Clayton Velicer, MPH
Peer support in the field of mental health has often been implemented as a means of improving symptoms and/or potentially reducing costs. A meta-analysis of peer support programs for depression in 2011 by Heisler and colleagues found that peer support interventions help reduce symptoms of depression. Promising findings have also been reported with promotoras, with veterans and peer-taught family education for mental illness. For more evidence on mental health peer support, we encourage our readers to check out the mental health evidence section of our website.
However, not all peer-led interventions for mental health have shown positive findings. A recent Cochrane Review by Pitt and Colleagues assessed the effects of employing current or past adult consumers of mental health services as providers of mental health services. These individuals filled a variety of roles, including peer support, coaching, and advocacy. To evaluate the effectiveness of these kinds of programs, Pit and colleagues examined 11 randomized control trials involving 2796 people and concluded that “involving consumer-providers in mental health teams results in psychosocial, mental health symptom and service use outcomes for clients that were no better or worse than those achieved by professionals employed in similar roles, particularly for case management services.” Does this conclusion suggest that peer support, primarily labeled “consumer-provider led service” in this paper, is not an effective means of improving mental health? A deeper analysis of the review reveals several key concepts that may provide insight into the conclusion.
It is important to know that the review acknowledges the quality of the studies included were moderate to low. The reason the authors stated for this rating included incomplete outcome data, selective reporting and lack of blinding.
Types of Interventions Reviewed
There were two main intervention types included in this review. The first type involved comparing consumer-providers and professional staff in the same role (Comparison 1). There were 5 studies included in this comparison; 4 of the studies used a consumer-provider in a case management role within a mental health team and 1 study trained consumer-providers as facilitators of mutual support group therapy otherwise facilitated by professional staff.
The second type of intervention included in this study had consumer providers as an adjunct to usual care. This included 4 studies in which consumer-providers worked as mentors or in advocacy roles and 2 in which consumer-operated services were integrated with traditional mental health services in addition to usual care.
For the first type of intervention, the authors reported there were no differences in psychosocial, mental health, and client satisfaction outcomes. However, there was a small reduction in use of crisis and emergency service for participants receiving consumer-provider led service. The authors note that there was no data provided on financial cost (this is a very important disclosure that will be discussed further in the implications section of this blog).
For the second type of study the authors also concluded there was no significant difference in psychosocial, client satisfaction, or service use outcomes. However, again the authors note that there was no reported information on financial cost with the study and furthermore, only 3 of the studies reported data on the amount of hospitalizations for the participants. Of these 3, two reported insignificant differences while one reported lower rehospitalizations, shorter hospital stays and lower use of services for participants in the intervention group. Unfortunately, the group reporting data on improved hospital and service use related outcomes did not provide data on the number of the 80 participants that were randomized to each condition making determining statistical significance impossible. Aside from one study reporting no significance difference in attendance rates for clinical appointment, there was no other data reported on use of services in this group. This will also be discussed in the implications sections of this paper.
Implications of this Review
This review does a very good job providing some data on the use of consumer-providers, or peer support, in mental health. Furthermore, the paper examines two different formats for this kind of care with consumer-provider support being compared to professional services or being examined as an addition to regular services. However, there are several key points that must be made regarding the findings.
For the first group of studies, in which consumer-providers were compared to professional staff in the same role, non-significant between group differences may be interpreted as evidence for the effectiveness of peer support. If a consumer-provider is able to deliver comparable outcomes as professionals at lower cost, their utilization can provide cost savings for providers. Furthermore, using peer supporters in appropriate areas of mental health care may free health professionals in care facilities more time to provide services where peer support is not as appropriate. Unfortunately, the authors of the studies included in the review did not provide any data on the financial implications for these interventions. With additional funding becoming available under the Affordable Care Act for the use of community health workers and peer supporters, understanding areas where they can provide comparable services to health professionals may represent significant cost savings for providers.
For the second group of studies, a key point to emphasize is the effect of consumer-provider services on service utilization. As defined on the Peers for Progress website “Peer support refers to practical, social, emotional, ongoing support from a person who shares similar experiences with a disease or health problem. Peer support is a powerful and affordable tool for facilitating the kind of knowledge, skills, encouragement, and linkages to resources that people need to adopt and maintain healthy behaviors.” When the use of care is not measured as part of a peer support or consumer-provider service, it does not take advantage of the increased comfort participants may feel taking advantage of their healthcare systems. Increased access to care may allow participants with mental health conditions to receive the ongoing support and preventive services necessary to reduce hospitalizations and crisis care for their condition. Of the 3 studies measuring hospitalization data in this second group, one found reduced number of hospitalizations, shorter stays and overall lower use of services. This outcome measure will need to be included in future programs measuring the effectiveness of consumer-providers in the field of mental health to more fully understand the impact of peer support and further demonstrate potential cost savings.
