WATERBURY – The Mental Health Integration Council, which was charged by the legislature with “helping to ensure that all sectors of the health care system actively participate in the state’s principles” for a holistic health care system, is nearing the end of its two years of work.
Peer support services emerged as a key component in discussions in the second year’s work, with a subgroup on primary care strongly endorsing development of peer and community health workers in support of whole health and as a point of entry to primary care.
The Department of Mental Health said at the Council’s May meeting that a final report and recommendations would be completed in July.
Mark Levine, MD, Commissioner of the Department of Health, said that national experts have said that the magnitude of change to achieve a “whole health” approach to health care would take decades of work and a “seismic cultural change.”
But in Vermont, “we have a fighting chance” to make it work, Levine told the group, because of the “positivity and energy” he witnessed in the collaboration among the many participants.
At the May meeting, members heard from the Veteran’s Administration peer program, which will have two peer support specialists in every primary care clinic by next year. The VA has some 13,000 peer specialists employed across the country, according to Christina Strook, PsyD, from the VA Center for Integrated Healthcare.
The discussion evoked questions from Allison Krompf, Deputy Commission at DMH, about how peers are recruited and certified, and what their roles are, noting that it was a topic Vermont is “trying to work through right now.”
David Kanar, who started as a peer support specialist in Georgia 18 years ago and now works for the VA in Tampa, explained that the role meant being someone “willing to self-identify as in recovery from mental health and substance abuse” and with training to use that experience “in a strategic way to provide hope.”
He sees it as a “pay it forward” role from his own recovery journey, saying that he was “someone you’d never, never expect” to be where he is today after having been a long-term patient with schizophrenia who was predicted 22 years ago to never leave the hospital.
Strook said the VA requires certification and continuing education through recognizing certain state programs which meet its criteria for vigor, as well as accepting two national programs.
Peer work in primary care is often a relationship of shorter duration, she said, but peer specialists have a unique role in supporting patients to be “engaging or not giving up on care.” They help as system navigators who “know access to community resources best” and are “acutely aware when [individuals] need more intensive services.”
“They have that gut instinct” and patients are often more likely to disclose challenges than with a clinician, she added.
Kanar and Strook both stressed that peer specialists are not clinicians and that it would be destructive to the peer relationship if they were. A peer specialist is “walking alongside [the peer] in building a self-directed life… not pushing someone from behind or pulling from ahead,” Kanar explained.
The systems-level approaches that were directed by the legislature in its creation of the Council never fully developed in its discussions, according to some. The proposals for primary care were one of four areas of focus, rather than part of a comprehensive proposal.
There was “some good awareness” and the creation of “collaboration among silos” among different health sectors that were positive, according to Dan Towle, who filled one of two positions on the Council appointed by Vermont Psychiatric Survivors.
However, the final outcomes that are emerging are a disappointment, he said, given “the number of people and amount of time, and how little we’ve accomplished.”
The Council, which was jointly chaired by the Department of Mental Health and Department of Health, focused on sub-committees in different specific areas: primary care, pediatric care, workforce, and funding and alignment of performance measures. Membership covered almost every sector of health care, including insurers, the state, private health delivery, hospitals and regulators. Recommendations in a preliminary report in February reflected the reports of the subcommittees, including the peer focus from the primary care group.
But Towle said that work, in which he participated, still just felt like “talk, talk, talk” with “very little evidence of action” to create structures that would actually build a system of peer support staff.
The tasks assigned to the Council by the legislature included “identifying obstacles to the full integration of mental health into a holistic health care system and identifying means of overcoming those barriers; helping to ensure the implementation of existing law to establish full integration within each member of the Council’s area of expertise; establishing commitments from non-state entities to adopt practices and implementation tools that further integration; and proposing legislation where current statute is either inadequate to achieve full integration or where it creates barriers to achieving the principles of integration.”
In a draft report, a pediatric subgroup made recommendations to incentivize serving child, youth, and family through pediatric-specific applications of the local integrated care model(s) and to increase integration of healthcare in Coordinated Services Planning.
A subgroup on integration of funding and alignment of performance measures recommended a formal needs assessment to assess parity by health insurance payers; the use of performance measures across health care providers and organizations, state government entities, and health insurance payers; and to pilot selected integration care models. The workforce subgroup recommended aligning with the work of the Health Equity Advisory Commission; identifying opportunities for shared or leveraged staffing; exploring best services at community mental health agencies or federally qualified health centers; and developing guiding principles.