Behavioral Health Programs and 

Practices 

for Emerging Community Care Hubs

Table of Contents 

Introduction .................................................................................................................................................. 1

Applied Suicide Intervention Skills Training (ASIST) ..................................................................................... 2

Brief Intervention and Treatment for Elders (BRITE).................................................................................... 3

Coleman Care Transitions Program (CTI)...................................................................................................... 4

Collaborative Care for the Management of Depressive Disorders............................................................... 5

Engagement-Focused Care (transitions from inpatient and emergency psychiatric facilities).................... 6

Healthy IDEAS ............................................................................................................................................... 7

Home-Based Depression Care Management................................................................................................ 8

Motivational Interviewing (MI)..................................................................................................................... 9

Peer Support...............................................................................................................................................10

Permanent Supportive Housing (PSH) ........................................................................................................12

Person-Centered Trauma-Informed Care (PCTI).........................................................................................14

Program to Encourage Active Rewarding Life for Seniors (PEARLS)...........................................................15

Resources for Enhancing Alzheimer’s Caregiver Health (REACH) and REACH II.........................................16

Screening, Brief Intervention, and Referral to Treatment (SBIRT) .............................................................18

Wellness Recovery Action Planning (WRAP) ..............................................................................................19
1

Introduction 

The behavioral health programs and practices described in this document provide support for and

promote the well-being of older adults and people with disabilities. The programs and practices were

selected based on their suitability for implementation in community-based venues, where they may be 

provided by the Community Care Hub (CCH) or via contractual arrangements with community-based 

organizations in their CBO network. They have been implemented in real-world settings and have been 

shown to be effective if implemented with fidelity to their original designs. 

Standardized implementation guides and training for service providers are available for most of the 

programs and practices described here. Most have standard process and outcome measures that enable 

organizations to monitor progress and evaluate program outcomes. In addition to facilitating continuous 

quality improvement in implementation, evaluation activities will help inform people who use the 

services and other community stakeholders about the impact of the program, and the results may be 

useful in fundraising endeavors. 

The document contains a section for each program/practice, summarizing the available evidence of its 

effectiveness and identifying resources for organizations interested in adopting it. These programs vary 

considerably in the number of studies that have been conducted. The citation selected for each is a 

study that presents the most central outcomes for which the intervention was designed. 
2 

Applied Suicide Intervention Skills Training (ASIST) 

ASIST is a 2-day training program aimed at developing “suicide first aid” skills and competencies. The program is available to anyone seeking to increase 

the immediate safety of persons at risk of suicide. Since people at risk are often inclined to reach out first to family and friends, ASIST fulfills a 

“gatekeeper” role that seeks to build and empower a broad network of community helpers. ASIST also provides those in more formal helping roles with 

professional development to ensure they are prepared to provide suicide first aid help as part of the care they provide. The ASIST Suicide Intervention 

Model (SIM) has three phases of caregiving: connecting, understanding, and assisting. The counselor’s task in the “assisting” phase is to establish a “Safe 

plan” that specifically addresses each element of risk identified in the previous phases of the intervention.

Research 

Summary Evaluation of the ASIST training program, examining counselor skills and caller response.

Citation Gould, M., Cross, W., Pisani, A., Munfakh, M., & Kleinman, M. (2013). Impact of Applied Suicide Intervention Skills Training on the 

National Suicide Prevention Lifeline. Suicide and Life-Threatening Behavior, 43(6), 676–691. 

Study design Randomized control trial to test whether the ASIST program increased the effectiveness of Lifeline’s telephone crisis services, with an 

intervention group of 17 lifeline suicide crisis centers receiving ASIST from counselors who received ASIST training, and a wait-list 

control group. Data was derived from 1,507 monitored calls from 1,410 suicidal individuals. “Silent monitors” assessed changes in 

counselors’ and callers’ behaviors in both groups. 

Population 1,410 suicidal individuals, 764 were directed to intervention group

Outcomes Of the twenty-three counselor behaviors assessed, six were significantly enhanced by the ASIST training. Four of the seven caller 

behavioral changes that were assessed were significantly associated with the counselors’ ASIST training. Suicidal callers whose 

counselors had been ASIST-trained were significantly more likely than callers whose counselors had not been ASIST-trained to be rated 

by the silent monitors as becoming less depressed, less overwhelmed, less suicidal, and more hopeful during the course of the call. 

Comments Differences between the intervention and control groups may have been attenuated by overlap in the training received by both. The 

authors note that a critical issue identified by the study that should be addressed in future training is inadequate assessment of suicide 

risk.

Resources 

Developer/Author Description of Content Target Audience Resource Type

Suicide 

Prevention 

Resource Center 

(SPRC) 

This PDF offers information on program description, evaluation, implementation and cost of 

training and implementation materials. ASIST is developed and disseminated by 

LivingWorks Education Inc. Individuals interested in providing their own ASIST workshops 

may become Registered ASIST Trainers. 

Organizations 

interested in ASIST

PDF
3 

Brief Intervention and Treatment for Elders (BRITE) 

BRITE represents an extension of the Screening, Brief Intervention and Referral to Treatment (SBIRT) program to nonmedical services that serve older 

adults. It was developed by the Florida BRITE Project and funded by a 5-year grant from the Substance Abuse and Mental Health Services Administration 

(SAMHSA). The study described below is a test of the SBIRT model conducted in community settings (for information on SBIRT, see page 18). The mission 

of the BRITE project is to serve individuals ages 55+ to identify non-dependent substance use or prescription medication issues and to provide effective 

service strategies prior to the need for more extensive or specialized substance use treatment. The vision is that BRITE will be incorporated into primary 

care settings, hospital emergency rooms, trauma centers, and other community and aging services settings as a comprehensive, integrated, sustainable 

public health approach to the delivery of services for older adults who are at risk of developing substance use disorders. BRITE has been listed in the tier of 

highest-level criteria for evidence-based disease prevention and health promotion programs under Title III-D of the Older Americans Act.