Overall, this review provides important data on peer support in the field of mental health and underscores the potential of peer support to provide cost savings through replacing professional led services or through potentially reducing the need for costly crisis care and hospitalizations. Future studies involving the use of consumer-providers in the field of mental health will need to measure outcomes related to cost and use of services to further understand the most effective use of peer support in mental health.
Patrick Tang, MPH
A major challenge for the Affordable Care Act (ACA) is to reduce overall healthcare costs while improving quality of care. Based on recent studies, policymakers were convinced that reducing hospital readmissions was a feasible approach to achieve both of these goals. Through performance-based penalties, the ACA is taking an aggressive course to rapidly reduce excess hospital readmissions. This effort will require greater coordination of care and cooperation between hospital and community resources.
Peer support programs can improve transition of care, promote outpatient physician visits, reduce stress, provide social support, and share their experiences to help discharged patients avert preventable hospital readmissions. Several ACA provisions are expanding the role of community health workers, making them eligible for Medicare reimbursement as patient navigators and as part of multidisciplinary care teams. Hospitals can take advantage of these funding opportunities to leverage peer support to improve quality and reduce rehospitalizations.
Costs and Rationale
According to a 2009 study by Jencks and colleagues, hospital readmissions for Medicare beneficiaries were highly prevalent and costly. 19.6% of beneficiaries were rehospitalized within 30 days and 34% were rehospitalized within 90 days, costing $17.4 billion of the $102.6 billion in hospital payments from Medicare (data from 2004).
In a New England Journal of Medicine editorial, Dr. Epstein writes that:
“The evidence of variability in readmission rates, of a failure to provide close patient follow-up, and of inadequate communication between doctors and patients and among doctors at the time of discharge has raised concerns that many readmissions may be preventable and has pointed to policy changes that might both improve health outcomes and substantially lower costs.”
A report released by the Robert Wood Johnson Foundation outlines the following strategies for effectively reducing rehospitalization.
- Plan for earlier hospital discharge
- Offer more intense education for new diagnoses
- Flag high-risk patients and provide case management
- Use multidisciplinary approach to discharge
- Check in with patients that have chronic conditions
- Provide follow up care
- Encourage connection with primary care providers
Medicare’s Hospital Readmission Reduction Program (HRRP)
Section 3025 of the ACA established the Hospital Readmissions Reduction Program (HRRP), which requires the Centers for Medicare & Medicaid Services (CMS) to reduce payments to Inpatient Prospective Payment System (IPPS) hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. Readmissions are defined as an admission to a hospital within 30 days of a discharge from the same hospital. Applicable conditions include acute myocardial infarction, heart failure, and pneumonia. Read the full measures and payment adjustment methodologies at the CMS website.
It is estimated that 2,217 hospitals across the country will be penalized in this initial round of evaluations, of which 207 will receive the maximum penalty. 887 hospitals had acceptable readmission rates and 346 hospitals did not meet the minimum number of cases for evaluation. The maximum penalty for the first year is 1% of base Medicare reimbursements, increasing to 2% in October 2013 and 3% in October 2014. In total, these hospitals will lose $280 million in Medicare funds this year, which accounts for 0.3% of the amount that Medicare pays to hospitals.
Critics of the HRRP contest that this program unfairly penalizes hospitals that serve high-risk, low-income, and minority populations, when in fact those hospitals need the money most. Some hospitals that have implemented reforms have not seen improvements, leaving some to wonder how to effectively tackle the issue. Fortunately, the ACA offers grants to help hospitals implement reforms and coordinate patient care in the community. For example, the Quality Improvement Program for Hospitals with High Severity Adjusted Readmission Rate will use patient safety organizations to help underperforming hospitals reduce their readmission rates. The Community-Based Care Transitions program is helping community-based organizations test models for improving care transitions for high-risk Medicare beneficiaries.
Peer Support as a Strategy to Reduce Rehospitalization
Several studies (Coleman et al. 2006, Naylor et al. 2004, Jack et al. 2009) have demonstrated the effectiveness of transitional care after hospital discharge in reducing rehospitalization rates. These programs have utilized coaches and nurses to deliver the intervention in the community. We propose that peer supporters would be well-positioned to deliver trusted, community-based support from “someone that’s been through it before.” The role of the peer supporter would be to reinforce clinical messages, help solve problems, provide social support, and link patients to outpatient care.
Rich et al. (1995) tested a nurse-directed, multidisciplinary intervention that improved quality of life and reduced hospital use for elderly patients with congestive heart failure. The intervention consisted of comprehensive education of the patient and family, a prescribed diet, social-service consultation and planning for an early discharge, a review of medications, and intensive follow-up. This multidisciplinary team includes a research nurse, a registered dietician, and a geriatric cardiologist. A peer supporter would add another dimension to this multidisciplinary team. Through individualized home visits and telephone contact, peer supporters can reinforce patient education, promote medication and dietary adherence, and identify recurrent symptoms that should be referred to outpatient treatment.
