, many had not incorporated IMR services into their practice because of lack of interest or time.

In response, the Department hired an expert consultant to provide a second IMR training at four "model" community mental health centers. Department staff are conducting fidelity assessments at these centers and continue to provide follow-up technical assistance. Policy and procedures are in place to support this initiative through both the Department and the Medicaid Agency.

Reimbursement Issues

For the four model centers, Medicaid reimbursement for RSS services provided as part of Illness Management and Recovery were unavailable until 2008 when CMS approved a State Plan amendment to reimburse these services through the Rehabilitation option. (Prior to Medicaid reimbursement, the State provided funding for the salaries of Recovery Support Specialists.) The State established a billing code specifically for IMR group services under the Medicaid State Plan Rehabilitation option. In two of the model sites, the Recovery Support Specialists are members of the Psychiatric Rehabilitation staff and co-facilitating IMR groups is one component of their position.

Recovery Support services provided through community mental health centers are also reimbursed through the Medicaid Rehabilitation option. If the State receives CMS approval for a State Plan amendment to expand Recovery Support services beyond the State's community mental health centers to private outpatient behavioral health providers, then the Medicaid agency will develop a budget request (for fiscal year 2010) to support this expansion.

Although Medicaid will pay for Recovery Support Specialist services provided through community mental health centers, it will not pay for these services on ACT Teams because CMS does not allow charges for these RSS services to be bundled with other ACT services.

Quality Assurance

The State has used the State Performance Improvement Process to monitor the quality of all mental health services. The State is also using the SAMHSA IMR fidelity instrument to assess providers at the four community mental health centers that received specialized training in Illness Management and Recovery. Evaluators found that consumers attending the IMR classes at the four centers were engaged and found the classes helpful, and clinicians report a greater commitment to recovery among those participating. Two of the four classes were co-facilitated by a Recovery Support Specialist (a clinician led the group).

Grant staff and a contractor conducted three annual consumer satisfaction surveys regarding recovery, peer-run services, and community connectedness. The first was conducted early in the grant period to obtain baseline data. The surveys incorporated recovery measures, which were monitored for improvement. Results have shown improved outcomes and satisfaction with services for individuals participating in Illness Management and Recovery programs and/or receiving peer support services in psychiatric rehabilitation units, transitional living settings, or as part of outpatient services. Recovery Support Specialists are running peer support groups and offering referral assistance, as well as teaching classes on such varied topics as WRAP (wellness recovery action plan), sober living, and other recovery-related topics.

Grant Outcomes

The Department has added Recovery Support as a new service statewide and will continue to fund the Recovery Support Specialist curriculum, training process, and credentialing system. The State's workforce for providing peer services—Recovery Support Specialists—has been expanded. Out of the cohort of 78 training participants, 63 are working in peer support roles—most as Recovery Support Specialists. The others work in some other capacity in the mental health system. Twelve have been promoted or earned degrees that advanced their careers to a higher position, enabling them to work as case managers and therapists who can provide a peer's perspective.

Illness Management and Recovery is being offered as a new service at four community mental health centers. Both services are reimbursable under Medicaid, and a specific billing code for IMR group services has been established. If the outcomes data from the four centers demonstrate the efficacy of IMR services, the State will consider expanding the service statewide.

Remaining Federal/State Issues

Because the State does not have a Medicaid buy-in program, Recovery Support Specialists have concerns about losing their Medicaid benefits—those receiving SSDI in particular—because of the potential of earning too much.
Lack of transportation is a huge access barrier in a rural state like Oklahoma. Community mental health centers have a van that will pick up individuals for day treatment (i.e., psychiatric rehabilitation). But many individuals do not live on or near the van route. As discussed above, under Reimbursement Issues, if CMS would approve Medicaid funding for Recovery Support services through private providers as well as community mental health centers, access to these services in rural areas could be increased. The current reimbursement rate for Recovery Support Specialists appears to be sufficient to cover both their salary and transportation costs to provider settings.

Oregon

The grant's primary purpose was to develop new and expand existing peer-operated programs and services and to promote their acceptance as evidence-based practices (EBPs) statewide as well as the infrastructure to sustain them. The target population was adults between the ages of 18 and 64 with mental illness. The grant was awarded to Portland State University (PSU) as a representative of the Oregon Addictions and Mental Health Division (hereafter, the Division).

Description of Grant Initiative

Grant staff worked with eight peer-operated organizations to develop and expand peer-operated programs and services. Grant staff also helped develop infrastructure within the organizations by identifying collaboration strategies, funding mechanisms, and policy changes needed to sustain peer-operated programs. They supported the Division in its effort to designate peer-operated programs and services as EBPs. Examples of peer-delivered services are peer specialists, peer-operated brokerages, and drop-in centers.

The grant's project director and leadership team members assisted leaders of peer-operated programs in eight regions to develop infrastructure by helping each leader develop a plan to improve peer-operated program structure and services and a related technical assistance (TA) plan. Based on each program's plan, grant partners provided ongoing TA using several approaches, including teleconferences, onsite visits, informational materials, listservs, and a statewide conference on peer-delivered EBPs. TA tools included a program-directed fidelity assessment process (administered with project staff assistance), examples of peer-delivered services curricula, and information on consumer-directed customized approaches to finding meaningful and satisfying employment.

Eight peer-operated programs expanded their service capacity by increasing the type of services they offered and their availability. One of the programs developed new employment services for its members, and two of the programs researched and prepared community information and resource guides for use by low-income community members within their regions. Concurrently, grant staff also supported the establishment of a new peer-operated organization that is now providing peer support services. In addition, grant staff facilitated the provision of training and consultation to peer-operated programs to implement a peer support model called Peer Bridgers that is used in several states, including New York, New Mexico, and Pennsylvania. The Peer Bridgers program offers direct assistance to consumers transitioning from the hospital to the community. Anecdotal information from the eight peer-operated programs participating in the grant project indicated that their service availability increased by about 50 percent.