Research 

Summary A comparison of standard substance use treatment and an adaptation of the SBIRT model, which is normally conducted in a primary care 

setting, to test effectiveness when delivered by health care, aging services, mental health, and substance use treatment provider 

agencies. 

Citation Schonfeld, L., R. W. Hazlett, et al. (2015). Screening, Brief Intervention, and Referral to Treatment for Older Adults With Substance 

Misuse. Am J Public Health, 105(1), 205-211.

Study design A pre-post multi-site study with 6-month follow-up. Staff from 29 agencies screened for substance use risk in 75 sites across 18 Florida 

counties. Clients at no or low risk received feedback about screening; moderate risk led to brief intervention; moderate or high risk led to 

brief treatment; and highest severity led to referral to treatment. Six-month follow-up was conducted with a random sample of clients. 

Population The characteristics of those screening negative (n=76,765) and those screening positive (n=8,165) were significantly different for mean 

age (younger for positive), gender (higher percent males for positive), and race (higher percent White people for positive). 

Outcomes Over 5 years, 85,001 client screenings were recorded. Of these, 8,165 clients were at moderate or high risk. Most received brief 

intervention for alcohol or medication misuse; about 20% did not receive brief intervention. Health educators screening solely within 

medical sites recorded fewer positive screens than those from mental health, substance use, or aging services in a variety of communitybased and health care sites. Six-month follow-ups for a random selection of 171 individuals revealed a significant decrease in substance 

use. Agency types differed in follow-up rates: aging services achieved the highest (57.4%) and health care providers the lowest (13.5%).

Comments The authors note that Area Agencies on Aging that include BRITE services may be reimbursed through their respective state units on 

aging that receive AoA funding.

Resources 

Developer/Author Description of Content Target Audience Resource Type

Florida Dept. of 

Children and 

Families

This PDF includes the mission and vision of BRITE along with a profile for Florida that shows 

how this program has been implemented and its benefits. There are 18 programs thus far 

located around the state of Florida. This program demonstrates that Screening, Brief 

Intervention and Referral to Treatment can be extended to nonmedical services that serve 

older adults.

Older adults at risk 

for or experiencing 

substance use 

problems

PDF
4 

Coleman Care Transitions Program (CTI) 

The Care Transitions Intervention® (CTI) is an evidence-based, short-term model. It complements a health care system’s care team by empowering the 

client to develop self-care skills and helps them assume a more active role in their health through a whole-person approach. The intervention is built on 

four conceptual domains: 1) assistance with medication self-management, 2) a patient-centered record owned and maintained by the patient, 3) timely 

follow-up with primary or specialty care, and 4) a list of “red flags” indicative of a worsening condition and instructions on how to respond to those, 

operationalized by means of a personal health record and visits and telephone calls with a transition coach. 

Research In addition to the base randomized control trial described here, CTI has published reports on several other applications of the approach—including 

veterans and children—along with additional cost analyses.

Summary An intervention designed to encourage patients and their caregivers to assert a more active role during care transitions may reduce 

rehospitalization rates. 

Citation Coleman, E.A., Parry, C., Chalmers, S., & Min, S. (2006). The Care Transitions Intervention: Results of a Randomized Controlled Trial. 

Archives of Internal Medicine, 166(17), 1822-1828.

Study design The study was conducted in collaboration with a large not-for-profit capitated delivery system in Colorado. A randomized control trial, 

the study involved 750 older adults assigned to intervention or treatment as usual. Inclusion criteria included age 65+, non-psychiatric 

admission to the system’s hospital community dwelling, no documentation of dementia, have documentation of at least one of eleven 

diagnoses: stroke, congestive heart failure, coronary artery disease, cardiac arrhythmias, chronic obstructive pulmonary disease, 

diabetes mellitus, spinal stenosis, hip fracture, peripheral vascular disease, deep venous thrombosis, and pulmonary embolism. 

Measures were 1) rate of non-elective rehospitalization at 30, 90, and 180 days after discharge; 2) rate of rehospitalization for the 

same condition that prompted the index hospitalization; and 3) non-elective hospital costs. The analysis adjusted for various patient 

characteristics (e.g., age, sex, race, chronic disease score, etc.). 

Population Individuals 65 or older with chronic medical conditions and high rates of prior hospital and emergency department use.

Outcomes 1) The intervention group had fewer rehospitalizations at all three time-intervals, statistically significant at 30 and 90 days. 2) The 

intervention group had fewer rehospitalizations for the same condition at all three-time intervals, statistically significant at 90 and 180 

days. 3) Intervention patients had significantly lower hospital costs at 90 and 180 days.

Comments The authors note that the intervention achieved reductions in rehospitalization even in a system where that had been a focus for many 

years; differences would likely be greater where there is less prior effort to reduce rehospitalizations.

Resources 

Developer/Author Description of Content Target Audience Resource Type

Care Transition 

Intervention

This webpage gives an overview of the CTI program, including the program’s history along 

with key findings/benefits. It also shares bios of CTI team members and provides a brief 

description of the Transitions Coach position.

All interested in CTI Webpage 

CTI This webpage lists the training components and the duration of each training. It also 

outlines the training process, shares training dates/availability, and includes links to a 

contact form.

Organizations 

interested in adopting 

and implementing CTI

Webpage
5 

Collaborative Care for the Management of Depressive Disorders 

Collaborative care for the management of depressive disorders is a multicomponent intervention at the health care system level that uses case managers 

to link primary care providers, patients, and mental health specialists. Case managers in the collaborative care model support primary care providers with 

functions such as education, follow-up to track depression outcomes and adherence to treatment, and adjustment of treatment plans for patients who do 

not improve.

Research 

Summary The Community Preventive Services Task Force recommends Collaborative Care as an evidence-based practice primarily based on two 

meta-analyses that showed strong evidence of effectiveness in improving depression symptoms, adherence to treatment, response to 

treatment, and remission and recovery from depression. The Task Force also finds that collaborative care models provide good 

economic value.

Citation Community Preventive Services Task Force (2010). Improving Mental Health and Addressing Mental Illness: Collaborative Care for the 

Management of Depressive Disorders Task Force Finding and Rationale Statement.

