Promoting Health and Wellness Through Peer-Delivered Services: Three Innovative State Examples

Promoting Health and Wellness Through Peer-Delivered Services:

Three Innovative State Examples

Margaret Swarbrick

Rutgers University

Timothy P. Tunner and David W. Miller

National Association of State Mental Health Program Directors,

Alexandria, Virginia

Pamela Werner

Michigan Department of Community Health, Lansing, Michigan

Wendy White Tiegreen

State of Georgia, Atlanta, Georgia

Objective: This article provides examples of the development, implementation, and funding of peer-

delivered health and wellness services in three states. Health and wellness services are critical to

addressing the health disparities facing people living with mental health and substance use disorders

served by the public behavioral health care system. Methods: Information was compiled from the

authors’ experiences as champions in three states (Georgia, Michigan, and New Jersey) and the National

Association of State Mental Health Program Directors, as well as documents from and discussions with

local state and national sources. Results: Key issues for the implementation and expansion of peer-

delivered health and wellness services include defining the model to be disseminated, providing training

to prepare the peer workforce, accessing funding for implementation, and establishing clear expectations

to sustain the services and maintain quality over time. Conclusions and Implications for Practice:

Peer-delivered health and wellness services can help address the health disparities facing people who are

living with mental health and substance use disorders through a variety of innovative models tailored to

local needs and circumstances.

Keywords: peer support, whole health, wellness, mental health, recovery

Nearly a decade has passed since the release of the landmark

technical report documenting the now well-known findings that

people with serious mental illnesses die, on average, 25 years

earlier than people in the general population. The evidence that

these deaths are the result of preventable causes that are either

concomitant with the mental illnesses or side effects of treatment

drugs served to mobilize many stakeholders to proactively address

this unacceptable health concern. Many people in recovery, care

providers, and family members were acutely aware of these phys-

ical health concerns, such as obesity and heart disease, and their

impact on health, wellness, life span, and quality of life. However,

they did not seem to know how to provide or obtain encourage-

ment, access support, set goals for and pursue healthy lifestyles, or

access needed treatments. To address this gap, the peer community

has adopted, modified, developed, and implemented services to

support people in recovery in their efforts to create and sustain a

healthy lifestyle centered on wellness.

The passage of the Affordable Care Act (2010), with its heavy

focus on prevention, created many opportunities for developing

and funding peer-delivered whole health and wellness services.

Many states have already initiated successful programs. This arti-

cle highlights successes in three states and provides examples and

ideas that others can draw upon to start, expand, or improve

peer-delivered health and wellness services in their own jurisdic-

tions.

Peer-Delivered Health and Wellness Services

The peer movement has a 40-year history of designing and

offering alternative supports for and by persons who have personal

experiences with the behavioral health system. Peer leaders were

quick to embrace the notion of peer-delivered health and wellness

services, a generic term encompassing a variety of peer-delivered

models that have become important components of the most ef-

fective recovery-oriented service delivery systems. Peer-delivered

health and wellness services are important complements for an

integrated care team model working to help a system merge the

concepts of recovery with physical well-being and overall recov-

ery (Swarbrick, 2013). Health and wellness services have, in many

states, become a subspecialty of peer support, with the develop-

ment of programs to train and employ peer workers to provide

these services in order to enhance quality of life and extend life

span. An effort to support and expand these services was the focus

Margaret Swarbrick, Collaborative Support Programs of New Jersey,

Rutgers University; Timothy P. Tunner and David W. Miller, National

Association of State Mental Health Program Directors, Alexandria, Vir-

ginia; Pamela Werner, Office of Recovery Oriented System of Care,

Michigan Department of Community Health, Lansing, Michigan; Wendy

White Tiegreen, Department of Behavioral Health & Developmental Dis-

abilities, State of Georgia, Atlanta, Georgia.

Correspondence concerning this article should be addressed to Margaret

Swarbrick, Rutgers University, Piscataway, New Jersey 08854. E-mail:

[email protected] or [email protected]

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2016, Vol. 39, No. 3, 204 –210 1095-158X/16/$12.00 http://dx.doi.org/10.1037/prj0000205

204

of the 2011 Pillars of Peer Support Services Summit at the Carter

Center in Atlanta, Georgia (Daniels et al., 2012).

