People diagnosed with chronic disease, behavioral health issues, and substance use disorders often find themselves exhausted managing their respective illnesses. Harvard research tells us the average medical visit takes 121 minutes.[i] Furthermore, according to the National Institute of Health (NIH), the median visit length averages 15.7 minutes covering a median of six topics.[ii] With 105.3 minutes unaccounted for, how can we better support patients during, or outside of a doctors’ visit?

The benefits of building Community Health Workers into service delivery creates a more trusting relationship with the patient and serves to link the client to social services of support and to improve the cultural competence of service delivery.[iii] Seventy percent of people with chronic disease fail without support.

Traditionally, Medicaid and Medicare pay for direct patient care, meaning a specific medical treatment. This does not allow for payment allocation to provide or link patients to additional social services that they vitally need. Providers must seek additional pay or sources to provide these valuable services. With this in mind, we really should ask ourselves would chronic disease be as chronic with additional supports?  Some providers have creatively accessed this additional funding through programming, grants, and fundraisers. It is imperative, whatever your strategy, to document your successes with these initiatives to demonstrate the on-going need for building capacity to provide these additional supports.

For clients with behavioral health and substance use clinical needs, a specialized Community Health Worker (CHW) in the role as a Certified Recovery Specialist (CRS), sometimes called Peer Recovery Specialist, can be a welcomed member of the treatment team. These trained individuals with “lived-experience”, community health worker training, CRS certification and agency/team training can assist in delivering this extra layer of support:  connections to housing, jobs, transportation, making appointments, food, shelter and more.

The national Peer Recovery Center of Excellence (PRCoE) was funded by SAMHSA in 2020 to provide training and technical assistance to the substance use peer recovery field. SAMHSA (Substance Abuse and Mental Health Services Administration) provides a wealth of information on EBPs (Evidence Based Practices), scholarly articles, and documented research which are vital for practitioners.

To provide a comprehensive overview of state peer recovery trainings and certifications, information offered in this report, PeerRecoveryNow,[iv] includes peer support training and certification types for peer support specialists with lived experience in substance use and/or mental health recovery. This report also reflects the integrated certifications for peer support specialists with either type of lived experience offered by many states.[v]

The chart below (extracted from the report) reflects several states who have a certified peer recovery specialist program and whether they are integrated (behavior health and substance use) or singularly behavioral health or substance use.

State Peer Support Specialist Certification Types:

This illustrates the on-going struggle with establishing universal standards for this work. Some states have established certifying bodies, listed criteria for acceptance, and noted disqualifying reasons.

While living with a mental illness isn’t a crime, many have been criminalized for it. Substance use, on the other hand, is a crime and many of our potential recovery specialists have encountered the criminal justice system as a result. This is a challenging concept for hiring agencies who wish to incorporate peer recovery specialists on their medical and response teams. Core competencies have been used to deliver and promote best practices in peer support.  The core competencies, combined with service delivery skills, and team integration training have led to the most successful teams.[vi]

SAMHSA defines recovery as process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.

How do we integrate this lived experience into our teams? Consider your hiring process for these positions. Rarely is a Certified Recovery Specialist (CRS) hired to do a job independently. They are incorporated into “team” work. Consider the set of skills you need on the team: Job coach, Life skills coach, trainer, mentor? Does this potential new member possess CSR skills as well as answer a void or provide an enhancement to your team? Consider this:

Your client has been asked how they have been sleeping. The answer to this one question can offer so much more into the client’s well-being. If the client replies that they don’t sleep, they merely doze in specific places- in the only places they feel safe, we may have identified trauma. The CRS on our team may have experienced something similar that they are willing to share, and by sharing, enables the patient to share more. Empathy and trust have been established.

Remember that our CRS is taking on some of the exhaustion of our clients’ illness as well as managing their own wellness. Are we protecting our CRS? Have we considered the workload that is reasonable for our team member? What support are we providing? What support does the entire team need, not just our CRS? Taking time out for personal care is imperative for each member of the treatment team. If you are expecting a 20-hour or 30-hour work week, training weeks should also match those hours.

Determine the baseline skills needed, core competencies, communication, team building and more. Do not separate trainings among team members. CRSs should attend agency trainings and specialized team trainings alongside their teammates for the most effective results. Safeguard against overestimating and underestimating the expertise of the CRS,

When you work in the human being business, documenting your successes and projects that have encountered undesired consequences is crucial to improving outcomes for your patients. That is why incorporating EBP’s (Evidence-Based Practices) and engaging in the research to create an emerging best practice has such an impact on the work we do. Keeping to the fidelity of those models ensures further success. Executing only a part of the model may not yield the results you seek or have an unwanted outcome.

Engaging academic support from a nearby university may help bring funds and efficacy to your program as well as assist in maintaining the fidelity to the model.

Can we hire a person who has a prior felony into our program? Here is an example of the state of Texas’ disqualifying charges:

These are valid considerations, and you must always assess what is best for your team.

Should we expect someone with mental illness will be unreliable? If we build the appropriate supports and protocols into our programs, we should be able to minimize those concerns and empower people in recovery to new positions with the possibilities of achieving new potentials. At the same time we are improving the quality of care of our patients and guiding them to self-directed, more independent living.

To everyone who works in this business, you know how unpredictable any day can be. Ensuring safety for staff and clients is absolutely paramount. Staff and clients must feel safe throughout every service. Working together by including, understanding, and appreciating the lived-experience of a Certified Recovery Specialist can bring new results with the appropriate incorporation of protocols.  It may even fill 105.3 minutes with something remarkable.

[i] Study: Average Doctor’s Appointment Length is 121 Minutes (bostonmagazine.com)

[ii] Time allocation in primary care office visits – PubMed (nih.gov)

[iii] CDC – Community Health Worker Resources – STLT Gateway

[iv] Final.Comparative.Analysis.pdf (peerrecoverynow.org)

[v] The data compilation occurred in partnership with the Texas Institute of Excellence in Mental Health (TIEMH) at the University of Texas-Austin and is indebted to past work by TIEMH (Kaufman, L., Kuhn, W., & Stevens Manser, S. 2016), Bringing Recovery Supports to Scale Technical Assistance Center (BRSS-TACS, 2020) and The Copeland Center for Wellness and Recovery (n.d. Copeland Center for Wellness and Recovery).

[vi] Core Competencies for Peer Workers in Behavioral Health Services (samhsa.gov)