Study design Literature review

Population Adults 20-64 years or older adults (age 65+); study populations consisted mostly of white populations with overrepresentation of 

African Americans and underrepresentation of other minorities.

Outcomes Statistically significant effects for “multiple depression related outcomes of sufficient magnitude to be of clinical significance and public 

health benefit.” Health outcomes include symptoms, adherence, remission, recovery, quality of life and functional status, and 

satisfaction. Economic outcomes: 14 studies provided evidence of program costs; costs per person per year ranged from $104 to $2,160 

with a median of $454, with the variation explained by various program features. Of five cost-benefit studies, four showed that averted 

health care costs, averted productivity losses, or estimates of what patients were “willing to pay” for treatment exceeded program 

costs. Six studies reported incremental net costs per quality-adjusted life year (QALY). For five of these studies, the estimates ranged 

from $3,000 to $71,000, with four reporting less than $21,000, indicating the interventions were cost-effective by the conventional 

threshold.

Comments Most of the programs employed physicians in the role of “primary care provider”; for the few studies that used nurses or physicians, 

most used nurses in the role of “case manager.” Three that used social workers and masters-level mental health workers had some 

evidence of smaller intervention effects. Most studies employed psychiatrists or psychologists in the role of “mental health specialists.” 

Resources 

Developer/Author Description of Content Target Audience Resource Type

The Community 

Guide

This webpage provides a brief description of Collaborative Care to Manage 

Depression, along with its purpose and benefits.

Adults, healthcare 

providers, and older adults

Webpage

The Community 

Guide

This page gives a summary of findings of the Community Preventive Services Task 

Force, benefits of intervention, considerations for implementation and links to 

supporting evidence and materials. 

Organizations interested in 

implementing Collaborative 

Care for the Management of 

Depressive Disorders

Webpage
6 

Engagement-Focused Care (transitions from inpatient and emergency psychiatric facilities) 

Patient engagement is a developmental process that involves the patient’s ability to take a more active role in their treatment or to feel more comfortable 

expressing their preferences or needs with their providers—even if living with a disease. Engagement-focused care (EFC) involves getting individuals into 

treatment rapidly and helping them communicate better with their provider using a shared decision-making coach. 

Research 

Summary EFC had two components not typically found in transitional care models: 1) an access group intake process and 2) shared decisionmaking (SDM) coaching for patients. Patients participated in an access group post-hospital discharge to accommodate individual 

needs, and an SDM coach met with the patient prior to and sometimes following appointments with the prescriber.

Citation Velligan, D. I., M. M. Fredrick, et al. (2017). Engagement-focused care during transitions from inpatient and emergency psychiatric 

facilities. Patient Preference and Adherence, 11, 919-928.

Study design Comparative effectiveness trial

Population 147 subjects were male and 179 were female. In terms of race and ethnicity, 160 were Hispanic, 135 were Anglo, 24 were African 

American, 3 were Asian, and the remaining individuals were of mixed ethnic background. Mean age of participants was 38.0. 

Outcomes 61% of both groups were engaged in services following discharge. There was greater improvement of quality of life in the intervention

group. In the decision-making process at baseline, 26% of subjects wanted mostly active roles, 22% wanted primarily passive roles, and 

52% wanted a collaborative process. There was no change at follow-up. Both groups improved in symptomology while in treatment

and rated their satisfaction with their treatment as very good. In the 6 months post discharge, 41% of standard care subjects and 35% 

of intervention subjects had at least one hospitalization, crisis visit, or incarceration, but these differences were not statistically 

significant. 

Comments Attrition rates between consent and first assessment were 31.85% for the standard care group and 28.9% for the intervention group, 

139 were lost to follow-up.

Resources 

Developer/Author Description of Content Target Audience Resource Type

Velligan et al, 

2017

This article examines engagement-focused care (EFC) versus treatment as usual in a 

university-based transitional care clinic (TCC) with a 90-day program serving individuals 

with SMI discharged from hospitals and emergency rooms

Organizations interested 

in the evidence for EFC

Journal article

National Alliance 

on Mental Illness

(NAMI)

This document reports on NAMI’s exploration of how the quality of relationships and 

interactions affect outcomes for people with mental illness and their families to better 

understand the process of engagement in mental health care

Organizations and 

providers interested in 

patient engagement in 

mental health care

PDF
7 

Healthy IDEAS 

Healthy IDEAS (Identifying Depression & Empowering Activities for Seniors) is a service delivery model that extends the reach of current community-based 

aging services by integrating depression awareness and self-management interventions into existing case-management programs. Components consist of 

four evidence-based interventions (screening and assessment, education, referral and linkage to health and mental health professionals, and behavioral 

activation), with face-to-face and telephone meetings delivered by case managers As one of the Administration for Community Living’s “Evidence-based 

Prevention Programs for Older Adults,” Healthy IDEAS uses evidence-based practices to identify and address depression symptoms in those most at risk of 

being unrecognized and undertreated for depression. 

Research 

Summary Assessment of program effects on depression and quality of life

Citation Quijano, L. M., M. A. Stanley, et al. (2007). Healthy IDEAS: A depression intervention delivered by community-based case managers 

serving older adults. Journal of Applied Gerontology 26(2): 139-156.

Study design Pre and post intervention study of a single cohort followed for six months

Population Ninety-four high-risk older adults; population consisted of 79% women, 44% Hispanic, with a mean age 72 at baseline and 67 at 

follow-up. 

Outcomes Depression (Change in GDS-15 score): improved significantly at 6 months

Self-management (Make an appointment for depression, identify symptoms, know what to do if depression increases, feel better by 

increasing activities): significantly improved at 6 months

Social and physical activity: non-significant positive trend

Quality of life (less pain, health not interfering with social life): significantly improved

Medical and mental health utilization in past 3 months: non-significant positive trend

Comments The lack of a comparison group allows for possible alternative causes.

Resources 

Developer/Author Description of Content Target Audience Resource Type

Healthy IDEAS 

program

This PDF gives an overview of the program, including who delivers the program, benefits, 

how it works, and recognition the program has received. 