Peer-delivered health and wellness services is an umbrella term

used here to describe interventions and program models that in-

volve a peer worker with specialized training who may have

previously completed a certification program as a peer specialist.

The specialized provider role involves assisting an individual with

accessing needed care and prevention services, helping set per-

sonal health goals to promote recovery and a wellness lifestyle,

and providing support for adopting and sustaining healthy habits

and behaviors in order to prevent disease onset and/or lessen the

impact of existing chronic health conditions (Swarbrick, 2013). In

keeping with the philosophy and principles of peer support, the

individual served is seen as the director of his or her health. Health

engagement or activation and health/illness self-management are

key objectives of peer-delivered health and wellness services and

are accomplished by facilitating health dialogues; exploring the

many options for health and wellness engagement; supporting the

individual in overcoming fears and anxiety related to engaging

with health care providers and procedures; promoting engagement

with health practitioners, including, at a minimum, participating in

an annual physical; assisting the individual in finding a compatible

primary physician who is trusted; and providing support for en-

gagement in other health and wellness activities as needed. By

helping individuals take charge of their own health via adopting

simple and practical strategies for making positive changes in their

health behaviors, peer-delivered health and wellness services pro-

vide an avenue for reversing the disturbing trend toward poor

health, shortened life spans, and poor quality of life.

Goldberg and colleagues (2013) conducted a controlled study in-

volving peer participation in health promotion for persons with seri-

ous mental illnesses. They created Living Well, which was a modified

version of Lorig’s Chronic Disease Self-Management Program

(Lorig, 1999). Living Well participants demonstrated improve-

ments in self-efficacy, patient activation, illness self-management,

overall well-being, and general health functioning outcomes.

Another program, called the Health and Recovery Program

(HARP), is a manualized self-management intervention delivered

by mental health peer providers to help participants become more

effective managers of their chronic illnesses and improve their

health-related quality of life (Druss et al., 2010). Physical health-

related quality of life, physical activity, and medication adherence

improvements have all been shown to be among the positive

outcomes in implementing the HARP program (Druss et al., 2010).

Peer wellness coaching has also been used to help individuals with

serious mental illnesses who are obese or overweight to decrease

their overall weight. In a small 6-month pilot study of 10 individ-

uals, over half lost a mean weight of 2.7 kg, showing that peer

coaching may be an effective intervention to help individuals with

serious mental illnesses to lose weight (Aschbrenner et al., 2015).

On August 15, 2007, a letter was released by the Centers for

Medicare & Medicaid Services (CMS), the single largest payer for

behavioral health services in the United States (Smith, 2007),

identifying mental health peer support services as an evidence-

based mental health model of care. This opened the doors for many

states across the country to modify state Medicaid mechanisms to

add peer support services among those reimbursed by Medicaid.

Also in 2007, the Substance Abuse and Mental Health Services

Administration’s (SAMHSA’s) Center for Mental Health Services

created the Transformation Transfer Initiative (TTI) to assist and

give states the opportunity to increase efforts in transforming their

state behavioral health delivery systems to be more consumer and

family driven and to break down the silos of state government that

impede recovery and resiliency. It began as a demonstration proj-

ect that sought to provide— on a competitive basis—flexible “tip-

ping point” resources for innovative state projects and has subse-

quently shown clear evidence of success, sustainability, and

positive impact of these projects on state behavioral health sys-

tems. The vast majority of the 80 TTI project have been centered

on developing, growing, and sustaining peer support programs.

Three of the original TTI projects—Georgia, Michigan, and New

Jersey—infused whole health and wellness into peer specialist

training and created peer-delivered health and wellness services to

combat the average 25-year premature death expectancy of con-

sumers served in the public behavioral health care sector (U.S.

Department of Health and Human Services, Substance Abuse and

Mental Health Services Administration, Center for Mental Health

Services, 2014).

In 2007, there were 14 states using Medicaid to fund peer

support services, and at the time of this writing, 37 states and the

District of Columbia use Medicaid to fund peer support services,

although not all of these include specialized peer-delivered health

and wellness services.

