Rachel Blanton
Chief Officer of Public Health Innovation, Fort Collins, CO 80525, USA
Correspondence to: rachel.harris.blanton@gmail.com
Additional information
- Ethical approval: N/a
- Consent: N/a
- Funding: No industry funding
- Conflicts of interest: N/a
- Author contribution: Rachel Blanton – Conceptualization, Writing – original draft, review and editing
- Guarantor: Rachel Blanton
- Provenance and peer-review:
Commissioned and externally peer-reviewed - Data availability statement: N/a
Keywords: Peer recovery support services, Rural
mental health, Substance use disorder, Stigma reduction, Workforce development.
Peer Review
Received: 15 October 2024
Revised: 3 December 2024
Accepted: 5 December 2024
Published: 17 December 2024
Abstract
Peer recovery support services (PRSS) have emerged as a promising model in addressing engagement in and access to treatment and recovery services related to mental health (MH) and substance use disorder (SUD) treatment. At the same time, rural America has continued to struggle with the MH/SUD burden, workforce, and access to care. Thus, PRSS present a unique opportunity to scale access to treatment and recovery services in rural communities. This article explores the current trends in PRSS broadly as well as more specific rural-based services through a social cognitive lens. Based on the current literature, PRSS remain a particularly promising strategy for behavioral health condition management and recovery in rural communities. However, rural communities should ensure a robust feasibility and planning process prior to introduction and take care in addressing barriers, such as stigma and payments. Finally, the research community should continue investing in robust research to identify the drivers of outcomes related to PRSS in the rural context.
Background
Rural counties in the United States face persistent challenges in accessing mental health (MH) and substance use disorder (SUD) treatment services while also experiencing a disproportionate burden of some behavioral health conditions.1 Over 65% of rural counties lack a psychiatrist, and residents of these communities face higher out-of-network rates for SUD treatment than their urban peers.2 Alarmingly, the suicide rate for rural adults over the age of 34 years is almost four times that of their urban counterparts.1 In addition, despite the increasing mortality rates related to SUD and overdose, rural communities have persistently lower access to SUD treatment, even among those with mandated treatment requirements due to justice system involvement.3 This has led the Centers for Disease Control to call for specific strategies to address suicide and related behavioral health issues in rural communities.4 In addition, a meta-analysis of rural vs. urban MH outcome studies found significantly higher rates of psychiatric emergencies in rural communities and consistently poorer MH indicators among rural communities.5 Researchers and policymakers have begun to call for solutions that address these disparities based on key gaps in care as well as differences in stigma related to behavioral health conditions.1 These have included expanding the non-psychiatric workforce and direct, in-person outreach to individual patients (Table 1).5
| Table 1: Number of states with SUD peer requirements by feature. | |
| SUD Requirements21 | |
| Types of Experience | Certifying Entities (#) |
| SUD personal recovery experience | 37 |
| Experience with SUD (dx) | 11 |
| Experience as a caregiver of someone with SUD (optional) | 8 |
| Recipient of services | 7 |
| Personal experience with abstinence recovery | 6 |
| Willing to share lived experience story with others | 6 |
| Personal lived experience with SUD challenges | 5 |
| No specific personal experience specified | 3 |
| Limitations on recent inpatient experience and/or incarceration | 2 |
An emerging intervention to address these needs is the utilization of an expanded peer recovery support service (PRSS) workforce. Peer support is a broad concept of social and/or emotional support from someone who has lived experience with MH and/or SUD challenges and/or diagnoses.6 Titles for PRSS can include peer recovery support specialists, peers, peer providers, peer specialists, certified peer specialists, recovery coaches, and peer mentors.7 While the more general concept of PRSS has been in practice in the United States for over 150 years, starting in the 18th century for MH concerns and in the 19th century for SUD, in recent years, PRSS have moved away from the model of mutual support to a more paraprofessional and client−dyad relationship.6,7 This has been termed a move from “mutually offered” services in which both parties provide support to each other through recovery to “offered by mutual agreement” in which one party provides support to the other by agreement (Table 2).6
| Table 2: Number of states with MH peer requirements by feature. | |
| MH Requirements21 | |
| Types of Experience | Certifying Entities (#) |