Organizations that 

serve elderly 

populations

PDF flyer

Healthy IDEAS

program 

This page provides information on training and requirements. Training is a multiphase 

process; the webpage gives a brief description of each phase along with a link to contact 

for more information. 

Case managers Webpage
8 

Home-Based Depression Care Management 

Home-based depression care management is a general term for a variety of home-based interventions designed to treat depression in older adults, 

including active screening for depression, measurement-based outcomes, trained depression care managers, case management, education, and a 

supervising psychiatrist, considered by an expert panel to be effective. 

Research 

Summary Consensus-based recommendations were formulated by an expert panel of mental health and public health researchers and 

community-based aging services providers. Panelists considered feasibility and appropriateness for community-based delivery, as well 

as strength of evidence for program effectiveness as indicated by a systematic literature review of articles published through 2005. 

Citation Steinman, L. E., J. T. Frederick, et al. (2007). Recommendations for Treating Depression in Community-Based Older Adults. American 

Journal of Preventive Medicine 33(3): 175-181.

Study design Expert panel and systematic review

Population Community-living older adults with depression

Outcomes The panel recommended individual cognitive behavioral therapy (CBT). Interventions not recommended as primary treatments for 

late-life depression included education and skills training, comprehensive geriatric health evaluation programs, exercise, and physical 

rehabilitation/occupational therapy. There was insufficient evidence for making recommendations for several intervention categories, 

including group psychotherapy and psychotherapies other than CBT. Many of the interventions that were not recommended or had 

insufficient evidence did not treat depression primarily and/or did not include a clinically depressed sample to establish efficacy. 

These interventions may provide other benefits but should not be presumed to effectively treat depression by themselves. 

Comments Expert opinion level of evidence

Resources 

Developer/Author Description of Content Target Audience Resource Type

The Community 

Guide

This document provides a brief overview of home-based depression care management, 

which includes intervention involvement, results, and accomplishments. Also, this provides 

information on estimated costs of implementation and applicability. 

Older adults & 

healthcare providers

Webpage

Bruce et al., 2015 This article provides information on the effectiveness of integrating depression care 

management into home-based care. This includes importance, intervention, results, and 

outcomes. 

Organizations 

interested in the 

effectiveness of 

home-based 

depression care

Journal article
9 

Motivational Interviewing (MI) Motivational Interviewing is a conversational approach designed to elicit motivation to change a specific negative behavior. MI engages, elicits change talk

(statements about the person’s desire, ability, reasons and need for change), and evokes motivation to make positive changes. It is widely used by 

practitioners from a range of disciplines in a variety of settings, including community-based organizations. 

Research 

Summary Meta-analysis of studies addressing motivational interviewing

Citation Lundahl, B. W., C. Kunz, et al. (2010). A Meta-Analysis of Motivational Interviewing: Twenty-Five Years of Empirical Studies. Research 

on Social Work Practice 20(2): 137-160.

Study design Meta-analysis of 119 studies addressing a range of outcomes: alcohol use, marijuana use, tobacco use, miscellaneous drug use (e.g., 

cocaine, heroin), increases in physically healthy behavior (e.g., exercise, eating patterns), reductions in risk-taking behavior (e.g., 

unprotected sex), gambling, emotional or psychological well-being (e.g., depression or stress and client motivation: engagement in 

treatment such as keeping appointments and/or participation in treatment), and self-reported intention to change (e.g., movement 

in the Stages of Change model). The analysis examined a number of potential moderators including type of comparison group, client 

level of distress, use of a manual, role in treatment (e.g., part of a broader intervention), fidelity, and manner of delivery. Metaanalysis accommodates the fact that the primary studies use many different measures with different populations by means of a 

metric known as effect size that standardizes results onto a single scale. An effect size refers to the magnitude of the effect or the 

strength of the intervention, expressed in standard deviations. Conventionally, effect sizes around 0.20 are considered small though 

statistically significant, 0.50 is moderate and 0.80 is large. Because most of the studies reported on multiple outcomes, a total of 842 

effect sizes were computed. 

Population Sample characteristics coded a moderating variable included average age, percent who were male or female, and percent who were 

White, African American or Hispanic.

Outcomes The average effect size across all outcomes was 0.22 (statistically significant, classified as a small but statistically meaningful effect). 

25% of the 842 effect sizes were either neutral or negative, 50% of the effect sizes were greater than classification of a small effect 

size, and 25% were larger than a medium effect size. Effect sizes were lower for studies that compared MI with another specific 

treatment such as 12-step than if the comparison was no treatment.

Comments Well-designed studies of interventions such as MI typically result in effect sizes similar to this. Based on this meta-analysis, MI is 

equally, though not more, effective as other interventions, and more effective than no treatment.

Resources 

Developer Description of Content Target Audience Resource Type

Motivational Interviewing 

Network of Trainers 2020

This website has information on MI training, learning, implementation 

and research. It also provides information about the MI Network of 

Trainers and news updates related to MI. 

Individuals and organizations

interested in MI

Website

Motivational Interviewing 

Network of Trainers

This PDF contains the definition of MI according to Miller (founder) & 

Rollnick, the usefulness and core elements of MI. 

Clinicians and other 

providers serving individuals 

requiring behavior change

PDF 

(Understanding MI)

Motivational Interviewing 

Network of Trainers 2020

This resource contains information on the requirements and process of 

implementation of MI in an organization

Organizations interested in 

implementing MI

PDF 

(Implementing MI)
10

Peer Support 

Peer support services are delivered by people with personal experience as service users of behavioral health services. Peer support services are theorized 

to help service users develop self-advocacy skills and build confidence to pursue their goals through establishing trust and rapport built on shared 

experiences. Those providing peer support services are referred to by a range of terms—including peer specialists, peer advocates (often mental healthfocused), and recovery coaches (often used in the substance use recovery community). Nearly all states have established peer training and certification 

trainings, and a majority of state Medicaid programs reimburse peer support services. Several states have peer specialist training and certification 

programs specifically for older adults (e.g., Massachusetts’ Supporting Older Adults Remotely – SOAR).