Examples of Peer-Delivered Health and

Wellness Services

As might be expected, implementation of peer-delivered health

and wellness services has varied significantly, with different

startup processes, interventions and program models, peer provider

training programs, and funding for sustainability. Successful peer-

delivered health and wellness services efforts in three states are

described here and identify key elements for successful implemen-

tation. These three states, Georgia, New Jersey, and Michigan,

were selected as examples because they (a) were members of the

inaugural TTI cycle, and they all have shown great success; (b)

have led the way on whole health peer support by adopting

curricula that make whole health a tenet in their peer support

(specialist) trainings; (c) represent geographic and population di-

versity; (d)have been models for and given technical assistance to

many other states; and (e) have created three separate paths and

curricula that other states/territories could adopt/adapt.

Georgia

Startup process. The Georgia Department of Behavioral

Health and Developmental Disabilities (DBHDD) was the first to

receive Medicaid fee-for-service reimbursement for peer support

in 1999. Since that time, the state has created a workforce of more

than 1,400 certified peer specialists (CPSs) who have infused

recovery principles into the community behavioral health system.

Beginning in 2006, Georgia began to target health improvement by

introducing wellness interventions into its peer support services

(Agency for Healthcare Research and Quality, 2014). In 2009,

Georgia received a TTI grant to create pilot programs for a service

called Peer Support Whole Health and Resiliency (PSWHR) and,

through this grant, demonstrated the positive impact that CPSs can

have when working with individuals on promoting health engage-

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PROMOTING HEALTH AND WELLNESS

ment, developing motivation, setting goals, and achieving positive

outcomes (Druss et al., 2010).

The Georgia Mental Health Consumer Network (GMHCN), a

peer-run statewide nonprofit organization, has been a partner

throughout the development of this policy and has complemented

this work using grants providing opportunities for people in re-

covery to learn about whole health through their annual consumer

conferences. Since 2006, the consumer conference has had key-

note speakers and learning tracks to promote healthy lifestyles and

wellness. GMHCN also has received consumer networking grants

that have supported PSWHR.

Interventions and program model. PSWHR is based on a

foundation of self-directed, strength-based recovery and the prin-

ciples and practices of peer support. The process includes person-

centered planning that focuses on a person’s strengths, interests,

and natural supports, while assisting individuals to choose and

create new healthy lifestyle habits and disciplines. PSWHR draws

from two evidence-based programs (Fricks & Jenkins-Tucker,

2014). These include the relaxation response (Benson & Klipper,

2000), developed at the Benson-Henry Institute for Mind Body

Medicine based at Massachusetts General Hospital, and HARP,

which was adapted from the Chronic Disease Self-Management

Program (CDSMP) based at Stanford University (Druss et al.,

2010). With the support of the SAMHSA Health Resource and

Services Administration (HRSA) Center for Integrated Health

Solutions, this training has evolved into Whole Health Action

Management (WHAM; Fricks, Powell, & Swarbrick, 2012), a

10-session program with a participant manual and leader guide

available from SAMHSA. The PSWHR pilot led the Georgia state

mental health authority to create a statewide service named Peer

Support Whole Health and Wellness (Georgia Department of

Behavioral Health and Developmental Disabilities, 2015), which is

provided by trained CPSs who assist individuals by helping set

personal expectations, introducing health objectives as an ap-

proach to accomplishing overall life goals, helping identify per-

sonal and meaningful motivations, and promoting health/wellness

self-management. Individuals served are encouraged to be the

directors of their health through identifying incremental, measur-

able, and personal steps and objectives that make sense to the

person and can serve as benchmarks for future success.

The overarching goals of PSWHR and WHAM are promoting

health engagement and health self-management, as well as access

to health supports. These goals are accomplished by supporting the

individual’s goals and action steps; providing materials that assist

in structuring the individual’s path to prevention, health care, and

wellness; partnering with the person to navigate the health care

system; assisting the person in developing his or her own natural

support network to promote personal wellness goals; creating

solutions with the person to overcome barriers that prevent health

care engagement; and linking the individual with other health and

wellness resources.

