Healthcare in the US is beset by a large number of serious problems that erode the confidence of the public. These include problems such as:
· A healthcare system that is the most expensive in the world but that produces relatively poor outcomes (Dieleman et al., 2020).
· Declining trust that clinicians listen, understand, and truly care about patients (Isaacs, 2022).
· Healthcare disparities that undermine the health of large subgroups of patients related to race, ethnicity, gender, age, education, rural status, and veteran status (Macias-Konstantopoulos et al., 2023).
· Rates of treatment dropout and poor participation that undermine the majority of patient care (Vermeire, Hearnshaw, Van Royen, & Denekens, 2001).
· Slow treatment entry that undermines success (Kessler, Olfson, & Berglund, 1998).
· Poor discharge outcomes that lead to relapse and extended treatment .
· Failure to develop care that is truly patient-centered and adapted for the individual client (Yu et al., 2020).
· A healthcare system that is now so complex that many clients can’t navigate it successfully (Chen et al., 2024).
Solving these problems has become an obsession for the healthcare world. The easy solutions have already been tried. True solutions will take significant creativity – not a quality that is often used to describe organizational efforts of healthcare organizations. Anyone who can find ways to address these serious problems will find motivated partners, offers of additional resources, and increased influence over the system. This is a real opportunity for Peer Support Specialists to increase their influence and voice in the healthcare world.
Peer Support Specialists are the newest arrivals to clinical work, and they come with a very different perspective. Peers see clinical work from the perspective of the client -- they know the challenges from the client’s perspective and so bring important new data to the discussion of these problems. They have not been socialized by years of graduate training and so they see healthcare in a way that can be more creative. Their “fresh eyes” are critically important in the search for ways to solve these complex problems.
Peers need to bring those fresh eyes and their insights to the table, and use them find new solutions. In my experience, Peers naturally have creative ideas about these problems, and are not often included in the right discussions or meetings to share those ideas. Peers must find ways to show clinicians that they have ideas that work and that they can make a real contribution. In my experience, when Peers get a chance to work closely with clinicians on finding solutions, the results are often remarkable.
Part of the reason for their success is that Peers are less constrained in the way they think about, and do their work. Many clinicians have a select menu of things they are allowed to do for their job. This ensures they get paid and are practicing safely – but these constraints also limit their work and their creativity. The relatively brief history of Peer Support Specialists means that the healthcare bureaucracy that creates guidelines and constraints on clinical staff have not yet gotten a full grip on Peer Support Specialists. This is a time-limited window that allows Peers unique opportunities to be creative.
Examples of real solutions developed by Peer Support Specialists:
1. Using peer support groups in the community to improve treatment outcomes and community integration. Relapse and rehospitalization is a large problem facing many clinical programs. I worked in a mental health system that was looking for ways to reduce the high rates of relapse and rehospitalization. A Peer Support Specialist suggested that if we created peer support groups in the community and encouraged clients who were approaching discharge to attend those groups, the groups would help those clients get connected to natural community supports, and that support would help them avoid relapse. We started with one group in the community. It was popular and successful. We added several more groups, all started by Peer Support Specialists who were flexible enough to work in the community. These groups were successful. Within 5 years, we have 40 weekly peer support groups in communities in our catchment area. This was an idea that Peer Support Specialists developed, based on their own experience. They had the flexibility to implement the groups, and the success was clear. Based on that success, the hospital administration funded additional Peer positions.
2. Using peers to increase treatment engagement and success in groups ‘at-risk’ for healthcare disparities. Healthcare disparities are differences in health and in participation in healthcare based on background variables like race, gender, age, immigrant status, sexual orientation, income, education, and veteran status. These disparities are very costly in terms of reduced health and longevity of the groups they effect.
Working with the Veterans Administration, I was aware that the VA had set a goal of getting more female Veterans enrolled in care. This was not easy, as most female Vets correctly felt that VA healthcare had traditionally been organized around the needs of the majority of male Veterans. There were subtle and not-so-subtle messages to female Veterans that “this is not a place for you”.
In our efforts to be more welcoming to female Veterans, a female Peer Support Specialist who was a Veteran, suggested that we create a new program that involved female Veteran peer support groups and female Veteran Peer Healthcare Mentors/Navigators. This Peer argued that female Veterans are used to being in organizations with a majority of men, but that they want and need a sense of connection with other female Veterans. We created these peer support resources and they were highly successful in building engagement between those Veterans. Similar peer support programming has worked for increasing treatment engagement and success among clients who face barriers related to their race, sexual preference, age, immigrant status, and Veteran status (Sokol & Fisher, 2016; Babamoto et al., 2009; Chapman, Damio, Young, & Perez-Escamilla, 2004).