Research 

Summary The study examines a program known as Peer Mentoring, for which the primary goal is reduction in hospital use. 

Citation Sledge, W. H., M. Lawless, et al. (2011). Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric 

hospitalizations. Psychiatry Services 62(5): 541-544.

Study design Randomized controlled design, with follow-up at nine months after an index discharge from an academically affiliated psychiatric 

hospital. Measures were number of hospitalizations and hospital days.

Population Patients were 18 years of age or older with major mental illness and had been hospitalized three or more times in the prior 18 months. 

Seventy-four patients were recruited, randomly assigned to usual care (N=36) or to a peer mentor plus usual care (N=38) and assessed 

at nine months.

Outcomes Participants who were assigned a peer mentor had significantly fewer rehospitalizations (.89 ± 1.35 versus 1.53 ± 1.54; p=.042 [onetailed]) and fewer hospital days (10.08 ± 17.31 versus 19.08 ± 21.63 days; p<.03, [one tailed]).

Comments According to the authors, despite limitations of the study (small sample size, single location, etc.), “The recovery mentor program has 

promise as an effective adjunctive component in a multifaceted approach to engaging and treating persons with serious and relapsing 

psychiatric illness.” There is now a variety of peer support models and an extensive body of research. This study was selected as being 

the most relevant to the business case for peer support services. A Cochrane systematic review of research on peer supports found that 

much of it demonstrates positive results for both personal recovery and clinical outcomes, though the number of high-quality studies is 

limited, and the heterogeneity of peer support models presents challenges for synthesizing this evidence. (Chien WT, Clifton AV, Zhao S, 

Lui S. Peer support for people with schizophrenia or other serious mental illness. Cochrane Database Systematic Reviews. 2019). 

Peer Support Resources 

Developer/Author Description of Content Target Audience Resource Type

Pillars of Peer 

Support

This page provides links to resources that include information on studies on 

certification, webinars, a PDF on guidelines for peer specialists and supervisors, 

along with supervision resources.

Peer supporters, 

specialists, and 

supervisors

Webpage

Pillars of peer 

support training 

This page provides links to upcoming training through the Copeland Center, along 

with recent webinar series and recordings. Also, allows registration for upcoming 

free webinars and provides certificates for webinars reviewed.

Individuals and 

organizations interested 

in peer support training

Webpage
11

Developer/Author Description of Content Target Audience Resource Type

Professional 

National 

Association of 

Peer Supporters

This site provides education information, building a community, resources, and 

recent posts sponsored by N.A.P.S.

Individuals and 

organizations interested 

in peer support training

Webpage

Pillars of Peer 

Support

This page contains the original toolkits which included PDFs on peer support services 

from 2009-2014.

Individuals and 

organizations interested 

in peer support

Webpage

SAMHSA Peer 

Support Resources

This page has information on core competencies for peer workers, the peer support 

role, and links to additional peer support resources. In English and Spanish.

Individuals and 

organizations interested 

in peer support

Webpage

University of 

Illinois at Chicago

This page offers an interactive map showing a National Overview of Peer Support 

Training & Certification Programs

Individuals and 

organizations interested 

in per support training

Webpage with 

interactive map

Center for 

Substance Abuse 

Treatment

A PDF explaining peer recovery support services, peer mentoring and coaching, 

adaptability of per support services and cross-project principles. 

Individuals and 

organizations interested 

in peer recovery support

PDF
12

Permanent Supportive Housing (PSH) Permanent supportive housing is an intervention that combines affordable housing assistance with voluntary support services to address the needs of 

chronically homeless people. The services are designed to build independent living and tenancy skills and connect people with community-based health 

care, treatment, and employment services. PSH, sometimes called supported housing, links subsidized housing with access to flexible, voluntary 

supportive services to help people with disabilities maintain stable housing and live productively in the community.

Research 

Summary PSH (also known as Housing First) has been the subject of extensive research; a literature review by the Corporation for Supportive 

Housing (CSH) presents the results of nearly 30 studies (CSH Literature Review of Supportive Housing). Outcomes reported in the CSH 

review for three of the most recent randomized control trials are presented here.

Study design Randomized control trial, more than 2,000 participants followed for two years.

Population Participants recruited from shelters, or the streets, represent a wide diversity of demographic characteristics.

Citation Paula Goering, Scott Veldhuizen, Aimee Watson, Carol Adair, Brianna Kopp, Eric Latimer, Geoff Nelson, Eric MacNaughton, David 

Streiner & Tim Aubry (2014). National At Home/Chez Soi Final Report. Calgary, AB: Mental Health Commission of Canada. Retrieved 

from: www.mentalhealthcommission.ca

Outcomes • Stable Housing: 62% percent of Housing First (HF) participants were housed all of the time, 22% some of the time, and 16% none of 

the time. Of treatment as usual (TAU) participants, 31% were housed all of the time, 23% some of the time, and 46% none of the time. 

• Healthcare: Both HF and TAU groups reported declines in ER visits with lower levels among HF participants over the course of the 

study. Outpatient HF participants also had lower levels of visits to hospitals for outpatient care (these included day hospital visits but 

not visits for laboratory or diagnostic tests). 

• Criminal Justice: The majority (89%) of participants had at least one interaction with police officers, around one-third of participants 

were actually arrested during the study timeframe. Both the HF and TAU groups reported substantial declines in their contacts with 

justice services (police, security services, courts, and other justice services), with no significant difference between the groups. When 

reasons for arrests were investigated, however, HF participants reported fewer arrests for public nuisance offenses and drug-related 

offenses over time, whereas TAU participants reported no such decline.

• Quality of Life: Improvements in community functioning and quality of life were somewhat greater in HF than in TAU; improvements 

in participants’ mental health and substance-related problems, but these changes were similar among both groups.

0 

Citation Basu, A., Kee, R., Buchanan, D. and Sadowski, L. S. (2012), Comparative Cost Analysis of Housing and Case Management Program for 

Chronically Ill Homeless Adults Compared to Usual Care. Health Services Research, 47: 523–543.