In Georgia, CPSs are funded to provide this service in traditional

community behavioral health service delivery sites, in the com-

munity (such as in the person’s home and/or work site), and in

other health settings such as federally qualified health centers

(FQHCs), emergency rooms, and primary health centers. This

multisite model allows CPSs to strengthen practices within tradi-

tional public behavioral health systems, build bridges to the gen-

eral health sector, operate within general health settings to increase

behavioral health competency, and assist in the accomplishment of

critical health engagement goals.

The Georgia model also builds in access to registered nurses for

CPSs to consult with on delivering health support, especially in the

case of complex health conditions that may require technical

support to the CPSs in supporting a person’s health goals. This

nurse may also provide whole health services when rendering

support to the served individual, at the request of the CPS provid-

ing PSWHW.

Peer provider training. Initially, and in the absence of a

nationally standardized training curriculum for peer-supported

health and wellness services, the PSWHR training was developed

in collaboration with the GMHCN as part of a TTI grant funded by

SAMHSA and administered by the National Association of State

Mental Health Program Directors (NASMHPD). This training was

provided to a small subset of CPSs who worked to promote whole

health along with offering traditional peer support services. Once

Georgia decided to move the PSWHW from a pilot to a statewide

model, the state selected WHAM to further establish a quality

standard for its CPS workforce. Georgia is currently using the

WHAM curriculum and training that promotes outcomes of inte-

grated health self-management and preventive resiliency. This

curriculum promotes CPS whole health competencies, which are

then utilized in the delivery of the PSWHW service.

Funding for sustainability. In June 2012, CMS approved

Georgia as the first state to have Medicaid-recognized peer whole

health (PWH) services provided by CPSs. As a part of this Med-

icaid design, peer workers in Georgia must have additional training

(SAMHSA HRSA Center for Integrated Health Solutions, 2012)

beyond becoming certified as a peer specialist to be able to provide

this specialized type of peer support. Since implementation, ap-

proximately 400 CPSs have added this specialized training to their

competencies.

New Jersey

Startup process. Faculty in the Rutgers School of Health

Related Professions and peers at Collaborative Support Programs

of New Jersey worked together to create a new workforce role—

peer wellness coach (PWC; Swarbrick, Murphy, Zechner, Spag-

nolo, & Gill, 2011). The initial PWC training, created in 2009, was

designed to prepare the peer workforce to address health and

wellness needs from a self-management perspective. The curricu-

lum was based on a strength-based eight-dimensional wellness

model (Swarbrick, 2006, 2010) and core competencies defined

through focus groups with people in recovery, family supporters,

and professionals.

Interventions and program models. In New Jersey, peer

wellness coaching is an emerging practice based on the wellness

model developed to address physical comorbidities. PWCs work

within the context of existing services such as supportive housing,

residential intensive support, and community wellness centers.

PWCs are qualified by the New Jersey licensed Integrated Care

Centers to provide integrated behavioral health and primary care

services.

A key task of the PWC is to help a person in recovery explore

eight wellness dimensions, which leads each individual to better

understand his or her own experiences, motives, and needs. There

is a specific focus on physical wellness, since that sometimes

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SWARBRICK, TUNNER, MILLER, WERNER, AND TIEGREEN

represents a challenge, including addressing low levels of physical

activity (a sedentary lifestyle); limited access to medical screen-

ings; poor management of medical conditions; inadequate nutri-

tion, low knowledge of a healthy diet, and a need for education on

glucose monitoring; oral hygiene and dental health practices; sleep

and rest; reduction or elimination of tobacco use and other addic-

tive substances; and prevention or management of HIV/AIDS

(Swarbrick et al., 2011). In the PWC model, peers apply the

principles and processes of coaching, effective communication

skills, and motivational enhancement strategies to help individuals

achieve the goal of a healthy lifestyle. Peer workers are taught to

collaborate and act as coaches, helping to guide people toward

successful and long-lasting behavioral changes (Swarbrick,

Hutchinson, & Gill, 2008). PWCs provide ongoing individualized

support and reinforcement by helping the people they serve with

setting and achieving their goals. The PWC helps each participant

find personal solutions by asking questions that promote insight

into the participant’s situation and guide him or her toward suc-

cessful and durable behavioral change (Swarbrick et al., 2011).

