SAMHSA defines a peer provider as “a person who uses his or her lived experience of recovery from mental illness and/or addiction, plus skills learned in formal training, to deliver services in behavioral health settings to promote mind-body recovery and resilience.” Generally, peer providers are known as “peer support specialists” in mental health settings. Peer support specialists are distinguished from traditional mental health service providers by their lived experience recovering from mental illness. People with serious mental illness generally receive longer term and more intensive treatment—either in a primary care or specialty setting—and peer support specialists may play a key role in the recovery process for these individuals. Peer support specialists work in a variety of settings, including clinical settings such as hospital emergency rooms, independent peer-run organizations, and on support teams in housing agencies that help eligible low-income families and persons with disabilities find rental housing. They can also deliver a varied set of services, including sharing of experience, goal-setting, developing coping and problem solving strategies to help individuals self-manage their mental illnesses, and linking individuals to desired resources like transportation or volunteer opportunities. Importantly, the services provided by peer support specialists complement, but do not replace, clinical services. Like other behavioral health specialties, the requirements for certifying peer support specialists vary by state, and certification bodies range from state government entities to independent non-profit organizations. The development of state-level peer support specialist certification programs was largely driven by another HHS agency, the Centers for Medicare & Medicaid Services, which in 2007 recognized peer support services as an evidence-based mental health model of care and established minimum requirements for states seeking federal Medicaid reimbursement for peer support services. One of these requirements is that peer support specialists complete a training and certification program as defined by the state. Another requirement is that peer support specialists receive supervision from a “competent mental health professional,” which may be provided through direct oversight or periodic care consultation. The state defines the amount, scope, and duration of the supervision as well as who is considered a competent mental health professional. States have used the flexibility allowed by the Centers for Medicare & Medicaid Services to create their own programs to certify peer support specialists. Some of these state peer support specialist programs are assessment-based certificate programs—programs that provide training and then evaluate whether applicants achieved the learning objectives of that training through an examination in order to receive certification. Other programs are professional certification programs—programs that evaluate applicants against predetermined standards of knowledge, skills, or competencies. In professional certification programs, the certifying body is independent from, and is not responsible for, the training process. SAMHSA supports the peer support specialist field through training, technical assistance, and grant funding. For example: From 2009 to 2014, SAMHSA partnered with stakeholders, such as the National Association for State Mental Health Program Directors, to gather nationally-recognized experts and stakeholders from across the United States for an annual meeting. These meetings, known as the “Pillars of Peer Support,” aimed to identify and create consensus around factors that facilitate the use of peer support services in state mental health systems of care. In 2015, SAMHSA developed core competencies defining the critical knowledge, skills, and abilities needed by anyone who provides peer support services through a technical assistance project. According to officials, the core competencies were developed in response to inconsistencies in the training and certification of peer support specialists that emerged as states began to develop their programs. SAMHSA’s core competencies reflected the five foundational principles of peer support identified by consumers and other stakeholders: services should be (1) recovery oriented; (2) person- centered; (3) voluntary; (4) relationship-focused; and (5) trauma informed. In addition to developing the core competencies, the project provides trainings and offers technical assistance to states, counties, providers, and other stakeholders. Although Medicaid provides the largest share of funding for state mental health agencies, followed by state funds, SAMHSA also provides grant funding that states can use for both the service and administrative components of their peer support specialist programs. For example, SAMHSA’s Center for Mental Health Services funds peer support programs through its administration of the Community Mental Health Services Block Grant, which provides flexible funding to the states to support services and related support activities for individuals with serious mental illness. While the Community Mental Health Services Block Grant accounted for less than 1 percent of total revenues received by state mental health agencies in fiscal year 2015, the flexibility of the funds allows them to be expended to pay for services that Medicaid and other health insurance will not pay for, such as training and developing standards. In fiscal year 2018, 40 states and the District of Columbia reported using the funds from the Community Mental Health Services Block Grant for peer support. SAMHSA also provides discretionary grants directly to domestic nonprofit organizations that aim to expand the capacity of peer support providers. These discretionary grants, including the Statewide Consumer Network Program grants, have helped establish recovery-oriented, consumer- driven services at the state level. SAMHSA also provides block and discretionary grants focused on substance use through its Center for Substance Abuse Treatment and Center for Substance Abuse Prevention, both of which have been used for peer recovery coaches. While most states use SAMHSA grants and state general funds to develop and sustain their peer support programs, as of 2016, 41 states and the District of Columbia were receiving federal Medicaid reimbursement for the services provided by peer support specialists. Georgia was the first state to receive federal Medicaid payment for peer support services in 1999, and additional state Medicaid programs began to provide coverage of peer support after the Center for Medicare & Medicaid Services issued guidance in 2007 