Study design Randomized control trial 

Population Homeless adults

Outcomes • Shelter: 0.07 fewer shelter days than control, 8.13 more days in respite care than control

• Stable Housing: 29.66 fewer days with family/friends than control, 109.9 more days in paid housing than control, 62 fewer days 

homeless than control

• Healthcare: 0.47 fewer hospitalizations than control, 2.64 fewer days in hospital than control, 1.27 fewer ER visits than control, 

Outpatient 3.84 more outpatient visits than control (includes mental health clinics, hospital clinics, substance abuse treatment visits)

• Criminal Justice: 0.05 fewer arrests than control, 4.06 more days in jail than control, 0.03 fewer convictions than control,7.73 fewer 

days in prison than control
13

Citation Aidala, Angela A., William McAllister, Maiko Yomogida, and Virginia Shubert. Frequent Users Service Enhancement ‘FUSE’ Initiative: 

New York City FUSE II Evaluation Report. Columbia University Mailman School of Public Health (2013).

Study design Randomized Control Trial 

Population Homeless adults

Outcomes • Shelter: Intervention group had 146.7 fewer days in shelter than comparison group. The percentage of FUSE II participants with any 

shelter episode over the study period was reduced on average by 70%.

• Stable Housing: At 12 months, over 91% of FUSE II participants were housed in permanent housing, compared to the 28% who would 

have been housed had they not received FUSE II housing and services. 

• Healthcare: Comparison group had an average of 1.2 ambulance rides; FUSE II participants had fewer than one ambulance ride (mean 

0.67). No significant difference in hospitalization days or emergency room visits. 

• Mental Health: Comparison group had 8 days of hospitalization for psychiatric reasons, 4.4 days more than intervention group. No 

difference in alcohol and other drug use (AOD use) inpatient hospital days and detoxification days. In the intervention group, the 

percent with any recent use of hard drugs was half that of comparison group and the percent of current alcohol or substance use 

disorder is one third less than comparison group.

Resources on PSH 

Developer Description of Content Target Audience Resource Type

Corporation for 

Supportive 

Housing 

This page provides information about who offers supportive housing, benefits 

and characteristics of quality supportive housing, common models and 

features of supportive housing.

Individuals and organizations

interested in PSH 

Webpage

National Health 

Care for the 

Homeless 

Council, Inc

This page gives an overview of supportive housing and links to technical 

assistance and training programs, as well as publications on supportive 

housing

Organizations interested in 

implementing supportive housing 

programs

Webpage
14

Person-Centered Trauma-Informed Care (PCTI) 

PCTI care is a holistic approach to service provision developed by the Center on Aging and Trauma. PCTI care infuses knowledge about trauma into agency 

programs and procedures as a way to promote the well-being and empowerment of trauma survivors. 

Research 

Summary Emphasis on trauma-informed practice in behavioral health care has increased dramatically, and organizational interventions that train 

staff about trauma-informed practice are frequently used to promote trauma-informed systems change.

Citation Purtle J. (2020), Systematic review of evaluations of trauma-informed organizational interventions that include staff trainings. Trauma, 

Violence, & Abuse, 21(4):725-740.

Study design A systematic review of 23 studies that evaluated the effects of organizational interventions that included a “trauma-informed” staff 

training component. 

Population Patients were 18 years of age or older with major mental illness and had been hospitalized three or more times in the prior 18 months. 

Seventy-four patients were recruited, randomly assigned to usual care (N=36) or to a peer mentor plus usual care (N=38) and assessed at 

9 months.

Outcomes Of those reviewed, 17 studies used a single group pretest/posttest design, 5 used a randomized controlled design, and 1 used a quasiexperimental design with a nonrandomized control group. The duration of trauma-informed trainings ranged from 1 hour to multiple 

days. Staff knowledge, attitudes, and behaviors related to trauma-informed practice improved significantly pre-/post training in 12 

studies and 7 studies found that these improvements were retained at ≥1 month follow-up. Of those reviewed, 8 studies assessed the 

effects of a trauma-informed organizational intervention on client outcomes, 5 of which found statistically significantly improvements.

Comments According to the authors, “The strength of evidence about trauma-informed organization intervention effects is limited by an abundance 

of single group, pretest/posttest designs with short follow-up periods, unsophisticated analytic approaches, and inconsistent use of 

assessment instruments.”

Resources 

Developer/Author Description of Content Target Audience Resource Type

The Jewish Federations This page provides a brief overview of PCTI care. The models’ purpose 

focuses on creating environments that promote the safety and well-being 

of all clients and staff.

Holocaust survivors, older 

adults with a history of 

trauma, and their family 

caregivers

Webpage

Substance abuse and 

Mental Health Services 

Administration (SAMHSA)

Guidance for trauma-informed approaches Organizations interested in 

person-centered traumainformed care

PDF
15

Program to Encourage Active Rewarding Life for Seniors (PEARLS) 

PEARLS is a national evidence-based program for late-life depression. It consists of an EBP—Problem-Solving Treatment (PST)—modified with greater 

emphasis on social and physical activation, delivered by trained masters-level social workers at a community senior services organization, and if indicated, 

recommendations to patients’ physicians regarding antidepressant medications. PEARLS brings high quality mental health care to community-based 

organizations that reach vulnerable older adults. Sessions take place in the client’s home or another community setting and focus on brief behavioral 

techniques. PEARLS counselors empower individuals to take action and make lasting changes so they can lead more active and rewarding lives. Other 

topics include depression, problem-solving treatment, behavioral activation (BA), and social activities 

Research 

Summary Randomized controlled trial (RCT) of the PEARLS program

Citation Ciechanowski P, Wagner E, Schmaling K, Schwartz S, Williams B, Diehr P, Kulzer J, Gray S, Collier C, LoGerfo J. (2004), Communityintegrated home-based depression treatment in older adults: A randomized controlled trial. JAMA 291(13):1569-77

Study design RCT design with 72 patients in the treatment group and 66 in the usual care group. Outcomes assessed at baseline, 6 and 12 months. At 

12-month follow-up, there were 67 in the treatment group and 60 in the usual care group. A difference in differences analysis 

(comparison of changes in outcomes over time between usual care and intervention groups) was conducted. 

