TOP 5 MISTAKES BY CLINICIANS: #1: FAILING TO USE PEERS STRATEGICALLY TO ADDRESS KEY PROBLEMS IN HEALTHCARE
Peer Support Specialists have a unique role in clinical settings, tied directly to their personal experience with illness, treatment and recovery. While clinicians have expertise in diagnosis and treatment, based on training and professional experience, Peer Support Specialists have expertise in the personal experience of illness and treatment. That personal experience gives them a strategic advantage when it comes to some of the most challenging problems facing current healthcare, including:
1. STRENGTHENING TRUST AND ALLIANCE BETWEEN CLINICIAN AND CLIENT
Trust is essential in healthcare, but a growing number of clients report a lack of confidence in their providers and healthcare institutions, raising calls for new efforts to “rebuild” the public’s trust (Isaacs, 2022). When clients are asked why they do not trust their providers, they often respond: “They don’t spend enough time with me” (25 percent), “They do not know me” (14 percent), and “They don’t listen to me” (14 percent). Lack of trust is associated with lower rates of following provider advice, and poor treatment outcomes (Birkhäuer et al., 2017).
Peer Support Specialists are ideally positioned to help build client trust in providers and healthcare organizations based on (1) their lived experience in treatment and success, (2) their presence which represents success and clinician’s recognition of the importance of client’s experience, (3) their credibility based on their own success, and (4) the time they spend providing peer counseling to clients.
2. INCREASING CLIENTS’ HOPE OF RECOVERY
Hope is critical to the healing process, particularly when the probability of success is not high. Many of the elements of “clinical culture” are designed to build the confidence of patients in the ability of clinicians to help them recover. Peer support, and particularly the work of Peer Support Specialists provides concrete evidence of, and a credible voice arguing for the hope for recovery in the clinical setting.
3. REDUCING TREATMENT DROPOUT
Dropout in medical and mental health treatment is very common (Olfson et al., 2009), and is associated with poorer outcomes and increased cost. Peer Support Specialists have unique credibility to help clients make better decisions about dropout and treatment completion, improving outcomes and treatment costs (Hernandez-Tejada, Acierno & Sánchez-Carracedo, 2017).
4. REDUCING DISPARITIES IN HEALTH AND HEALTHCARE
Health disparities are differences that exist among specific subgroups of the population related to different rates of illness, treatment, and recovery. Most of the current concern focuses on dramatic differences in health and treatment as a function of race and/or ethnicity, gender, sexual orientation, age, disability status, socioeconomic status, and geographic location. While some of the differences are related to genetic vulnerabilities, many are related to societal factors that impact how people participate in treatment. For example, compared to non-Latino white adults, members of all other racial or ethnic groups in the US are significantly less willing to use mental health treatment (Cook et al., 2019).
These disparities are a major problem, undermining the health of millions of adults. Major healthcare organizations such as the National Academy of Medicine and the American Medical Association have called for new initiatives to reduce the associated differences in health and treatment participation. Peer Support Specialists are ideally positioned to help. When Peer Support Specialists who represent diverse clients are present on the clinical team, healthcare disparities are reduced (Gutierrez Kapheim & Campbell, 2014).
5. REDUCING STIGMA
Stigma has been defined as “the prejudice and discrimination directed at a group by the population” and includes “negative attitudes held by members of the public about people with devalued characteristics,” including mental or physical illness (Corrigan et al., 2015). Self-stigma is similar to stigma but occurs when people in a specific group internalize negative public attitudes about that group. Stigma and self-stigma are often focused on serious medical and mental illnesses.
Stigma is most destructive when it is unrecognized. As a member of stigmatized groups, Peer Support Specialists have a key role in identifying and openly fighting stigma in every setting, regardless of whether it is public stigma or self-stigma. Education is the key strategy for changing stigma in the community and self-stigma in clients.