Grant staff developed a compendium of research on peer-delivered services (Peer-Run/Peer-Driven Programs, Services, and Organizations: A Review of the Evidence) for use by mental health organizations and consumer/survivor organizations in Oregon to help them identify evidence-based and promising peer-delivered services used elsewhere in the United States. The Division used the compendium to clarify the nature and scope of peer-delivered services across the United States.

The Division also provided additional funding to expand peer-delivered services, implement trauma-informed services as part of the system of care, and undertake a consumer/survivor-informed planning process for peer-delivered services certification and training. The planning process includes consumer/survivor identification of the training curricula to be used for various peer specialist certification categories.

Designation of Peer-Operated Drop-In Centers as an EBP

In 2003, the State enacted legislation requiring that the proportion of evidence-based mental health services delivered under the Oregon Health Plan be incrementally increased over the subsequent 6 years. The mandate was 25 percent for the 2005 biennium and 50 percent for the 2007 biennium; and 75 percent for the 2009 biennium. Oregon classifies evidence about mental health services using six levels (with Category 1 denoting practices with the highest level of evidence), and to meet the legislation's requirements, services must meet the criteria of the top three levels. To be considered an EBP, a mental health service must have been researched in studies with random assignment or have been subjected to rigorous evaluation, with the results documented in peer-reviewed publications.

Upon review of the evidence, in 2006 the Division designated the socialization aspect of peer-operated drop-in centers as a Category 3 EBP. The Division also approved a service description and associated Medicaid billing code for peer-operated drop-in centers to provide this service. However, to be able to bill for it, a peer-operated organization must be a certified mental health provider agency that is able to offer all mental health services—or subcontract to another certified mental health provider agency to provide drop-in center and other peer-operated services. As of October 2008, only one peer-operated organization in the State is a certified mental health provider agency that can bill Medicaid for drop-in center services. (See discussion under Reimbursement Issues below.)

The Division provides information about this evidence-based practice on its website at http://www.oregon.gov/DHS/mentalhealth/ebp/practices/consumer-runin-dropin-centers.pdf. The Division is interested in research to determine how the specific service elements employed in drop-in centers contribute to improved client functioning but, as of October 2008 had not designated funding to conduct such research.

Systems-level Challenges

Grant staff faced three system-level challenges in developing an infrastructure to support the provision of EBPs. First, the Division has historically provided mental health funding to regional managed care mental health organizations and counties, which exercise local control in distributing funds to local mental health providers. Because some counties want and expect state funding to continue to be distributed in this manner, they did not support—and sometimes impeded—grant staff's efforts to encourage the Division to increase direct funding to peer-operated programs for TA to help them develop and expand peer-delivered services. Grant staff had to meet with stakeholders in two counties to persuade them that the provision of TA would not interfere with their regular funding and usual operations.

Second, the Division and traditional provider agencies historically have been reluctant to provide direct funding to peer-operated programs because of concerns about their lack of financial infrastructure ability to effectively manage state funds and third-party payment for services. Although the Division provided some funding to help peer-operated programs to establish organizational and financial infrastructure, the programs need additional funding to continue this work.

Third, when the grant began, many existing peer-operated programs lacked the infrastructure, such as service tracking mechanisms, to enable them to expand services; and technical assistance to help them develop it was limited. Oregon does not have an entity providing ongoing training, technical assistance, and support to peer-operated organizations that wish to either increase their capacity or the array of services they offer.

Mental Health Provider Education and Training

Some counties and traditional provider agencies were unfamiliar with the concept of peer support services, so they were reluctant to embrace it initially. In addition, counties and provider agencies were uncertain about how to address potential ethics issues, such as whether consumers providing peer support services should work for agencies from which they receive services, and the extent to which a peer support specialist should disclose information about his or her mental illness. Grant staff, peer leaders, and representatives of peer-operated organizations had to educate counties and traditional provider agencies regarding these issues to help them understand and accept the role of peer-delivered services.

Grant staff believe that peer-delivered services and programs should be integrated into the existing system of mental health services but offered as distinct services that are not medically oriented. They also believe that peer support services have the potential to be most beneficial if offered as part of a comprehensive array of services.

Grant staff thought that having peer support specialists working as staff in traditional provider agencies was necessary to ensure responsive services for agency clients, but their presence alone was not sufficient to provide the full benefits that peer-provided services can offer. Traditional provider agencies need to offer, in addition, a broad selection of peer support services, including outreach, education, advocacy, and personal assistance. Without this range of peer-provided services, peer support specialists may attain only a token status, and, as a result, may not receive sufficient acknowledgment and support for their role.

Reimbursement Issues

Although other states have struggled to develop reimbursement methods for peer supports and other peer-delivered services, Oregon has developed three Medicaid reimbursement methods for these services. To understand these methods, it is necessary to describe the contracting relationships in Oregon's mental health service delivery system, how the Division certifies provider organizations and staff, and the three reimbursement methods. Even so, these reimbursement methods do not completely meet the needs of peer-operated organizations.

Mental Health System Contracting Relationships

Nine managed care organizations administer mental health services for the Division by contracting with counties and nonprofit organizations to provide services. The Division certifies counties or private nonprofit organizations to provide mental health services under the Rehabilitation option. In some cases the county serves only as the organization of record, performing administrative functions and contracting with service providers.