Population 138 patients 60 years of age or older with minor depression (51.4%) or dysthymia (48.6%); major depression excluded receiving homebased services from senior service agencies or living in senior public housing. Many were medically ill and low-income, most were 

homebound. 79% female, 58% Caucasian, 36% African American, 4% Asian American, 1% Indians or Alaska Natives, and 1% Latino

Outcomes At the 12-month follow-up, the treatment group had greater improvement in depression status, functional well-being, and emotional 

well-being. There was no change noted in social well-being, physical well-being, outpatient visits, emergency department visits or 

hospitalizations in the two groups. 

Comments 1) Demonstrates that PEARLS can be disseminated within community agencies already providing care for isolated, low-income older 

adults by adding depression management to established case management; 2) Further research is needed to determine how much each 

component contributed to the overall intervention effect; 3) Despite the significant effect of the intervention, only a third of patients in 

the intervention group and 12% in the usual care group experienced remission (similar to other late-life depression studies using 

antidepressants and psychotherapy) 

Resources 

Developer/Author Description of Content Target Audience Resource Type

PEARLS This page provides a brief overview of the program which includes 

target audience, health outcome, program type, who the program 

is delivered by, and format. It also contains contact information 

for training information.

Organizations serving older adults 

with depression

Webpage

University of Washington This page has detailed information about PEARLS, implementation 

requirements, cost, training, and other benefits. 

Organizations interested in 

adopting and implementing PEARLS

FAQ Webpage
16

Resources for Enhancing Alzheimer’s Caregiver Health (REACH) and REACH II 

The REACH program is an in-home, tailored, caregiver support intervention administered through the Department of Veterans Affairs, the Rosalynn Carter 

Institute, and other sites. REACH provides education and support for caregivers to improve overall caregiver health and reduce the burden from caregiving 

and the risk for depression. REACH II was designed to address the needs of culturally diverse caregivers of persons with dementia, including White, 

Hispanic, and African American caregivers. REACH II has been successfully adapted to use in the community (e.g., by personnel in local Area Agencies on 

Aging) and has been effectively adapted for use with family caregivers of persons with acquired physical disabilities (e.g., spinal cord injury). 

Research on REACH I 

Summary Meta-analysis was used to examine nine active conditions compared with six control conditions of REACH project at 6 months on caregiver 

burden and depressive symptoms.

Citation Gitlin, L. N., Burgio L., Czaja S., Mahoney D., Gallagher-Thompson D., Burns R., et al. (2003). Effect of multi-component interventions on 

caregiver burden and depression: The REACH multi-site initiative at 6 months follow-up. Psychology and Aging, 18, 361-374.

Study design Meta-analysis of results from randomized controlled studies at six sites (cities). Each site tested different theory-driven interventions: 

individual information and support strategies, group support and family systems efforts, psychoeducational and skill-based training 

approaches, home-based environmental strategies, and enhanced technology systems. The REACH sites overall retained 89% of the 

participants through the first follow-up time point of 6 months.

Population Racially and ethnically diverse (White/Caucasian, Black/African American, and Hispanic/Latino) sample of 1,222 caregivers

Outcomes Burden: At 6 months the difference between total active and control groups, though statistically significant, was small. For women, the 

active interventions were superior to the control conditions. 

Depression: For the 6-month scores, only one intervention site was more efficacious than the control. Although not statistically significant, 

mean scores at baseline and 6 months for the active treatment group showed a slight decline, whereas the mean scores for control group 

conditions showed a very small increase. There were no statistically significant differences between combined active and control group

conditions for White (n = 611) and African American (n = 260) caregivers. However, the estimate for Hispanic (n = 207) caregivers indicated

that active interventions were superior to control group. Those with high school or less education assigned to active interventions 

improved in comparison with caregivers of the same educational level who were in the control group conditions. However, for both 

outcomes higher educated individuals in active interventions were not significantly different at 6 months.

Comments This study had a more rigorous design than much previous research, and according to the authors, the results confirm the conclusions from 

recent reviews of the caregiver intervention research that there is no single, easily implemented, and consistently effective method for 

eliminating the multiple stresses of providing care to persons with dementia.
17

Research on REACH II 

Summary REACH II is a multicomponent intervention package with one component addressing caregiver (CG) self-care and health behaviors. CGs 

received educational materials on self-care and preventative health practices and a “health passport” that provided reminder information 

regarding health maintenance activities and a place to track pertinent health information. CGs were also referred to the healthy living 

feature of a computerized telephone support system.

Citation Elliott AF, Burgio LD, Decoster J. (2020). Enhancing caregiver health: Findings from the resources for enhancing Alzheimer's caregiver 

health II intervention. J Am Geriatr Soc. 58(1):30-7. 

Study design Randomized, multisite clinical trial in five cities examining caregiver self-reported health, burden and bother. Intervention subjects 

received individual risk profiles and the REACH intervention through nine in-home sessions and three telephone sessions over 6 months.

Population 642 caregivers randomly assigned to control or intervention groups, 495 included in the analyses, 166 African American, 169 Hispanic, and 

160 Caucasian.

Outcomes The intervention improved caregiver health in four domains of health (general self-rated health, sleep, mood improvement, and physical 

improvement). Hispanics and whites were more likely to report improvements in these domains than African Americans, although all racial 

and ethnic groups benefited from the intervention. Depression was a potent mediator. 

Comments As a more cohesive intervention than REACH I, REACH II accordingly had stronger results.

REACH Resources 

Developer/Author Description of Content Target Audience Resource Type

American Psychological 

Association

This page contains links to a brief overview of the purpose, strategy used, and 

research outcomes of the REACH I and REACH II studies.

Alzheimer’s caregivers, 

family caregivers for 

persons with dementia

Webpage

Family Caregiver 

Alliance

This page contains the transcript of a Q&A with the developers of the REACH 

Community program and gives information on how it was developed, how it 

works, where it has been implemented, and how organizations adopt it.