on the requirements for federal payment for such services. In addition to meeting the minimum requirements for peer support services—including training and certification, supervision, and care coordination—states that bill for peer support services under the Medicaid program must comply with all Medicaid regulations and policies. Programs in all six states that we reviewed generally use the same process for screening, training, and ultimately certifying peer support specialists. See figure 1 for an illustrated example of this process. Although the six states’ programs generally use the same process for certifying peer support specialists, as of May 2018 the programs varied in the specific requirements applicants must meet for each of the three stages of certification: screening, training, and certifying. See appendix II for detailed information on state program requirements. To determine applicants’ eligibility for peer support specialist certification, all six state programs we reviewed have screening requirements applicants must meet when applying for certification. These screening requirements include requirements related to education, lived experience with mental illness, prior work or volunteer experience, and letters of recommendation. The extent to which each screening requirement was used by each state varied, and the specifics of each requirement also varied across the six programs we reviewed (see fig. 2). Education. Five of the six states that we reviewed required a high school diploma or equivalent. Officials from four of these states indicated that this level of education was necessary given the skills needed by peer support specialists, such as reading comprehension and communication skills. In contrast, Oregon officials told us that they did not require a high school diploma or equivalent; however, the officials noted that most of their peer support specialists have at least a high school education. Mental health experience. While all six state programs we reviewed required applicants to have lived experience in recovery from mental illness, the programs implemented this requirement in different ways. Some required a mental health diagnosis, while others required a minimum length of recovery time or required applicants to have received services for a mental illness. Texas officials said they did not have a specified length of recovery requirement due to the difficulty of pinpointing the specific time a person began his or her recovery; rather, Texas required applicants to self-identify as having experience living in recovery. Prior work or volunteer experience. Three of the six state programs required applicants to have prior relevant work or volunteer experience, although the amount of experience required varies. For example, to start the certification process, applicants in Michigan must be currently working in a peer support specialist role and have been in that position for at least 10 hours a week for the past 3 months. In contrast, Georgia officials told us that they found this requirement to be a barrier for some individuals who have not been able to work; therefore, Georgia did not have this requirement. Letters of recommendation. Three of the six states required letters of recommendation as another way to assess applicants’ readiness to become peer support specialists. State officials stressed that the letter should be a personal, work, or volunteer reference, rather than a clinical reference. To ensure the competence of the peer support specialist workforce, all six state programs we reviewed required applicants to complete an initial training, which we refer to as “core training.” The core training is the initial training provided to applicants seeking to become certified peer support specialists and, while the curricula may vary by state or training vendor, its purpose is to convey the skills and competencies that peer support specialists need to enter the workforce. Topics covered during the training typically include ethics, recovery, sharing the recovery story, and communication skills. (See app. III for an example of a peer support specialist core training schedule.) While all six states require applicants to attend core training, the length, cost, and curricula of these trainings varied across the states, as figure 3 shows. Length of training. All six programs required at least 40 hours of in- person core training, with Georgia and Pennsylvania requiring more than 70 hours. The six states required at least a week of core training to allow sufficient time to cover a core curriculum of general peer-related information, such as the meaning and role of peer support services, and at times including role play, in an effort to develop the interpersonal skills needed for an effective peer leadership. Cost of training. All states but Florida charged applicants fees to attend training. Training fees varied by state, ranging from $85 in Georgia to $1,400 in Pennsylvania. These fees varied because what they covered also varied. For example, state program officials from Michigan told us that, among other things, the $600 fee covers the price of lodging for the core training, consultant fees, materials, and college credit hours that can be earned by attending the training and the graduation ceremony. In contrast, state program officials from Georgia told us that the $85 they charge covered the cost of producing the course manual and that all other costs are covered by the state. Training curriculum. Four of the six state programs had their own approved core training curriculum to be used for applicants, while the remaining two programs in Oregon and Pennsylvania allowed applicants to select from approved training vendors—each of which had its own training curricula. To complete the certification process, all state programs we reviewed assessed applicants’ knowledge of the concepts taught in the core training through an examination. The applicants also had to sign and abide by a code of ethics. However, as of May 2018, the state programs varied as to who administered the certification examination, the type of code of ethics applicants were required to sign, the frequency with which certifications had to be renewed, and the continuing education requirements certified peer support specialists had to meet. (See fig. 4.) Examination. Four of the states we reviewed administered a single, statewide exam that applicants must pass before becoming certified, while in the remaining two states applicants had to pass an exam administered by the approved training vendor. The exams included multiple choice or essay questions. One training vendor responsible for conducting training in at least two states told us that