| MH personal recovery experience | 36 |
| Experience with MH (dx) | 15 |
| Recipient of services | 10 |
| Experience as a caregiver of someone with MH (optional) | 9 |
| Willing to share lived experience story with others | 8 |
| Personal lived experience with SUD challenges | 6 |
| Personal experience with abstinence recovery | 3 |
| No specific personal experience specified | 2 |
| Limitations on recent inpatient experience and/or incarceration | 1 |
PRSS can be staffed in a variety of settings including clinical or community with core skills, including active listening, facilitating groups, recovery planning, and storytelling.8 Services essentially encompass the key elements of acting as an ally, an honest confidant, a resource navigator, an advocate, and a model of hope in recovery.7 These can be performed by meeting someone in recovery for coffee, accompanying them to treatment appointments, being available for a text exchange or a phone call during a difficult time, and being a bridge to care in moments of crisis, representing a variety of types of support such as emotional, informational, and instrumental.9 Thus, the framework of PRSS is grounded in key practices of recovery orientation; relationship focus; person-centeredness; voluntary engagement; and trauma-informed services (Figure 1).8
Consistent research on the model is in its early stages. Identified benefits range from increased self-efficacy among participants to reduced cost of care.6 However, to date, research on the impact of PRSS on patient outcomes has shown small-to-moderate positive effects but has not been consistent in demonstrating these outcomes.10 Researchers have noted that these mixed results are likely the result of challenges with consistent methodological rigor in the study, particularly given the breadth of services and supports potentially offered through PRSS and supplemental support programs.6 Despite these results, the Substance Abuse and Mental Health Services Administration (SAMHSA) has deemed the current promising evidence sufficiently strong to recommend the utilization of PRSS.9 The result is the majority of states have their own certification process and available billing codes under Medicaid for services. Yet, there is great variation in the rates of reimbursement for services and the resulting access to/sustainability of PRSS state by state.11 In spite of the promising research results, the widespread implementation of PRSS programs faces multiple challenges. These include stigma against people with a history of SUD by those who would establish PRSS programs (system level); lack of training and role understanding among potential colleagues and supervisors within agencies (organization level); and poor reimbursement and potential return to use/history of arrests for PRSS staff (individual level).7 Thus, PRSS programs have not been universally adopted as an SUD/MH intervention in the United States (Figure 2).
Even with these implementation challenges, PRSS present a significant opportunity to expand access to recovery and treatment services in underserved rural communities.8 Given that the key barriers to care and support in rural communities include lack of professional staff and stigma, PRSS present an opportunity to extend the limited workforce into community settings and present a cultural responsiveness to concern regarding the stigma surrounding behavioral health.8 Studies have shown increased engagement in treatment and recovery activities with representative PRSS in a variety of settings ranging from those who have been recently incarcerated to protective service- involved families to those in emergency shelters.12–14 In fact, PRSS may be uniquely suited to addressing these challenges specific to the rural setting as rural residents are less likely to seek formal treatment for behavioral health conditions. Yet, engagement in treatment among rural residents with SUD/MH is increased while addressing behavioral health concerns in an informal and flexible setting.15 One of the original formal presentations of PRSS in a rural setting, the RECOVER Project based in remote New England, noted that many of the features that make rural behavioral health access most challenging also make PRSS a highly tenable solution. These include higher social isolation, resistance to formal treatment, and a need for community representative outreach.16 Finally, SAMHSA has pointed to rural PRSS as an emerging opportunity to enhance services in rural underserved areas.8 Thus, current research and recommendations should be explored in the context of rural implementation and scaling supports.
Key Considerations
As noted above, rural implementation settings require special considerations, given the distinct resource profiles, levels of cultural appropriateness, and health disparities. Therefore, the current literature regarding PRSS should be interpreted through the lens of rural community assets, limitations, and features of care and support for SUD and MH conditions.
