Faced with problems, persistent people enable a peer solution

There are a lot of stories going around these days, and many of them aren’t very good. Thinking you may be up for a good story, I have one to tell you. Refreshing huh? I’m not sure how to classify this story. It could be a drama, or comedy, or a mystery, but I think it really falls in the category of action/adventure. You can decide as you read along.

I’ll set the stage for you with a little background. The story takes place in Phoenix, Arizona, but actually it could happen just about anywhere if someone were willing to make it happen.

The story begins a few years ago in July of 2010 when Arizona, facing some severe budget reductions, eliminated state funding for general mental health and substance abuse services for non-Medicaid-eligible children and adults, a group designated as “non-Title XIX.” The only positive here is that the state was still able to fund these services to those individuals who have serious mental illnesses (SMI).

However, the following year, 2011, brought even tougher challenges so the state is forced to cut even deeper, this time reducing funding for the non-Medicaid SMI population (there were about 14,000 statewide at the time) by $36 million, leaving only $61 million to serve this need. Because the state prioritizes the most vital services that support living in the community — starting with medications, crisis services, and some supported housing — other services including case management, counseling, residential and inpatient services, peer support, and more are eliminated. (I know this doesn’t sound like a very good story yet, but hold on. From here on it just keeps getting better.)

In May 2010, a special election is held: a public referendum to create a temporary 1 percent sales tax increase to help with the budget crisis. It passes! One-third of these temporary tax funds are designated for health and human services and two-thirds for education funding.

For fiscal year 2013 (July 1, 2012-June 30, 2013), Arizona’s Governor, Jan Brewer, successfully restores $36 million to behavioral health services. Between the sales tax, other state revenue, and permanent reductions in other areas of the state budget, the funds are secured and the Governor prioritizes restorations to behavioral health. You can read more about this at https://www.azdhs.gov/bhs/non-title19.htm. In particular, see the FY13 Budget: Stakeholder Letter from the ADHS/DBHS Deputy Director.

While this alone sounds like a pretty happy ending, we aren’t to the end of the story yet. What happens next? The Governor and the department decide that they didn’t want just to restore what was lost; they want to do creative, innovative things with the funds, and they wanted a bigger bang for their buck. Implicit in their plan was recognition of the value of peer support and the desire to expand the good work peers are already doing in Arizona.

To keep this good story from being too long, let me focus on just one part of the rest of it: how these state decisions impacted the Regional Behavioral Health Authority (RBHA) known as Cenpatico. Let me set the scene: the region of Arizona served by Cenpatico is geographically large but not highly populated. There are long stretches of desert between towns like Yuma, Sierra Vista, Benson, Safford, and Casa Grande. As to the key characters, Terry Stevens is the President and CEO and Jay Grey is COO at Cenpatico. The other major player in this story is Kathy Bashor, Arizona DBHS’ determined and feisty manager of individual and family services. Kathy comes by her tenacity honestly. It’s a byproduct of surviving hard-won battles with mental illness. While she had some good service experiences along the way, she also suffered mistreatment multiple times from service providers who didn’t take the time to understand what she was going through. She rose from this battle on bent and battered wings, but was able to stand her ground when it comes to insisting on recovery services and peer inclusion.

This phase of the story started with a lot of tension — not unusual when a feisty state staffer comes into contact with two conscientious Regional Directors. After a few rounds with Kathy, Terry and Jay realize that Kathy is making some good points, so they begin to listen to her from a viewing point, instead of a point of view.  From their new viewing point they see that they have been focused on strengthening recovery practices by adding peers to their intake providers. In contrast, Kathy is focused on strengthening recovery practices by adding resources and additional peers to peer and family run programs. Two different approaches, both are good ones. With a little planning these two approaches can create synergistic win/win outcomes. Kathy, Jay and Terry decided to bring in an objective party to help discover ways of reaching their mutual objectives so they asked the Recovery Opportunity Center (ROC) to help with the process.