PWCs are trained and employed to promote health and wellness

through approaches based on empowerment, self-direction, and

mutual relationships. In this way, PWCs can intervene in areas

where there are modifiable risk factors, such as diet and exercise,

and can support better access to primary care. The PWC generally

helps the participant focus on physical wellness domains that can

help contribute to overall balance and health, addressing priority

areas that the person identifies as important. A person with a

co-occurring medical condition, for example, may be assisted by

his or her PWC to address high-risk behaviors and health risk

factors such as smoking, poor medical self-management, infre-

quent use of primary care, inadequate diet, and infrequent exercise

(Swarbrick et al., 2011).

Peer provider training. The PWC training, initially offered

through Rutgers University for six academic college credits, was

updated and refined in 2014 based on the evaluation of implemen-

tation efforts throughout New Jersey and other states. The training

now leads to an academic Certificate in Wellness Coaching for

Physical Mental and Addictive Illnesses offered by the Rutgers

School of Health Related Professions. The certificate requires nine

academic credits over two semesters, and graduates can apply

those credits to associate’s or bachelor’s degree programs offered

by Rutgers University within the School of Health Related Pro-

fessions, or they can transfer the credits into other academic

programs.

Funding for sustainability. The peer wellness coaching ser-

vice is billable through the New Jersey Community Support Ser-

vices supportive housing regulations. Mental health services in

New Jersey are funded through agency contracts, rather than

through fee-for-service, so the peer-delivered health and wellness

services do not add an expense or income stream but instead are a

component of how services are designed. Although initially de-

veloped as a peer-provided service, wellness coaching is being

adapted to train nonpeer service providers, who then incorporate

wellness coaching into their roles and, as desired by people using

services, include wellness goals and plans in the larger service

planning process. The PWC training also has been adapted to

address different job roles, including the peer workforce (Brice,

Swarbrick, & Gill, 2014), and addressing the needs of older adults

and youth. This model of incorporating health and wellness into

existing services is being adopted in other states by government

authorities (Missouri, Oklahoma), the City University of New

York (Nelson & Shockley, 2013), the New York Peer Bridger

training, and through managed care (Pennsylvania). PWC training

also has been provided for integrated health projects in Tennessee

and Rhode Island.

Michigan

Startup process. Michigan has a rich history of supporting

the role of certified peer support specialists (CPSSs) in providing

Medicaid-reimbursable services that include health, wellness, self-

management, and the integration of behavioral health and primary

care. CPSS requirements listed in the state Medicaid provider

manual have included wellness activities as a covered service since

2006. CMS approved reimbursement for services provided by

CPSSs in April 2006 under Section 1915 (b)(3) of the Social

Security Act, which allows a state to make available services that

are in addition to the Medicaid state plan services. Peer-delivered

services provided under the Medicaid waiver are based on the

medical necessity criteria of community inclusion and participa-

tion, independence, and productivity.

In 2009, and again in 2012, Michigan received a TTI grant from

SAMHSA and NASMHPD.

Funding was used to provide a foun-

dation for CPSSs to gain skills and training in a variety of whole

health initiatives. In 2009, several CPSSs were employed in five

community mental health centers to implement health, wellness,

and prevention activities that included leading classes such as

Wellness Recovery Action Planning (WRAP; Copeland, 2002),

smoking cessation, and the evidence-based CDSMP (Lorig, Ritter,

Pifer, & Werner, 2014), which also influenced the Georgia curric-

ulum.

Interventions and program models. The Michigan Mental

Health Code requires that each individual plan of service be

completed using a person-centered planning process. This mandate

supports individuals in identifying self-management goals and

developing individualized plans to address health and wellness. In

addition, a contract requirement mandates that the state’s 10 re-

gional Prepaid Inpatient Health Plans must offer arrangements to

support self-determination when requested by an individual. Indi-

viduals have exercised choices to hire wellness coaches, purchase

fitness memberships, and attend community classes using their

individual budgets.