Stigma
PRSS serve as a critical link between community members with SUD/MH and services and are ideally positioned to help reduce stigma in help-seeking behaviors.8 However, a persistent barrier to the effective implementation of PRSS in both general and professional settings is that of stigma against people with SUD/MH conditions.17 Compounding this in rural settings is the fact that stigma, particularly in the context of help-seeking, is elevated in rural communities.1 This can result in PRSS working in rural settings facing an intensified stigma threat based on the service community. Stigma reduction efforts for PRSS should occur at all levels, but one of the first targeted areas of focus can be with staff in agencies where PRSS are employed. Given that over one-third of PRSS professionals have reported microaggressions in their employment settings such as, “the doctor on the unit told other staff not to trust me or listen to me because I have my own diagnosis,” staff should be educated on the importance of PRSS in promoting positive outcomes and the very real physiology and burden of SUD/MH.17 This is particularly critical in relationships where there is a high power differential such as between PRSS and a clinician or PRSS and a probation officer.17 Not only is stigmatizing language against the PRSS staff in professional interactions deleterious to the confidence of that staff member, but the PRSS staff may have experienced stigma from these positions of power as a former or current consumer of treatment and recovery services. In addition, stigmatizing behaviors regarding people with SUD/MH can bleed over into care provision for the clients of PRSS programs. The current literature shows a strong connection between perceived stigma and poor treatment outcomes including reductions in treatment duration, treatment engagement, and increased poor health outcomes, such as drug use, overdose, and self-harm.18,19 As a result, given the potential burden of stigma in rural implementation sites, it is particularly critical to engage in a targeted stigma reduction approach. Training resources include testimonial videos, podcasts, literature reviews, and slide decks from agencies, such as SAMHSA.9,15,20
Workforce Training and Capabilities
The training and certification criteria for PRSS are based on core Centers for Medicaid and Medicare Services requirements but vary greatly by state and by the certifying body.21 In addition, while the majority of states certify both MH and SUD certifications, a select few only certify either MH or SUD. At the time of this publication, South Dakota, a largely rural state, is the only state without a program.21 The criteria for certification include some level of formal training (most typically around 40–46 hours) along with lived experience and some level of supervised work. Some trainings are in-person and some are virtual. Programs looking to implement PRSS should review the offered trainings and the budget/plan for travel stipends, given the greater distance to travel for rural residents. Other considerations include a review of the highest prevalence substance involved in SUD in the community, given the significant variation from rural to urban settings. Rural communities show lower rates of heroin use and higher rates of alcohol, methamphetamine, and opioid use as compared to urban sites.3 As a result, hiring should be based on representative experience with SUD and supplemental education based on best practices for PRSS related to that specific substance.
Critically, some requirements bar PRSS certification based on non-abstinence-based forms of recovery and treatment and/or inpatient services. This can limit the pool of PRSS candidates, particularly given that medication-assisted treatment (MAT) is evidence-based and typically the standard of care.8 In addition, many states include disqualifications for drug-related offenses, including driving under the influence and prostitution. Given the elevated likelihood of arrest for these charges for people with SUD, this can be a major limitation in the available workforce.21 This has led experts to suggest a move to more inclusive certification standards and policy shifts toward more consistent national training standards.7 Additional recommendations include specific training on health-care system navigation due to the complexity of care systems to address MH and SUD.22 However, in the interim of policy change, any agency or institution, whether rural or urban, should be aware of the local certification requirements for PRSS within their community.21
Team Training
Not only is training essential for the certification of PRSS staff, but it has also been recommended as a critical component for PRSS colleagues. While the aforementioned stigma regarding MH/SUD conditions can be a significant barrier to the implementation of PRSS in professional settings, misunderstanding regarding the role of PRSS can also be an equally destructive force in the program’s success.23 In fact, a lack of program leadership and supervision capacity has been identified as a major barrier to successful program implementation.24 This can be particularly impactful in rural settings where staff are less likely to have exposure to peer workforce and more likely on the whole to report stigmatizing attitudes. Thus, organizational readiness should be assessed prior to implementation and addressed through training and engagement focused on the value of PRSS in recovery, the professional role that PRSS occupy with full consideration of privacy and communication management, and the impact of services on patient/client well-being.8 Supervisors should be carefully selected to align with these values and formal training as available/required.23 Depending on the certifying body, supervisors may require certification as well.21 Opportunities to train members include those included in the discussion of stigma as well as certifying body supervision training materials.