Provider Certification

The Division uses the Medicaid State Plan Rehabilitation option to pay for peer support and other peer-delivered services, reimbursing various types of organizations and staff who provide them. To be reimbursed, organizations providing traditional or peer-operated mental health services must be certified by the Division as mental health provider agencies and must offer a complete set of mental health services (e.g., emergency care, medication orders). Staff at these agencies must be either Licensed Medical Professionals (e.g., physicians, licensed nurse practitioners); Qualified Mental Health Professionals (e.g., master's degree or comparable); or Qualified Mental Health Associates, who have a bachelor's degree or similar and perform non-clinical work under the supervision of a Qualified Mental Health Professional or Licensed Medical Professional. Peer support specialists hired by certified mental health provider agencies to provide peer support services are generally employed as Qualified Mental Health Associates.

Managed care organizations are responsible for credentialing their providers and have the flexibility to determine whether a service user has the training and supervision needed to provide peer services. Certified organizations can work with their managed care organization and determine the credentialing requirements they want to use to hire peer support specialists in order to receive reimbursement. The State has been reviewing training curricula for peer support specialists, and is considering approving criteria that a peer support specialist would have to meet. Once approved, the State Plan Medicaid Rehabilitation option would need to be amended to include these criteria.

Currently, Oregon has 26 peer-operated organizations, many of which want to receive Medicaid reimbursement for providing peer support or other peer-delivered services. However, only 1 organization currently meets the service provision and staff supervision requirements for certification, and it is having difficulty complying with all of the certification requirements. Grant staff believe that peer-operated organizations should not have to be certified as mental health provider agencies to receive Medicaid reimbursement for providing the array of services they typically offer (which do not include emergency care and medication orders). Instead, they suggest that the Division develop a method to certify peer-operated programs to provide their usual range of services. To do this, the Division would need to amend administrative rules and obtain CMS approval.

Reimbursement Methods

Currently, Oregon uses the Medicaid Rehabilitation option to reimburse peer support services in three ways: (1) a new Medicaid billing code; (2) "prevention, education, and outreach" services required of the nine managed care organizations (MCOs) that administer mental health services for the Division by contracting with counties and nonprofit organizations to provide services; and (3) the State's consumer-directed personal care program. Each is described below.

New Medicaid billing code. Certified organizations that hire peer support specialists can bill Medicaid for peer support services they provide, using a recently established Medicaid billing code, chargeable in 15-minute increments. The MCO determines the amount of reimbursement, which is relatively small. This billing code was still not being widely used after the grant ended.

In addition, MCOs and counties can subcontract with peer-operated organizations that are not certified so that the latter can receive reimbursement for peer support services using this billing code. In this case, the MCO or county serves as the certified entity for the peer-operated organization delivering services. Two consumer-directed peer-delivered services organizations began independently billing for services (Safe/Wonderland Drop-In Center and the Union) using this subcontracting method.

Prevention, education, and outreach services. This second reimbursement method provides another way for uncertified peer-operated organizations to receive Medicaid reimbursement for peer support and other peer-operated services. Under their contracts with the Division to administer mental health services, managed care organizations are required to provide "prevention, education, and outreach" services. Unlike services provided by certified mental health provider agencies, these services do not have to be specified in a treatment plan. Thus, the provision of peer support or other peer-operated services under the auspices of prevention, education, and outreach services allows payment for services that are not necessarily rehabilitative in nature. For example, peer-operated organizations can obtain reimbursement through this mechanism for a drop-in center or psycho-education support group. These services are covered at the Medicaid administrative rate (50 percent) rather than the 60 percent match rate for service delivery.

To set rates for the managed care organizations for prevention, education, and outreach services, the Division obtains data about the specific services individuals receive and the total funds spent across all of them (as opposed to the amount of funds spent on each person). The Division uses the total funds spent to determine the amount of money managed care organizations use for prevention, education, and outreach services, under which peer support or other peer-delivered services are reimbursed.

Self-directed personal care program. The Division encourages the use of peer support specialists in this community-based long-term services and supports program to help them gain employment and to raise their profile—even though they are not providing peer support services. The service user whom the peer support specialist helps must be eligible for Medicaid due to a disability and not living in a foster home, residential treatment setting, or nursing facility. The service user identifies a peer support specialist who can function as their Personal Care Assistant (PCA), who provides services under the approved treatment plan proposed by the service user and his or her PCA.

Quality Assurance

Grant staff modified an existing fidelity assessment protocol used in the peer-operated services field, the Fidelity Assessment Common Ingredient Tool, and shared it with eight peer-operated organizations. The tool is designed to help each peer-operated organization assess the extent to which it shares a set of common elements identified by participating consumer-operated service programs in the Consumer-Operated Services Program Multi-site Research Initiative funded by SAMHSA. The common elements cover personnel, finance, advocacy programming, and the organization's attitude about recovery. All of the eight participating peer organizations implemented the tool as part of their technical assistance plan and used the findings to identify areas of peer-operated services in need of improvement.

Grant Outcomes

Eight peer-operated organizations expanded their service capacity by increasing the type of services they offered and their availability. In addition to establishing Medicaid reimbursement for peer support services, the Division designated the socialization aspect of peer-operated drop-in centers as an EBP and approved a service description and associated Medicaid billing code for consumer drop-in center services to provide this service under the Rehabilitation option. One peer-operated organization is providing this service as a certified mental health provider agency.

Remaining Federal/State Issues

Grant staff believe that peer support and other peer-delivered services need to be available as one option among many in an integrated mental health services system. Thus, CMS should allow more flexible requirements for the provision of these services under the Rehabilitation option so that peer-operated organizations can provide services without having to become certified mental health provider agencies.