Caregivers and 

organizations interested 

in REACH

Webpage

Best Practice Caregiving This page is a comprehensive program profile and provides information on 

program components, programs costs, sources of funding, implementation and 

research evidence.

Caregivers and 

organizations interested 

in REACH

Webpage
18

Screening, Brief Intervention, and Referral to Treatment (SBIRT) SBIRT is an approach to the delivery of early intervention and treatment to people with substance use disorders and those at risk of developing these 

disorders. Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment. Brief intervention focuses on increasing 

insight and awareness regarding substance use and motivation toward behavioral change. Referral to treatment provides those identified as needing more 

extensive treatment with access to specialty care. SAMHSA frequently offers grant funding to eligible state governments, federally recognized American 

Indian/Alaska Native (AI/AN) tribes, and public and private non-profit health care or behavioral health care systems for SBIRT services. 

Research 

Summary Re-analysis of data from a previous evaluation of the SAMHSA program that reported large positive effects but was widely criticized for 

poor methodology

Citation Aldridge, A., R. Linford, et al. (2017). Substance use outcomes of patients served by a large US implementation of Screening, Brief 

Intervention and Referral to Treatment (SBIRT). Addiction 112(S2): 43-53.

Study design Evaluation of SAMHSA SBIRT grantee programs using multi-site pre-post, clustered design. Each program developed its own SBIRT model. 

Most used the validated Alcohol Use Disorders Identification Test (AUDIT) and the Drug Abuse Screening Test (DAST). Services were 

provided by specialists (e.g., social workers, substance abuse counselors, health educators) who were associated with the SBIRT project, 

pre-screening and screenings were also conducted at some sites by a combination of medical generalists (e.g., nurses) and selfadministration. All projects incorporated motivational interview techniques. This report used multi-level models on matched pre–post 

patients to account for the clustering of observations and to explore possible bias from sample selection and attrition.

Population Sample of 754,525 patients, 171,921 of whom screened positive for hazardous or harmful use and were recommended to brief 

intervention (BI), 10% sample randomly selected for follow up with 48% response rate. Separate comparison of outcomes for BI, brief 

treatment (BT) and referral for treatment (RT).

Outcomes Estimates of substance use reduction were smaller than the previous analysis but still positive. Prevalence of alcohol use was lower 6 

months later by 35.6%, heavy drinking by 43.4% and illicit drug use by 75.8%. Greater intervention intensity was associated with larger 

decreases.

Comments The authors note that without a comparison group, “study design does not support causal conclusions and estimated decreases in 

reported substance use are due, at least in part, to a well-known set of confounders and natural substance use patterns that may be 

unrelated to any particular SBIRT intervention.” However, the authors compared their results to a review of 32 controlled trials of Brief 

Interventions targeting alcohol problems and found that their results were within ranges of estimates from a large number of past SBIRT 

trials. Other studies have shown that SBIRT lacks efficacy in settings other than primary care such as emergency rooms and that 

effectiveness is limited for other drugs and mental health conditions such as depression and anxiety [Field, C. A., Baird, J., Saitz, R., 

Caetano, R., & Monti, P. M. (2010). The mixed evidence for brief intervention in emergency departments, trauma care centers, and 

inpatient hospital settings: what should we do? Alcohol Clin Exp Res, 34(12), 2004-2010].

Resources 

Developer/Author Description of Content Target Audience Resource Type

SAMHSA This page provides links to information about SBIRT, coding 

for reimbursement, SBIRT grantees, and a link to find more 

resources on SBIRT.

Organizations interested in early 

intervention and treatment to people 

with or at risk for substance use disorders 

Webpage

SAMHSA Technical Assistance 

Publication Series (TAP 33)

This document provides information on system-level 

implementation of SBIRT, sustainability, and case examples.

Organizations interested in implementing 

SBIRT

PDF 
19

Wellness Recovery Action Planning (WRAP) WRAP® is a personalized wellness and recovery process with the goal to help individuals monitor their feelings and behaviors, increase personal 

empowerment, and improve quality of life. It can be used by individuals and by health care systems and mental health systems to address all kinds of 

physical, mental health and life issues. 

Research 

Summary The study compared WRAP, a peer-led illness self-management intervention, to usual care.

Citation Cook JA, Copeland ME, et al. (2012). Results of a randomized controlled trial of mental illness self-management using Wellness Recovery 

Action Planning. Schizophr Bull 38(4): 881-891.

Study design A total of 519 adults with severe and persistent mental illness were recruited from outpatient community mental health settings in six

Ohio communities and randomly assigned to the 8-week intervention or a waitlist control condition. Outcomes were assessed at end of 

treatment and at 6-month follow-up. 

Population One fifth (21%) reported diagnoses of schizophrenia or schizoaffective disorder, another 38% reported bipolar disorder, and another a 

quarter (25%) reported a depressive disorder. Most were not employed (85%) nor married/cohabiting (88%). About three fourths had a 

history of psychiatric inpatient treatment.

Outcomes Primary outcome was reduction of psychiatric symptoms, with secondary outcomes of increased hopefulness and enhanced quality of 

life. Compared to controls, at immediate post-intervention and at 6-month follow-up the WRAP participants reported: 1) significantly 

greater reduction of symptoms; 2) significantly greater improvement over time in hopefulness; and 3) enhanced improvement over time 

in quality of life. Positive changes persisted for at least 6 months after the intervention’s conclusion.

Comments This is a well-designed study with careful randomization and blinding and using an intention-to-treat (ITT) analysis. One possible 

confounding factor is that both the intervention and control groups were involved with other peer support services, thus possibly 

resulting in underestimating the effect that would occur in settings with fewer peer support resources.

Resources 

Developer/Author Description of Content Target Audience Resource Type

Advocates for 

Human Potential, 

Inc. (AHP)

This page offers information on uses/benefits of WRAP, key recovery 

concepts, action plan and access to WRAP wellness tools

Individuals, healthcare and mental 

health systems interested in addressing

all kinds of physical, mental health and 

life issues

Webpage

Copeland Center This page provides information about starting a WRAP program and 

facilitator training. 

Individuals and organizations

interested in WRAP 

Webpage