6. SUPPORTING INDIVIDUALIZED CARE
There has been growing recognition within the healthcare world that care customized to meet the specific needs and preferences of individual clients results in better outcomes, reduced cost, and higher client satisfaction (Riis et al., 2020). The challenge is that individualized care takes more time and personal understanding on the part of clinicians who already don’t have enough time to do their work. As a result, clients often feel that their individual desires and needs are not addressed.
Effective Peer Support Specialists function as advocates for clients in a way that increases the likelihood that treatment will reflect those clients’ individual needs. As a client advocate on the clinical team, Peer Support Specialists routinely amplify the individual needs and preferences of clients, encouraging personalized care.
7. PROVIDING SYSTEM NAVIGATION
Healthcare systems have become so complex and confusing that their value has been undermined (Griese, Berens, Nowak, Kelikan & Schaeffe, 2020). Clients are typically required to find an entry point into the system, to maneuver through a confusing array of services and programs, and to communicate clearly with a wide range of individuals about technical and confusing topics. Many clients are simply unable to meet these requirements, leading to disorientation, futile and stressful searches, uncertainty, and discontinuities in healthcare. Peer Support Specialists are ideally suited to serve as “navigators” and “coaches” for clients because they are part of the system, have inside knowledge and experience with staff and programs, and have personally navigated care for themselves.
8. IMPROVING HEALTHCARE FLUENCY WITH PATIENT/FAMILY EDUCATION
Being an effective client requires knowledge about illness, treatment, and recovery—knowledge that many clients and family members do not have. Clinicians are increasingly expected to educate their clients, but this is typically focused on clinical topics related to illness. Peer Support Specialists are ideally positioned to educate clients and their families about the experience of different illnesses and different forms of treatment, as well as the experience of recovery, improving their “healthcare fluency.” This information is essential to guiding the client’s participation in their own treatment and increasing the probability that they will be successful in recovery.
9. FACILITATING TIMELY TREATMENT ENTRY
We generally assume that people get mental healthcare when they need it. This is clearly not true. For example, more than half of adults with mental healthcare needs in the United States do not participate in any treatment, and when they do, there is a median delay of eleven years before they enter needed care (Drebing, 2024). Healthcare organizations tend to be passive in the face of this pattern of long delays in treatment entry. Their traditional stance is to wait until patients come to them. The problem with this strategy is that it results in long, unnecessary delays, with more suffering and more cost to those individuals, their families, their employers, the broader community, and ultimately, the healthcare industry.
Peer Support Specialists are well positioned to play a key role in helping people make timely decisions to enter needed treatment. They have the credibility and the connections inside and outside healthcare organizations to facilitate timely entry into care.
10. IMPROVING SUCCESSFUL DISCHARGE BY BUILDING DISEASE SELF MANAGEMENT AND COMMUNITY INTEGRATION
Many people who complete formal treatment fail to develop the disease self-management habits that are needed to support their independent functioning after the end of treatment. Others fail to recover functional roles in the community despite being able to do so, resulting in a loss to the person, the family and the community. Many become more isolated and in mental healthcare, many become more symptomatic, which increases the risk for relapse and need for more treatment.
Peer Support Specialists are ideally positioned to help patients develop the disease self-management habits that will sustain their recovery. As models of recovery, Peers are credible coaches who can encourage successful transitions to active roles in the community. Successful community integration reduces the need for subsequent healthcare, thus reducing cost.
11. REDUCING THE COST OF HEALTHCARE
Healthcare is more expensive in the US than in almost any other country, while lagging in many quality indicators (Dieleman et al., 2020). This has led to extensive efforts to find ways to reduce those costs. While the primary goal of incorporating Peer Support Specialists and peer support into healthcare is to improve client recovery, NOT to reduce costs, it is important to note the ways that Peer Support Specialists can be used appropriately to save healthcare dollars. These strategies result in positive improvements in health and quality of life for clients. Consider the following examples of ways that Peer Support Specialists can help reduce the cost of healthcare:
· Integrating Peer Support/Self-Help into Traditional Healthcare. When peer support is integrated into traditional healthcare, the success rate is often improved while the cost is reduced (Humphreys & Moos, 2007).