Pennsylvania

The grant's primary purpose was to integrate recovery-oriented practices in the State's mental health services delivery system by training service users to provide peer support services and by developing a Medicaid reimbursement methodology for these services. The grant was awarded to the Pennsylvania Department of Public Welfare, Office of Mental Health and Substance Abuse Services (hereafter, the Department). The Institute for Recovery and Community Integration at the Mental Health Association of Southeastern Pennsylvania (hereafter, the Institute) was contracted to provide technical assistance and conduct the training.

Description of Grant Initiative

The grant was used to introduce and support a certified peer specialist (CPS) program in the Northeast, Central, and Western regions of Pennsylvania, based on a successful CPS program that had been implemented in the Southeast region of the State. Grant staff selected 17 counties to pilot the program and conducted a conference to prepare the counties to participate. Grant staff also set up a statewide work group with broad stakeholder representation—24 members—that developed the standards for Medicaid-funded peer support services.

The Institute developed a course to train service users to work as peer specialists with traditional providers, and a program to certify them as such. It created a team of trainers, which included service users, to conduct the trainings in the pilot area initially and then statewide. The Institute also developed a 2-day training curriculum for supervisors of peer specialists.

One of the grant's goals was to support and expand CPS activities by establishing a self-help network for CPS graduates. To achieve this, grant staff conducted two conferences as networking opportunities for CPS staff, which 70 people attended. Attendees recommended that the State develop a consumer-run statewide peer support association and continuing education opportunities. The statewide Peer Support Association was subsequently formed and was scheduled to conduct its first meeting in January 2009. Continuing education opportunities have been developed, including training on working with older adults and individuals involved in the justice system.

In 2005, the Department developed and submitted an application for a State Plan Amendment (SPA) to include peer support services as a component of Rehabilitation services, and at the same time developed the coding and billing mechanisms for reimbursement. The SPA was approved by CMS in 2007. Grant staff developed a 17-point checklist to help providers meet requirements for furnishing the new service. They also provided technical assistance and training to all of the State's 67 counties to ensure implementation of Medicaid-funded peer support services.

Counties and provider organizations varied in their degree of readiness to work with certified peer specialists. Some do not understand their value; others are attached to a medical model of service delivery and do not recognize the importance of adopting a recovery orientation. Many providers have concerns about employing certified peer specialists because they do not understand how to handle ethical, boundary, and other human resources issues. For example, some are concerned about employing an individual who is a also a client; some worry that the peer support specialist will relapse and be unable to work reliably and consistently; and others lack an understanding of the reasonable accommodations required under the Americans with Disabilities Act for employees with disabilities. The State is just beginning to systematically address these concerns and issues.

Mental Health Provider Education and Training

Institute staff used an education and training approach based on the knowledge and experience they gained through implementation of CPS initiatives in Montgomery County, PA, starting in 2002.³ This approach includes an intensive, 2-week curriculum with 75 hours of didactic and experiential training focused on communication skills, cultural competency, outreach, engagement strategies, problem-solving skills, and helping clients build their own self-directed recovery tools (e.g., Wellness Recovery Action Plan), and understanding how to navigate the workplace.

The approach features a unique focus on preparing mental health agencies to hire and support certified peer specialists by training administrators and staff about recovery perspectives, the role of peer support in service delivery, and how to deal with workplace and personal challenges associated with hiring peer specialists. They also receive assistance in developing job descriptions for certified peer specialists and learning and developing effective supervisory skills. About 50 individuals received this training during the grant period.

A total of 151 individuals applied for the certified peer specialist training across the three regions and 74 were accepted to participate, all but 2 of whom completed the certification process. To become certified, trainees were required to attend every training session and demonstrate knowledge and competence on the required skills.

Reimbursement Issues

Once peer support services became Medicaid reimbursable, the State focused considerable time and resources on assisting counties and providers to meet the qualifications required to bill these services through Medicaid. Traditional mental health Medicaid providers can add peer support services to their current array of services, and nontraditional providers—such as consumer-run organizations or advocacy organizations—can become Medicaid providers and offer the service. Although the State encouraged nontraditional providers to enroll as Medicaid providers, because they were not accustomed to Medicaid's complex billing and documentation requirements, only a few had enrolled and were offering peer support services when the grant ended.

Many of the counties considered the reimbursement rate to be insufficient to cover the travel costs related to the provision of peer support services, particularly given the increase in gasoline costs at the time and extensive travel distances in rural areas. In response to the counties' concerns, the State authorized reimbursement for peer specialist services provided through telephone contacts.

Quality Assurance

Through a work group process, the Department established statewide qualifications for reimbursement of peer support services. These qualifications included minimum training and certification standards and the ability to implement quality improvement processes. Pennsylvania is currently contracting with a consultant to develop a data collection system to track a variety of outcomes, such as hospitalization admission rates.

Peer support services are now viewed as a promising practice and have been recognized as such in the President's New Freedom Commission Report and the Surgeon General's report. Given that they are basically a new service, however, additional research is needed to determine their outcomes and to delineate the specific factors that contribute to their effectiveness.

Grant Outcomes

The Institute implemented a CPS training and certification pilot demonstration program in three regions of the State, which trained and certified 72 individuals. One year after the training, most of these individuals were employed in some capacity, although job titles varied greatly—43 percent of those employed had the job title certified peer specialist—and it was not always apparent whether the work was related to their CPS training. Individuals were considered to be working as a peer support specialist if they indicated that their position involved the use of the knowledge and skills that they obtained from their CPS training.

