Essential new roles for peers and service recipients in the whole-health era

Much attention currently is devoted to the dramatic changes that the Affordable Care Act (ACA) will bring to behavioral healthcare providers. The major ACA change agents are insurance expansion with parity and service reconfiguration due to integrated care. By contrast, virtually no attention is devoted to the equally dramatic changes that the ACA will bring to the roles of peers and service recipients. I would like to explore these latter changes here.

How the ACA will Produce Change. As a framework for this discussion, several features of the ACA need to be described. The ACA promotes whole health--considering all aspects of a person's health together--through person-centered care--considering the person to be the "true north" of their own care. In turn, person-centered care requires shared decision-making between a person and their provider, and shared responsibility both for one’s care and one’s health.

These important goals can be achieved through integrated care systems that combine primary care and behavioral healthcare. Such service systems may be organized either through medical homes operated by primary care entities or health homes operated by behavioral health entities. It is in the incubator of these new service contexts that we need to implement the new roles for peers and service recipients.

In behavioral health, either for mental health or substance use services, the traditional peer role has been to engage and support a person with a behavioral health condition while that person receives behavioral health services. Frequently, this has occurred in public sector specialty service systems, particularly for persons with very severe conditions. Over the past decade, this effort has served to solidify the definition and range of actions of a peer supporter. The result has been funding of peer support services by the majority of states through the Medicaid Program.

New Peer Role Beyond Behavioral Healthcare. With the implementation of the ACA and integrated care systems, the role of peer supporter has the potential to undergo very significant expansion. Most dramatically, an opportunity will exist for a peer to serve persons who have no behavioral health conditions. Some will be persons with conditions ranging from simple medical ailments to diabetes or heart disease. Others will be people without any disease condition who are seeking to facilitate their own wellness through prevention and promotion services. Perhaps almost as dramatic, an opportunity will exist for peers to help improve wellness interventions for persons who do have behavioral health conditions, especially in a whole-health oriented integrated care system. 

Emerging Service Recipient Role. Similarly, the ACA will provide an opportunity for all service recipients to take on a new role by seizing the initiative to help define and shape their own care. Very clearly, key concepts, such as person-centered care, shared decision-making, and shared responsibility, will be integral to these revolutionary changes in the service recipient role. One simply needs to imagine a person with a severe heart condition taking on this new role to actually see how revolutionary these changes could potentially become.

What makes all of this very exciting is that the genesis of these new roles comes directly from modern behavioral healthcare, particularly its consumer movement. Because this is the case, we will have a once-in-ever opportunity to shape both of these new roles as the ACA is implemented. We must take this opportunity very seriously.

We will need to prepare for these landmark changes. Some of the actions that deserve our attention right now include:

• Defining the new roles clearly. We will need clear specification of the characteristics and actions that comprise the new peer role and the new service recipient role.
• Developing user-friendly labels. Because we are describing new roles, it is essential that they not be confused with current roles. As just an example, for peers, we probably should not be talking about a “peer supporter” but rather a “health supporter”.  Similarly, for service recipients, rather than an “engaged patient” or “service recipient”, we should be talking about a “health seeker”. Mind you, these simply are examples. Collectively, our field needs to evolve good, effective terms.
• Training providers, peers, and service recipients to advocate for the new roles. Once the new concepts are developed, it will be imperative that our own providers, peers, and service recipients understand the new roles and begin employing them.
• Exporting the new roles to primary care providers and medical service recipients. To reach their full potential, these new roles must be adopted by our primary care colleagues and medical service recipients. This transformation only can occur as we begin to work more closely together in the integrated care systems that are beginning to emerge.

These developments offer wonderful, progressive opportunities, as we address the challengies they bring. I am very confident that much ferment will occur in both of these new roles during 2014, and equally optimistic about the outcomes.