3. Using peer support lifestyle interventions to build disease self-management.
I worked with a Peer Support Specialist who decided that they would create a “walk-and-talk” peer support group for clients who wanted to socialize but also increase their physical activity and reduce their weight. She organized a weekly walking group, publicized it with clinicians, and met with potential participants to set personal goals. The group was immediately popular because it paired low-demand exercise with socializing - real needs that many clients had trouble meeting. It was used by clients with diabetes and other medical conditions that required disease self-management habits. Using peer support instead of clinical providers, made this group more acceptable and resulted in better outcomes. I have seen other Peers who started or led peer support groups focused on healthy eating, exercise, exposure to nature, connecting with the community, and exploring spirituality.
4. Using community-based peer support to reduce the cost of US healthcare. Arguably, the biggest problem of healthcare in the US is the cost. Americans pay more for their healthcare than any other country, and yet have poorer quality and poorer outcomes (Dieleman et al., 2020). For years, I have heard Peer Support Specialists and clients pointing out that if peer support groups were systematically used in healthcare, that the cost of care would go down, as people relied more on the community for their long-term recovery.
Dr. Keith Humphreys is a researcher who studied this possibility (Humphreys & Moos, 2007). He compared substance use treatment programs that integrated peer support group vs. programs that focused only on clinical interventions and did not encourage peer support. He followed participants for 3 years during and after treatment. Not surprisingly, participants in the groups that encouraged peer support, were much more likely to participate in community-peer support groups after being discharged. The clinical outcomes, in terms of abstinence, were similar over the three years, with the peer-oriented programs having slightly better success rates. The most important finding was that the cost of care dropped dramatically in years 2 and 3 for clients of the programs that emphasized peer support. Those clients were more successful, participated in free community-based peer support groups at much higher rates and used follow-up formal (expensive) treatment at much lower rates. Clients found that peer support groups met their need and so they didn’t use expensive clinical care. This is a brilliant model that Peer Support Specialists have been championing for years. It has application to a range of other clinical fields, and could save the healthcare system a large amount of money while improving healthcare outcomes.
Peer Support Specialists come to their work with “fresh eyes” that see more creative solutions to the serious problems that our healthcare system faces. Many Peers recognize their unique ideas and views, but don’t recognize that the system needs them to be vocal and engaged in promoting their ideas and piloting their ideas. Their creativity is one of their greatest assets, and they need to be persistent and assertive in helping clinicians to recognize this.
REFERENCES
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Chapman DJ, Damio G, Young S, Perez-Escamilla R. (2004). Effectiveness of breastfeeding peer counseling in a low income, predominantly Latina population: a randomized controlled trial. Arch Pediatr Adolesc Med. 2004;158(9): 897–902
Chen, M., Wu, V. S., Falk, D., Cheatham, C., Cullen, J., & Hoehn, R. (2024). Patient navigation in cancer treatment: a systematic review. Current oncology reports, 26(5), 504-537.
Dieleman, J. L., Cao, J., Chapin, A., Chen, C., Li, Z., Liu, A., ... & Murray, C. J. (2020). US health care spending by payer and health condition, 1996-2016. Jama, 323(9), 863-884.
Humphreys, K., & Moos, R. H. (2007). Encouraging posttreatment self-help group involvement to reduce demand for continuing care services: two-year clinical and utilization outcomes. Focus, 5(2), 193-198
Kessler, R. C., Olfson, M., & Berglund, P. A. (1998). Patterns and predictors of treatment contact after first onset of psychiatric disorders. American Journal of Psychiatry, 155(1), 62-69.
Macias-Konstantopoulos, W. L., Collins, K. A., Diaz, R., Duber, H. C., Edwards, C. D., Hsu, A. P., ... & Sachs, C. J. (2023). Race, healthcare, and health disparities: a critical review and recommendations for advancing health equity. Western journal of emergency medicine, 24(5), 906.
Sokol, R., & Fisher, E. (2016). Peer support for the hardly reached: a systematic review. American journal of public health, 106(7), e1-e8
Vermeire, E., Hearnshaw, H., Van Royen, P., & Denekens, J. (2001). Patient adherence to treatment: three decades of research. A comprehensive review. Journal of clinical pharmacy and therapeutics, 26(5), 331-342.
Yu, C., Xian, Y., Jing, T., Bai, M., Li, X., Li, J., ... & Zhang, Z. (2023). More patient-centered care, better healthcare: the association between patient-centered care and healthcare outcomes in inpatients. Frontiers in Public Health, 11, 1148277.