Of the 63 individuals who were contacted at some point up to a year after their training, a total of 51 individuals had worked or were working as a peer support specialist, including 28 who had been employed as such prior to their training. Ten out of 15 persons who were unemployed prior to their CPS training were employed in some capacity. Sixteen trainees who had never before worked as a peer support specialist were employed in a new CPS position, and these new positions were fairly equally divided among the three regions. Those with the CPS job title reported positive feelings such as self-esteem and self-confidence as a result of finding and sustaining employment.

The grant's CPS initiative has been successful in supporting continued employment for peer support specialists who participated in the training. However, given the high number of already-employed persons who underwent training, the initiative had only moderate success in increasing the number of new peer support specialists employed in the mental health system.

After the grant initiative ended, one county trained and certified an additional 120 peer support specialists, about half of whom are employed. Progressive counties such as this one understand that employment of peer support specialists can help to change the mental health system to be more recovery oriented. However, some counties are not committed to providing peer support, some providers do not have funds for implementation costs, and some have taken a wait-and-see attitude. The State is currently in the process of notifying such counties that they must begin to make progress in providing peer support services.

The grant initiative enabled the State to increase access to peer support services statewide among individuals who use mental health services. In December 2008, these services were available from at least one provider in 58 of the State's 67 counties, and from at least two providers in half of these counties.

Pennsylvania is the most recent of six states (along with Arizona, Georgia, Hawaii, Iowa, and South Carolina) and the District of Columbia to adopt a certification process for peer support services and to receive approval for Medicaid reimbursement for these services.

An article on findings from this project was recently accepted for publication in the Psychiatric Rehabilitation Journal.

Remaining Federal/State Issues

Lack of transportation, high travel costs, and long travel distances are major challenges that impede access to peer support services. In addition, despite many positive changes, there continues to be a stigma associated with peer support services within the behavioral health system, which poses a major obstacle to recovery. Finally, some providers lack funding—or sufficient funding—to develop and implement certified peer specialist positions (i.e., creating job descriptions, recruiting and interviewing candidates, aligning the new position with existing jobs, and establishing supervisory responsibilities).

Virginia

The grant's primary purpose was to develop the infrastructure to introduce and sustain the provision of evidence-based practices (EBPs) and peer support services to adults with serious mental illness. The grant was awarded to the Virginia Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS; hereafter, the Department). The Department of Medical Assistance Services (DMAS) and the Department of Rehabilitation Services (DRS) partnered with grant staff in reviewing and analyzing federal and state regulations pertaining to vocational rehabilitation and employment services, and in clarifying and streamlining funding for the evidence-based practice of supported employment.

Description of Grant Initiative

Several grant activities focused on increasing stakeholder knowledge about the principles of self-determination, recovery, and empowerment, and increasing the number of mental health service users who participate in policy, planning, and evaluation. Over the grant period, grant contractors conducted conferences for a range of audiences, including service users, family members, and service providers. Conference topics included individual choice, consumer leadership, grant writing, mental illness, person-centered planning, supported housing, and trauma-informed services; recovery-oriented practices such as Peer Support and Wellness Recovery Action Planning (WRAP); and ways to improve the mental health system. Grant funds supported consumer attendance at the conferences.

The Department also developed and launched a state-specific Recovery, Empowerment, and Self-Determination website with educational resources for mental health professionals, service users, and other stakeholders (http://www.dmhmrsas.virginia.gov/OMH-Recoverydefault.htm). In addition, a grant contractor developed an advanced Consumer Empowerment Leadership Training (CELT) academy and provided training on advocacy skills to about 40 service users. These skills will enable them to assume leadership functions and roles on Community Service Boards (CSB) and in mental health systems transformation activities. Community Service Boards are quasi-public units of local government that have statutory responsibility for providing mental health services. By state law, these boards must include "one-third identified consumers or former consumers or family members of consumers or former consumers, at least one of whom shall be a consumer receiving services."

A major grant goal was to align Medicaid Mental Health Rehabilitation option services with three evidence-based practices: Assertive Community Treatment (ACT), Illness Management and Recovery, and Supported Employment. To achieve this goal, (1) grant contractors provided training and technical assistance to community mental health staff, including peer specialists and other interested stakeholders, on Medicaid reimbursement for the State's Programs for Assertive Community Treatment (PACT) expansion; (2) the PACT coordinator arranged for the training of two PACT teams to enable them to deliver Illness Management and Recovery within the context of Assertive Community Treatment; and (3) the Department's Office of Mental Health designated several Community Service Boards as "Shadow Sites" for new or developing PACT teams. The Shadow Sites have PACT teams that maintain high standards of fidelity to the ACT evidence-based practice, and provide visiting PACT teams with experiential learning and mentoring as well as copies of policies/procedures and assessments.

Supported Employment is an evidence-based practice that uses a well-defined approach to help people with mental illnesses find and keep competitive employment. Grant partners developed a Mental Health Supported Employment demonstration program and enrolled 30 service users in one county to demonstrate the integration of services and supports that individuals in recovery need to succeed in employment (e.g., through DRS-funded vocational rehabilitation services and Medicaid-funded Mental Health Support Services).

At the completion of the demonstration program, program staff and peers produced a manual about supported employment, which discussed models for organizing supported employment at a Community Service Board, work incentives and benefits planning, integrating peer supports into service delivery, combining Medicaid and DRS funding streams to sustain Supported Employment services, and ongoing systems challenges. The manual, entitled Successful Competitive Employment for Consumers in Recovery from Mental Illness: Strategies and Approaches, was distributed to the Community Service Board and Vocational Rehabilitation staff and partners at a statewide training. Fourteen (47 percent) of the demonstration participants obtained employment.