Kaiser Health News reports that “hospitals that treat the most low-income patients will be hit particularly hard (by the penalties).” It is likely that these hospitals serve a large number of Medicaid and dual beneficiaries. A small percentage of high-risk patients accounts for a large proportion of Medicaid spending through frequent hospital admissions. Raven et al. (2011) piloted an intervention that reduced hospitalizations in this population by 37.5%, reduced usage of emergency care while increasing outpatient visits, and decreased Medicaid costs by $16,383 per patient over 12 months.
This patient-centered intervention was multidisciplinary and strengthened cooperation between hospital and community resources. Peer supporters would enhance the care team’s ability to 1) provide coordinated care that is responsive to patient needs, 2) provide care that continues into the community, 3) serve patients “where they are” both physically and mentally, and 4) share data and track progress among team members.
The penalties imposed by the ACA’s Hospital Readmission Reduction Program will prompt hospitals to reform their policies around patient discharges and the provision of continuing care. Epstein writes that “the care that prevents rehospitalization occurs largely outside hospitals.” As part of a multidisciplinary care team, peer supporters are uniquely positioned to provide the type of community-based care that could prevent unnecessary rehospitalizations. Furthermore, Jencks et al. reports that “risk of rehospitalization persists over time.” As one of the four key functions of peer support is to provide ongoing support, peer supporters would be following up with patients months following a discharge.
Reducing rehospitalizations is only one of the many ways in which peer supporters/community health workers could satisfy the mandates in the Affordable Care Act. See our ACA Issue Brief to learn more about opportunities for peer support in the ACA.
Rau J. (2012). Medicare to Penalize 2,217 Hospitals For Excess Readmissions. Kaiser Health News; Aug 13, 2012. Retrieved from http://www.kaiserhealthnews.org/Stories/2012/August/13/medicare-hospitals-readmissions-penalties.aspx
Raven MC, Doran KM, Kostrowski S, Gillespie CC, Elbel BD. (2011). An intervention to improve care and reduce costs for high-risk patients with frequent hospital admission: a pilot study. BMC Health Serv Res; 11:270.
Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM. (1995). A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med; 333(18):1190-5.
Institute for Hispanic Health, NCLR
For me, the word “cancer” is one of the most frightening words in the English language. As someone whose family has been touched several times by this ugly word, I understand the fear and anxiety that even thinking about cancer can bring about. Like anything worrisome, it’s tempting to push that word out of our minds and pretend that cancer doesn’t exist. However, I also understand the danger of ignoring it.
Cervical health is an issue that hits us close to home at NCLR for several reasons. For starters, Latinas have the highest rate of cervical cancer among racial groups and the second highest rate of death from cervical cancer, according to the Centers for Disease Control and Prevention (CDC). Despite these high rates of disease and death, Latinas age 18–44 have lower screening rates than Whites and Blacks.
What’s particularly heartbreaking about cervical cancer, however, is that it is not only highly preventable, but also highly treatable. Getting routine Pap tests is a valuable way of catching cervical cancer when treatment is still simple and effective. The CDC reports that 60% of cervical cancers occur in women who have never received a Pap test or have not been tested within the last five years.
So why aren’t Latinas getting tested? Research on this topic has found that there are a lot of factors that come into play. Common reasons women don’t get tested include embarrassment, cost, and fear of getting abnormal results. However, there are also many factors that promote cervical cancer screening. For example, low-cost or free services for cervical cancer screenings exist at places such as federally funded health centers or Title X family planning clinics. And, in terms of education, we here at NCLR are doing our part to empower and promote the well-being of the Latina community.
I recently started working at NCLR, focusing on their Mujer Sana, Familia Fuerte (Healthy Woman, Strong Family) project. Mujer Sana, Familia Fuerte was funded by the CDC in late 2009 to address the need for effective cervical cancer education among Latinas. This community-based project seeks to improve knowledge, change attitudes, and get women to seek cervical cancer screenings, especially among Latinas in Washington, DC and Chicago. I’m happy to report that thanks to partnerships with inspiring organizations and the work of some dedicated promotores de salud (lay health workers), we’ve been able to reach thousands of Latinas with important cervical cancer prevention information.
If I’ve learned anything from my time working at NCLR and my family experiences, it’s the power of getting tested. Sure, the thought of getting tested or receiving an abnormal result can be daunting, but the thought of not finding out in time to do something about it is much more frightening.
As part of our collaboration with NCLR, we will be sharing news and stories around promotores de salud and Latino health. Please visit the NCLR blog for more.