The ROC listened, translated, added some ideas, offered some training, and flashed the light on the two great peer run programs in the region. Both programs are unique and have a lot to offer people who receive services from the intake agencies. They are well positioned to offer advocacy and mutuality without the encumbrances that often limit agencies that are licensed to provide clinical services. They are not boxed in by rigid regulations that limit their ability to be real.

The challenge now for Jay and Terry is positioning the peer and family run programs to play a stronger role in the overall service delivery process in partnership with the intake agencies. Kathy strongly encourages Jay and Terry to use a substantial portion of the newly restored tax allocation for peer services. Yes, she wants to see more peers integrated into the intake agencies, but she is focused on strengthening peer operated programs since they are at a distinct disadvantage (I’ll explain this pretty soon). Terry and Jay agree with Kathy. They encourage their intake agencies to add even more peers to their workforce and they invest in strengthening the two peer-operated programs and also add a family operated program. Once again, this could be another place to end the story on a high note, but there’s more.

Now we come to the part of the story where, with a happy ending in sight, one last plot twist comes into play, an ugly problem that threatens the story with a very unhappy ending.

The problem is this: Peer-operated programs cannot bill for the services they provide unless they get referrals from the intake agencies — the distinct disadvantage I told you about earlier. And, since the intake agencies invested in building up their own peer workforce, they aren’t focused on making referrals. The other force at play is that all providers, both mainstream and peer, had only a short time to provide their services and bill for them.

These two issues combined to create a real crunch, a need to utilize the available funds — by delivering and billing services — responsibly and quickly. In a number of cases, it pushed providers toward a self-centric mentality as each strove to meet their own contractual obligations. Under the circumstances, this attitude posed a real threat to peer operated programs. Ultimately peer-operated programs could be starved out if they could not get the cooperation and referrals that they needed to do business. This brought up some tough questions:

• What is the role of peer-operated services?
• How are peer-operated services different from peer services that are integrated into mainstream service organizations?
• Should we retain peer-operated services or have they run their course?

You can just imagine what Kathy Bashor had to say about the threat of losing peer-operated services: “Absolutely not!” Given the respect Terry and Jay now have for Kathy, they said exactly the same thing. “It would be a travesty if we lose our peer-run services,” says Jay. “They bring a special approach that is not replicated in clinical settings, even when there are peers working there.”

Worried? Don’t be. They aren’t going to let us down. Kathy, Terry, and Jay put their heads together and came up with some solutions and started rolling them out:

• They decided to track referrals from intake agencies to peer-run organizations. They knew this would help the intake agencies see the big picture more clearly and give them a way to measure their progress in this area.
• Another idea that emerged, expressed by Jay and others at nearly the same time, was to ask the peer-operated programs to make the first contact with those people who are just coming into the system. This approach gives the peer programs a chance to connect with people at the outset, explain their organization’s services, share ideas, and tell a personal story about individual recovery.  
• Then, inspired by Kathy’s strong leadership Jay and Terry proposed that a minimum of 50% of behavioral health services offered by all providers should be delivered via peer support. Kathy said that with this type of commitment, “Cenpatico will be leading the way for the state in how to transform our behavioral health service system.”

If you are looking for some take-aways from this story, here’s a list to get you started:

• Listen hardest to the people who seem to be on a different page than the one you’re on. Listen from a viewing point instead of a point of view. You just may find that you have more in common with them than you first thought. Together, you could make some amazing things happen; things that teach important lessons to the rest of us.
• Take care of your peer programs. They can be one of your most valuable assets when it comes to services that support community interdependence and recovery.
• Ask your peer-operated programs to do meaningful work. Ask them to create expectations for recovery starting the minute that new people come in seeking help. Peers are really good at doing this type of work.
• Hire peers to work in all of your programs. You’re going to need their help, especially with the anticipated workforce shortages that loom on the horizon.

Lori Ashcraft, Ph.D. is executive director of the Recovery Opportunity Center at Recovery Innovations in Phoenix. She can be reached at lori.ashcraft@recoveryopportunity.com.