In addition, grant staff produced two papers: Policy Briefing on Mental Health Supported Employment Services under Medicaid, which critiques current CMS policy on employment-related services for individuals with disabilities and recommends revisions to this policy; and Interpretive Guidance Regarding Medicaid Reimbursement for Mental Health Support Services in Supported Employment Programs, which provides guidance for determining which Mental Health Supported Employment services are strictly vocational and can only be supported by non-Medicaid funds (e.g., Vocational Rehabilitative Services), and which are provided in a work setting and may be reimbursable under the Medicaid Rehabilitation option.

Mental Health Provider Education and Training

Adopting evidence-based practices and incorporating peer support services into the mental health system is a major change for providers; in particular, they find it difficult to change how they relate to consumers. Because the State has no formal process for training providers to adopt evidence-based practices, the grant was used to provide several different kinds of training to help stakeholders understand EBP concepts and their role in service provision. Grant staff noted that generic training is not effective, so it is important to target training to specific groups.

In addition to the Illness Management and Recovery training provided to two PACT teams (noted above), the Dartmouth Evidence-Based Practices Center on Integrated Dual Disorders Treatment trained 45 staff persons from PACT teams statewide. Also, the Department's Office of Mental Health sponsored training for staff from 12 PACT teams and 11 Community Service Boards by awarding them scholarships to attend the National Annual ACT Conference in Tampa, FL.

The Department also contracted with the Mental Health Association of Southeastern Pennsylvania (MHASP) Institute for Recovery and Community Integration to conduct four 10 day certified peer specialist training events for 79 service users who were either employed or seeking employment in the public or private behavioral health system. The trainings focused on recovery, peer support, and the employment of peer specialists. In addition to the service users, trainings in orientation to peer support services also were provided to other stakeholders, including consumer-operated program staff, support group leaders, state staff, Community Services Board staff, and individuals from other groups such as NAMI Virginia. The MHASP Institute also conducted three supervisor/manager trainings on the supervision of peer specialists in recovery-oriented environments.

Reimbursement Issues

Grant staff reported that obtaining Medicaid reimbursement for specific evidence-based and recovery-oriented practices is a major challenge. The project was unsuccessful in amending its Medicaid Plan to add Peer Support Services. However, service users who successfully completed the training provided under the MHASP Institute curriculum (described above) met the qualifications for being considered a paraprofessional, thereby enabling them to be reimbursed under Medicaid for a variety of community-based mental health services. The Department of Medical Assistance Services clarified its policy on qualifications for paraprofessional providers to recognize the MHASP Institute on Recovery and Community Integration Peer Specialist curriculum.

Quality Assurance

The Mental Health Systems Transformation grant was designed to build infrastructure, not to measure the fidelity of evidence-based practices once implemented. The Department advocated that Community Service Boards use the Recovery Oriented Systems Indicators (ROSI) scale, which helps provider agencies determine the extent to which their services are recovery oriented. The ROSI survey tool includes a consumer assessment and an organization assessment, but grant funds were sufficient to conduct only the consumer assessment.

Grant staff and contractors surveyed consumers in 2005 using the ROSI survey tool at 43 sites in 11 local Community Service Board areas. Grant funds were used to train and pay mental health service users to conduct the survey. The peer surveyors interviewed 600 consumers and also disseminated 400 "Roadmap to Recovery" pamphlets at mental health centers across Virginia.

The Department has encouraged Community Service Boards to continue to use the instrument, and, in 2008, 496 consumers were surveyed with the ROSI tool in one of the State's seven planning regions. The results were similar to those from the grant survey, but some improvements were noted in the scores for such items as "Staff stood up for me to get the services and resources I needed"; "I have a say in what happens to me when I am in crisis"; and "There are consumers working as paid employees in the mental health agency where I receive services."

Grant Outcomes

The Department adopted the ROSI survey as its standard tool to measure the extent to which Virginia's mental health system has incorporated a recovery orientation in the provision of services. Because the Department does not administer Community Service Boards, it cannot mandate that providers use the ROSI, but it has recommended that they use it to track their adoption of a recovery orientation. However, to encourage its use, the Department modified its performance contract with Community Service Boards and state hospitals to require the use of a standardized instrument to assess their recovery orientation, referencing the ROSI survey tool as one possible instrument.

Grant staff developed a data entry and reporting system for community mental health providers—primarily the Community Service Boards—to enter individual ROSI survey responses from consumers as well as provider administrative data. The system produces reports on recovery strengths in the mental health system, such as (1) staff encouraging meaningful activities, peer support, and social relationships; (2) provision of choice; and (3) critical roles that formal service staff play in helping or hindering the recovery process. The ROSI data entry and reporting system is available on a CD.

The Department posted the ROSI assessment for consumers on its website and plans to use consumer responses to provide information about how the system is working for service users. The Department then plans to inform the Community Service Boards of the results. However, because few service users have used the online ROSI to date, the Mental Health Association of Virginia recently implemented a marketing plan to inform service users of its availability.

Grant staff were instrumental in drafting the Department's State Board POLICY 1039: Availability of Minimum Core Services, and POLICY 1040: Consumer and Family Member Involvement and Participation. The first policy states that individuals, regardless of where in the State they live, shall have comparable and consistent access to the same minimum array of core services and supports that promote self-determination, empowerment, recovery, resilience, health, and the highest possible level of community life, including work, school, family, and other meaningful relationships.

The second policy states that consumers and family members shall be invited, encouraged, and supported to participate and be involved in the development, operation, and evaluation of Virginia's public mental health, mental retardation, and substance abuse services system to the greatest extent possible at local, regional, and state levels through the following activities: (1) analyzing, formulating, and implementing policies; (2) planning services and designing programs; (3) providing direct services; (4) advocating for resources and fulfilling unmet needs for services; (5) monitoring and evaluating services, providers, and the services system; and (6) providing accountability and engaging in quality improvement activities.