In the Michigan Medicaid manual,

a detailed provider descrip-

tion includes a variety of peer duties, many of which emphasize

health, wellness, and prevention activities. The list of covered

services outlines the essential job functions of peers across the

state. The explicit language for integrated behavioral health and

primary care includes developing health and wellness plans; de-

veloping, implementing, and providing health and wellness classes

to address preventable risk factors for medical conditions; and

integrating physical and mental health care. Additional covered

CPSS services that enhance and complement health and wellness

include providing vocational and housing assistance, assistance

The Michigan program is described at https://innovations.ahrq.gov/profiles/

peer-specialists-federally-qualified-health-centers-enhance-access-behavioral-and-

physical%20#diw

http://www.michigan.gov/mdch/0,1607,7-132--87572--,00.html

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207

PROMOTING HEALTH AND WELLNESS

and facilitation of the person-centered planning process, and de-

veloping advance directives.

A new and emerging model began in 2012 with the second

round of TTI funding, which began placing two full-time and two

part-time CPSSs in all FQHCs. These peers work with medical

practitioners, physician assistants, doctors, midwives, nurses, and

diabetes educators to assist individuals who are there for a physical

health concern but also have a mental health and/or substance use

disorder. The goal is to support people in self-managing their

chronic conditions by providing them with health and wellness

classes, as well as support in navigating complex health systems to

improve their quality of life. Activities associated with navigation

include help with accessing such community resources as housing,

employment, gym memberships, and support group meetings. The

work that the CPSSs provide in the clinics has been supported and

recognized by medical staff as an enhancement to the medical

services that are routinely provided. Family practice physicians

have made referrals to the smoking cessation groups and provided

information on the peer-to-peer model.

Peer provider training. The initial core training curriculum

for peer-delivered health and wellness services in Michigan in-

cludes health and wellness information and mindfulness exercises.

In addition, state requirements for the enhanced training provide a

significant amount of instruction devoted to SAMHSA wellness

initiatives, self-management activities for preventable risk factors,

and tobacco recovery. Continuing education activities related to

wellness include WRAP, WHAM, CDSMP, and motivational in-

terviewing. A large initiative was implemented as part of the

Michigan TTI grant to train CPSSs in leading CDSMP classes. In

addition, 20 peer specialists were certified as master-level CDSMP

trainers, which increased the state’s capacity to train additional

leaders to facilitate classes. In approximately 1 year, over 180

CPSSs were trained to run 6-week classes, with positive outcomes

(Lorig et al., 2014).

Funding for sustainability. The Michigan Primary Care

Association continues to be a strong partner in employing

CPSSs on a much larger scale in FQHCs. Discussions on

capturing peer services at the FQHCs with a designated encoun-

ter code have been ongoing. Currently, individuals and advo-

cates have met with the state Medicaid office on providing

reimbursement for community health workers (CHWs). Several

state-level grants have funded positions, and local community

health centers are seeking additional opportunities. Job duties

and professional responsibilities of CPSSs allow them to be

recognized as CHWs, expanding the job opportunities for CPSS

in integrated care settings. Discussions with the Michigan As-

sociation of Community Health Workers are under way to

create a train-the-trainer initiative, with CPSSs serving as train-

ers for certification of CHWs, which will expand the opportu-

nities for CPSSs to be employed in dual roles.

Lessons Learned

Peers are uniquely qualified as supports for health and well-

ness for other peers. As the peer specialist role in supporting

mental health becomes more established (and accepted) in a

state, it then may be easier to add whole health and wellness

services after the initial value of peer support is shown. The

details of how peer-delivered health and wellness services are

designed and implemented in the behavioral health system will

necessarily vary across states, given differences in local needs

or persons served, service requirements, and funding mecha-

nisms. Providing specialized services by including peer well-

ness coaches on service delivery teams is just one way to

structure services. Specially trained peers can serve as bridgers

or navigators between behavioral health and medical/dental

service systems, or they can be embedded within traditional

health models, such as health homes, FQHCs, medical hospi-

tals, and emergency rooms. Alternatively, peers may be just one

of the service providers focused on health and wellness. Thus,

the focus on health and wellness becomes part of the existing

array of services, such as through incorporating health goals

into all behavioral health service plans and placing health and

wellness in the forefront of services, rather than as ancillary

work with a designated specialist. The service-wide focus on

health and wellness, although intuitively appealing given the

current push toward integrated care, requires a significant in-

vestment in training for all service providers, which may make

this approach prohibitively expensive for some mental health

authorities.