· Safely and Effectively Diverting People from More Expensive Care. In mental health systems, use of peer support is predictive of reduced risk of psychiatric hospitalization (Landers & Zhou, 2011). For example, peer respite programs are voluntary, short-term, overnight alternatives that provide community-based, nonclinical support for people experiencing or at risk of acute psychiatric crisis, reducing more expensive inpatient care while improving mental health outcomes and reducing self-stigma (Pelot & Ostrow, 2021).
· Delivering Disease Self-Management Services. Chronic health conditions account for 90 percent of healthcare dollars spent. Peer Support Specialists encourage effective disease self-management and have been found useful in virtually every one of the top ten most costly chronic health conditions, including heart disease, stroke, cancer, diabetes, obesity, arthritis, dementia, epilepsy, and lung disease (Druss et al., 2018).
· Replacing Clinicians with Less Expensive Peer Support Specialists When the Work is Appropriate for Peers and Success Rates are Equal or Better. It is reasonable and even responsible to look at services that can be appropriately provided by either a clinician or a Peer Support Specialist, and to use the less expensive alternative if the outcomes are similar or even better. Researchers have found a range of services that clinicians and Peers are both qualified to provide and that result in similar success rates (Eisen et al., 2012).
12. ADDRESSING THE “EPIDEMIC” OF SOCIAL ISOLATION AND LONELINESS
In May 2023, the US Surgeon General issued an advisory regarding the urgent public health challenge raised by the loneliness and social isolation “epidemic.” The healthcare system in the US is now being asked to lead the way to address this challenge, and yet it has little experience or expertise in doing so. Peer Support Specialists are ideally positioned to help people increase their social support, particularly when using peer support and self-help groups. Peers are often well acquainted with the challenges in addressing social isolation and loneliness, and their work involves building networks of social contacts and support groups that are key resources for clients. Social support is positively correlated with the effective use of healthcare and reduced healthcare costs (Shier, Ginsburg, Howell, Volland & Golden, 2013).
13. HELPING ADDRESS THE IMPACT OF SOCIAL DETERMINANTS OF HEALTH
In the last ten years, healthcare organizations and providers have increasingly recognized that the environment in which clients live has a big impact on their health and treatment. These environmental factors, referred to as the “social determinants of health,” include
· Safe housing, transportation, neighborhoods, and social connections
· Education, job opportunities, and income
· Access to nutritious foods and opportunities for physical activity
· Clean air and water
· Freedom from discrimination, violence, and racism
· Language and literacy skills
The Centers for Disease Control and Prevention (CDC) and other healthcare organizations place a top priority on incorporating the social determinants of health into our system of healthcare—but how? Peer Support Specialists can play a key role in this effort. Given their life experience with illness and recovery, many understand the ways in which these environmental factors impact health and recovery. They are natural educators for clients and can provide interventions in the community that reduce the risk caused by these factors.
IN SUMMARY: Peer Support Specialists are ideally positioned to contribute to efforts to address these 13 key problems facing healthcare. Clinical providers and managers have routinely overlooked Peers’ unique potential for contributing to this work and instead assigned Peers to routine and even inappropriate work that fails to take advantage of their role. This leaves clinicians and Peers wondering about the true value of peer support.
Clinical providers need to build more sophistication in their understanding of how peer support works, and how it can be used to address specific problems across clinical settings. There are a number of exemplars that provide models. For example, failure to enter treatment, and dropout from treatment is common, particularly when clients are concerned about failure. I have seen programs position Peer Support Specialists so that they are the first staff members that new clients meet when they enter a new program. Those Peers are proactive in asking about clients’ fears and concerns, and then use their own experience to reduce those fears and concerns. When clients appear to be ambivalent about treatment, the clinical team assigns a Peer Support Specialist to intervene to build hope and motivation.
Failing to use Peer Support Specialists strategically is an unforced error on the part of clinical providers and managers – one that costs us in terms of continued struggling with age-old problems. Only when clinicians see the true advantages of peer support and Peer Support Specialists, will these new positions be able to live up to their potential.
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