A total of 79 service users were trained and awarded the certified peer specialist designation from the MHASP Institute for Community Integration and Recovery. (Of 124 peer specialists trained under the grant and through other programs, 95 are employed.) Having peer support specialists working in provider agencies has helped providers understand recovery-oriented practices and has helped them to adopt a recovery orientation in the provision of services. Also, the direct work that service users do as peer support specialists helps to facilitate their own recovery. Some more traditional providers are resistant to having peer support specialists involved in service delivery, making it very difficult for peers to work with them. However, the State Mental Health Commissioner is a psychiatrist who champions recovery and has credibility with providers, so it is professionally unacceptable for providers to openly oppose recovery practices.

The Department of Medical Assistance Services revised its Community Mental Health Rehabilitative Services Provider Manual to improve alignment of Virginia's Intensive Community Treatment standards with the ACT model, and Virginia's Mental Health Support Services standards with mental health supported employment. However, grant staff and partners did not implement the Illness Management and Recovery evidence-based practice because service users and advocates maintained that the practice as described by SAMHSA was not recovery oriented. They preferred to use the Wellness Recovery Action Plan (WRAP) approach, and therefore the Department is continuing to fund WRAP trainings and WRAP facilitation trainings by peer specialists.

Grant training and technical assistance activities increased the number of mental health service users who participate in and have leadership roles in the State's mental health system.

Remaining Federal/State Issues

Although service users and providers share the goal of successful supported employment for individuals in recovery from serious mental illness, adoption of supported employment services has been slow. DMHMRSAS, DRS, and DMAS should continue to jointly develop and disseminate guidance to clearly delineate the various components of supported employment and their respective reimbursement mechanisms through coordinated funding streams.
The State is geographically and demographically diverse with 40 Community Service Boards. The State's provider systems range from progressive and sophisticated with significant local tax revenue funding to rural and impoverished and struggling to meet minimal State Plan service provision requirements. As a result, ensuring the adoption of a core set of evidence-based services across the State is very difficult. Additionally, the State lacks the resources and infrastructure needed for training providers to adopt evidence-based practices and systems transformation initiatives in order to bring about large-scale change in the mental health system.
The CMS letter to State Medicaid Directors provided useful guidance about Medicaid coverage of peer-support services. However, CMS proposed changes in the definition of rehabilitation services and targeted case management, many of which would create problems for the State's mental health system. Because of opposition to the changes from the states, Congress issued a moratorium and delayed implementation until it reviews the changes sometime in 2009. As a result, Virginia cannot amend its State Plan to add peer support as a Medicaid-reimbursable service until it knows whether the proposed changes to rehabilitation services and targeted case management will be made and funding can be ensured.

Endnotes

¹ DBT therapy combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of mindful awareness, distress tolerance, and acceptance largely derived from Buddhist meditative practice. DBT is the first therapy that has been experimentally demonstrated to be effective for treating individuals with borderline personality disorder.

² Consumers use WRAP to develop individual plans that include practical activities and friends and family to support wellness on a daily basis. Through BRIDGES, consumers learn crisis planning, principles of support, problem solving, wellness management, communication, supportive listening, and assertiveness.

³ The Institute's curriculum also incorporated effective approaches used by Arizona; Georgia; Hawaii; Iowa; South Carolina; and Washington, DC. Other states that want to replicate Pennsylvania's approach can obtain standards and materials at http://www.parecovery.org/services_peer.shtml, but not the curriculum, which is proprietary. The Institute is under contract with other states and is currently helping Virginia develop its CPS program.

Appendix B: Text of CMS Letter to State Medicaid Directors

August 15, 2007

Dear State Medicaid Director:

The purpose of this letter is to provide guidance to States interested in peer support services under the Medicaid program. The Centers for Medicare & Medicaid Services (CMS) recognizes that the mental health field has seen a big shift in the paradigm of care over the last few years. Now, more than ever, there is great emphasis on recovery from even the most serious mental illnesses when persons have access in their communities to treatment and supports that are tailored to their needs. Recovery refers to the process in which people are able to live, work, learn and participate fully in their communities. For some individuals, recovery is the ability to live a fulfilling and productive life despite a disability. For others, recovery implies the reduction or complete remission of symptoms.

Background on Policy Issue

States are increasingly interested in covering peer support providers as a distinct provider type for the delivery of counseling and other support services to Medicaid eligible adults with mental illnesses and/or substance use disorders. Peer support services are an evidence-based mental health model of care which consists of a qualified peer support provider who assists individuals with their recovery from mental illness and substance use disorders. CMS recognizes that the experiences of peer support providers, as consumers of mental health and substance use services, can be an important component in a State's delivery of effective treatment. CMS is reaffirming its commitment to State flexibility, increased innovation, consumer choice, self-direction, recovery, and consumer protection through approval of these services. The following policy guidance includes requirements for supervision, care-coordination, and minimum training criteria for peer support providers.

As States develop behavioral health models of care under the Medicaid program, they have the option to offer peer support services as a component of a comprehensive mental health and substance use service delivery system. When electing to provide peer support services for Medicaid beneficiaries, State Medicaid agencies may choose to collaborate with State Mental Health Departments. We encourage States to consider comprehensive programs but note that regardless of how a State models its mental health and substance use disorder service delivery system, the State Medicaid agency continues to have the authority to determine the service delivery system, medical necessity criteria, and to define the amount, duration, and scope of the service. States may choose to deliver peer support services through several Medicaid funding authorities in the Social Security Act. The following current authorities have been used by States to date:

Section 1905(a)(13)
1915(b) Waiver Authority
1915(c) Waiver Authority

Delivery of Peer Support Services

Consistent with all services billed under the Medicaid program, States utilizing peer support services must comply with all Federal Medicaid regulations and policy. In order to be considered for Federal reimbursement, States must identify the Medicaid authority to be used for coverage and payment, describe the service, the provider of the service, and their qualifications in full detail. States must describe utilization review and reimbursement methodologies. Medicaid reimburses for peer support services delivered directly to Medicaid beneficiaries with mental health and/or substance use disorders. Additionally, reimbursement must be based on an identified unit of service and be provided by one peer support provider, based on an approved plan of care. States must provide an assurance that there are mechanisms in place to prevent over-billing for services, such as prior authorization and other utilization management methods.