Based on the experiences in the three states described here,

public mental authorities need to address a number of key issues

related to implementation and expansion of peer-delivered

health and wellness services, including defining the model to be

disseminated, providing the necessary training to prepare the

peer workforce for delivering the new service, accessing fund-

ing for implementation, and establishing clear expectations

from funders to enhance and maintain quality while sustaining

programs and staffing over time. Addressing these issues before

implementation will facilitate a smooth rollout of services and

ensure consistent quality.

Similar to peer support services in general, peer-delivered health

and wellness services have the potential to alleviate some of the

workforce shortage concerns that many states and regions of the

country are experiencing. Peer health coaches will not replace trained

medical staff, of course, but their work with peers on more basic

issues such as healthy eating and self-care could reduce the burden on

medical personnel of addressing these areas and free up their time to

focus on other concerns and needs.

For states that already have a peer workforce but no peer-

delivered health and wellness, this could provide an area of spe-

cialization for peer specialists who wish to advance and/or enhance

their careers. Although peers are usually happy to get a job

providing support to other peers, as addressed in the 2012 Pillars

of Peer Support Services Summit, there is an increasing awareness

of the need to develop opportunities for career development and

advancement for peer specialists. As with any profession, as it

grows and becomes more established, there is a need to create new

opportunities to take advantage of existing expertise, while keep-

ing individuals in the profession interested and feeling like they are

advancing their careers (Daniels et al., 2013).

One important area to expand upon in research is the savings

that might be generated by the implementation and use of peer-

delivered health and wellness services in a state. As with any new

service, there is the need for political will and funding to make it

happen. Many states are missing one or both as they consider

developing and implementing basic peer support services. Peers in

the mental health and addictions fields are typically very mutually

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supportive in that if peers find something that works for them-

selves, they like to see it made available to others. Even states that

already have the political and economic will to implement peer-

delivered health and wellness services could strengthen their cause

by being able to demonstrate positive cost savings. Data on pos-

itive outcomes such as the substantial cost savings claimed by the

Missouri Behavioral Health Homes (http://www.mocoalition.org/

#!health-homes/c14fu) could both strengthen the sustainability of

programs in their own states and provide needed incentives for

other states to create and sustain peer-delivered health and well-

ness services. For states with established peer-delivered health and

wellness services, there is always the risk that political will could

shift, running the risk that such services would be cut in a tight

budget year. Having data to demonstrate cost savings would help

alleviate that possibility.

Areas to capture when evaluating cost benefits include not only

the obvious possible benefits, such as decreased hospitalizations

and medical expenses, but also more abstract benefits, such as how

improved physical health might enhance peers’ abilities to accel-

erate their recoveries from mental illnesses and improve their

quality of life. Advancing recovery may result in additional cost-

benefits to a state, as people gain greater independence in housing,

work, and life management.

Additional areas of future research include examining whether

peers are more effective than nonpeers, defining personally mean-

ingful outcomes valued by peers (not just the financial outcomes

valued by funders), examining what outcomes are achieved, and

developing fidelity scales for the different models of peer-

delivered health and wellness services.

Conclusion

Peer-delivered health and wellness services help address the

health disparities facing people who are living with mental health

and substance use disorders. A variety of innovative models tai-

lored to local needs and circumstances are now being implemented

using different funding sources. These varied service models share

common features in their structure, such as being peer delivered

and focused on improving health and wellness as desired by the

person served, increasing knowledge about preventing disease,

lessening the effects of the chronic medical conditions that affect

many people with mental disorders, and promoting change to

adopt and maintain healthy lifestyle habits. Given the urgency

evident in the prevalence of medical comorbidity and the reduced

life span for people with mental disorders, the need to expand and

replicate health and wellness services is compelling, with special-

ized peer-delivered services providing an effective and feasible

method for launching this expansion.

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Received July 28, 2014

Revision received May 17, 2016

Accepted May 17, 2016 䡲

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