Sites of Care
PRSS can be deployed in a variety of settings ranging from recovery centers to drug courts to clinical care sites.7 Recently, SAMHSA has even promoted the utilization of PRSS in virtual platforms as well.8 While this can be beneficial for access to care, as presented before, it does present issues with consistency in outcome data, given the variety of contexts for services.25 Studies reviewing effectiveness in rural communities consistently point to the benefit of community settings in promoting linkage to care.26 In these types of programs, PRSS staff can work across agencies and sectors to support clients where they are. For example, in a more community-based setting, PRSS staff can support clients through drug court services and go to MAT appointments with them. This is distinct from programs where PRSS are bound by agency jurisdiction (i.e., can only provide support to medical clinic patients or are assigned a caseload through a drug court). It should be noted that these types of community programs can be difficult to implement, given the complex resource-sharing and funding arrangements involved. However, they may be key to success in rural communities, especially given the lower levels of access to formal treatment services among rural sites as compared to urban sites.1 Thus, researchers from these studies recommend engaging cross-sector partnerships that include clinical services, first responders, law enforcement, faith groups, and local businesses.26
This is supported by the literature on PRSS in the broader context.10 Studies of specific sites of care in rural settings have largely focused on rural emergency departments (EDs) and have found enhanced impact for programs that include non-overdose encounters in eligible PRSS referrals.27 For example, someone may come into the ED with injuries related to a sprained ankle but screens positive for SUD or MH issues. A referral to PRSS would be appropriate and could result in linkage to formal treatment services. This points to a common theme in the reviews of PRSS programs across different types of rural sites: a wide net. Given the lower access to formal treatment and services and the comparatively reduced formal support-seeking behaviors in rural communities, it is essential to connect with people where they are, literally and in their identity, experiences, and values. From a logistics standpoint for PRSS programs, it also means reserving budget and resources for travel between sites in more highly dispersed rural communities.28 This promotes low-barrier access to care and addresses some of the key issues with resource navigation related to SUD/MH supports in rural communities, including treatment sites, stigma, care coverage, and provider availability. As a result, rural communities looking to implement PRSS should review opportunities to deploy staff throughout informal and formal care settings for people with SUD/MH conditions.
Special Populations
A consistent finding within the studies of PRSS is that personal identification with the provider of services can improve client engagement and outcomes.29 This is related not only to the experience of MH or SUD but also to personal characteristics, such as race, age, language, and community affiliation.28 However, this can be more challenging in rural communities where there is less population to draw from for PRSS staff and a lower total volume of encounters in the service area. For example, 1 to 2 PRSS may be necessary in the rural county as opposed to 8 to 10 in the urban county. Therefore, the total representative diversity capacity within the rural workforce is diminished. However, programs should explore local needs related to representation and underserved communities.30 This includes identifying whether or not programs will target outreach to communities, such as non-English-speaking residents, perinatal persons, Native American/tribal communities, and racial/ethnic minorities.8 Staffing of PRSS who are either from similar backgrounds or are trained in culturally appropriate services can support clients/patients in navigating MH/SUD through their experience. This can improve the program’s impact among underserved populations experiencing significant disparities.31
Program Financing and Reimbursement
PRSS program financing can be quite complicated involving grants, reimbursement, and drug court funds.7 In addition, rural communities may rely on a more blended funding structure, given the lower total volume of supported encounters and economies of scale to promote large care teams. This can make program financing and subsequent service sustainability a major challenge in any program, especially in rural communities.11 Agencies and/or collaboratives across communities looking to implement peer services should research and model both reimbursement rates and supplementary funding contributions prior to implementation. This is critical on a community-by-community basis, given the extreme variability in Medicaid encounter rates by state, ranging from $5.98 per 15-minute unit in South Carolina to $36.32 per 15-minute unit in Ohio, and the available local funds.30 Shared positions across sectors (public health, medical agencies, community MH organizations, and drug courts) could lessen the financial burden on any one agency and support not only a more wide-scale deployment of PRSS recommended in rural settings but also financial feasibility.26 Rural service sites should also explore opportunities to partner with state agencies including drug court funds and MH divisions to leverage block grants where available.11
Conclusions and Future Directions
PRSS represent a promising practice for SUD/MH treatment and recovery services, particularly within the context of rural communities where clinical care resources are diminished and burden can be elevated. However, there remain persistent barriers to implementation based on stigma, training, workforce, and reimbursement. Rural communities should conduct thorough feasibility assessments and planning and development activities before initiating the implementation of services to design programs that are effective and durable. This includes carefully selecting the site of services and promoting team-based training related to stigma and roles. At the same time, policymakers and researchers should engage more rural stakeholders and PRSS staff to develop solutions and research questions to address the realities of PRSS in the community.23 Payments and reimbursements in particular must be addressed to ensure the long-term viability of services. This will build the evidence base and practical strategies to reduce the burden of SUD/MH and promote engagement in clinical and community services.
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