Peer support providers should be self-identified consumers who are in recovery from mental illness and/or substance use disorders. Supervision and care coordination are core components of peer support services. Additionally, peer support providers must be sufficiently trained to delivery services. The following are the minimum requirements that should be addressed for supervision, care coordination and training when electing to provide peer support services.

1) Supervision

Supervision must be provided by a competent mental health professional (as defined by the State). The amount, duration and scope of supervision will vary depending on State Practice Acts, the demonstrated competency and experience of the peer support provider, as well as the service mix, and may range from the direct oversight to periodic care consultation.

2) Care-Coordination

As with many Medicaid funded services, peer support services must be coordinated within the context of a comprehensive, individualized plan of care that includes specific individualized goals. States should use a person-centered planning process to help promote participant ownership of the plan of care. Such methods actively engage and empower the participant, and individuals selected by the participant, in leading and directing the design of the service plan and, thereby, ensure that the plan reflects the needs and preferences of the participant in achieving the specific, individualized goals that have measurable results and are specified in the service plan.

3) Training and Credentialing

Peer support providers must complete training and certification as defined by the State. Training must provide peer support providers with a basic set of competencies necessary to perform the peer support function. The peer must demonstrate the ability to support the recovery of others from mental illness and/or substance use disorders. Similar to other provider types, ongoing continuing educational requirements for peer support providers must be in place.

Please feel free to contact Gale Arden, Director, Disabled and Elderly Health Programs Group, at 410-786-6810, if you have any questions.

Sincerely,

Dennis G. Smith
Director

cc:

CMS Regional Administrators

CMS Associate Regional Administrators
Division of Medicaid and Children's Health

Martha Roherty
Director, Health Policy Unit
American Public Human Services Association

Joy Wilson
Director, Health Committee
National Conference of State Legislatures

Matt Salo
Director of Health Legislation
National Governors Association

Jacalyn Bryan Carden
Director of Policy and Programs
Association of State and Territorial Health Officials

Christie Raniszewski Herrera
Director, Health and Human Services Task Force
American Legislative Exchange Council

Debra Miller
Director for Health Policy
Council of State Governments

Initiatives of the FY2004Mental Health Systems Transformation Grantees

Acknowledgments

Table of Contents

Executive Summary

Mental Health Systems Transformation Grants

Implementing Recovery-Oriented Initiatives

Implementing Evidence-Based Practices

Provider Training and Supervision

Ensuring Reimbursement for Evidence-Based Practices

Ensuring the Quality of Evidence-Based Practices

Conclusions

Next Steps

Section 1. Introduction1

Challenges Faced When Implementing Evidence-Based Practices

Challenges Faced When Adopting a Recovery Orientation25

Mental Health Systems Transformation Grants

Study Methods

Limitations

Organization of This Report

Section 2: Overview of Grantees' Initiatives

Target Populations

Specific Practices Selected by Grantees

Section 3: Implementation of Grant Initiatives

Implementing Recovery-Oriented Initiatives

Training Individuals with Mental Illness to Provide Peer Support in Traditional Mental Health Settings

Provider-Related Challenges and How They Were Addressed

Challenges for Peer Support Staff and How They Were Addressed

Reimbursement Issues for Peer Support and Other Recovery-Oriented Services

Determining the Extent of Organizations' Recovery Orientation

Remaining Recovery-Orientation Challenges & Recommendations to Address Them

Implementing Evidence-Based Practices

Provider Training and Supervision

Ensuring Reimbursement for Evidence-Based Practices

Medicaid Reimbursement Issues

Ensuring the Quality of Evidence-Based Practices

Remaining EBP Challenges and Recommendations to Address Them

Section 4: Conclusions

Using Research to Help Ensure Successful Initiatives

Understanding Medicaid's Reimbursement Options and Limits

Measuring Progress

Next Steps

Endnotes

Appendix A: Description of MHST Grant Initiatives

Delaware

Description of Grant Initiative

Systems-level Challenges

Education and Training

Reimbursement Issues

Quality Assurance

Grant Outcomes

Remaining Federal/State Issues

Maine

Description of Grant Initiative

Peer Support Education and Training

Reimbursement Issues

Quality Assurance

Grant Outcomes

Remaining Federal/State Issues

Massachusetts

Description of Grant Initiative

Peer Specialist Training and Certification Program

Reimbursement Issues

Quality Assurance

Grant Outcomes

Remaining Federal/State Issues

Michigan

Description of Grant Initiative

Development of Michigan Recovery Center of Excellence

Systems-level Challenges

Adoption of a Recovery-Orientation by Mental Health Providers

Reimbursement Issues

Quality Assurance

Grant Outcomes

Remaining Federal/State Issues

Minnesota

Description of Grant Initiative

Mental Health Provider Education and Training

Quality Assurance

Grant Outcomes

Remaining Federal/State Issues

Initiatives of the FY2004
Mental Health Systems Transformation Grantees

Section 1. Introduction¹

Challenges Faced When Adopting a Recovery Orientation²⁵