the vendor included an oral evaluation component as part of the exam, in light of the communication and interpersonal skills needed for the peer role. Similarly, a state program official from Pennsylvania told us that observational assessments are also used to determine an applicant’s skills and knowledge. Code of ethics. Like other health professions, peer support specialists typically must agree to abide by a code of ethics. All six states we reviewed required peer support specialists to sign a code of ethics before becoming certified. Of the six states, the codes of ethics in Pennsylvania, Georgia, Michigan, and Texas were unique to peer support specialists, while Florida and Oregon used codes of ethics that also applied to other workforces, such as substance use disorder professionals and community health workers. Relatedly, five of the six states also had formal processes in place to investigate and take action in the event that a peer violated the code of ethics by, for example, disclosing confidential information. These actions range from reprimand to revocation of certification. Certification renewal. Three of the six states we reviewed required peer support specialists, once certified, to renew their certifications every 1 to 3 years, while the remaining three states awarded lifetime certifications. Continuing education. Five of the six states required certified peer support specialists to meet annual continuing education requirements, which ranged from approximately 10 hours per year to 36 hours every 2 years. According to some state program officials, requiring continuing education ensures continued competence in the field of peer support or provides specialized training, such as training for working with specific populations (such as veterans) or incorporating additional approaches or skill sets (such as training about the Wellness Recovery Action Plan). Officials from peer support specialist programs in selected states generally cited six leading practices for certifying peer support specialists. The 10 stakeholders—representing the perspectives of researchers, training or consulting organizations, associations, and advocacy organizations—we spoke with generally agreed that the six identified leading practices should be incorporated into programs that certify peer support specialists because the practices can lead to stronger quality of services for individuals with serious mental illnesses. Leading practice one: Systematic screening of applicants. Program officials in five of the six selected states cited the importance of systematic or detailed screening of applicants to become peer support specialists as a leading practice. All six state programs assessed applicants through a variety of approaches, including (1) using screening questions about the applicants’ understanding of the peer role, (2) conducting telephone interviews with applicants, (3) reviewing applications with a standardized tool or scoring rubric, and (4) having multiple people review applications for objectivity. Eight of the 10 stakeholders we interviewed confirmed that this was a leading practice, though some cautioned that these requirements should not unnecessarily exclude individuals with unique backgrounds or little work history. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, which in 2011 explored how to most effectively apply peer support in the military environment as part of its ongoing mission, has similarly identified systematic screening with defined selection criteria as a best practice for peer support programs. While work or volunteer experience can be used as a screening requirement for applicants and was required by three of the states we reviewed, four of the stakeholders we interviewed commented that meeting these requirements can be challenging for individuals with a history of mental illness who may have been previously unable to enter the workforce. Research has shown that the stigma associated with mental illness is a significant barrier to work for individuals with mental illness and has shaped employer decisions about hiring or keeping a person with mental illness in the workplace. These workplace barriers, along with others, such as access to mental health treatment, contribute to the relatively low workforce participation of adults with serious mental illnesses. One stakeholder commented that peer support programs have a responsibility not to contribute to barriers in the workplace for individuals with mental illnesses. Our review shows that some of the peer support specialist programs in the six selected states are taking steps to address these barriers. For example, Florida recently changed its requirements and now provisionally certifies peer support specialists who meet all the certification requirements except for the requirement to have 500 hours of work or volunteer experience. After receiving the provisional certification, peer support specialists have 1 year to complete the work or volunteer hours necessary to upgrade to the full certification. Leading practice two: Conducting core training in-person. Program officials from five of the six selected states cited core training that is conducted in-person, as opposed to online, as a leading practice. Three program officials told us that core training should be done in-person to foster relationship building and experiential learning to develop the interpersonal skills a certified peer support specialist needs. All six state programs had in-person core training, regardless of whether the training was run by the state program itself or through approved vendors. For example, Michigan hosts its core trainings at a retreat center where participants are encouraged to stay for the week. Michigan program officials told us that this creates a place for training participants from across the state to network, discuss how their agencies work and the types of issues they face as peer support specialists, and share best practices. SAMHSA’s core competencies identify the importance of using active listening skills, understanding when to share experiences and when to listen, and using their own recovery story to inspire hope. All 10 stakeholders we interviewed confirmed that providing in-person training was a leading practice, though 3 commented that some of the knowledge segments could be done online. Five stakeholders we interviewed told us that observing the skills of peer support specialists during training or incorporating observation as part of the certification exam is important. One stakeholder explained that while written tests are a good measure of basic knowledge, the tests cannot fully assess the skills and competencies needed for certification. While 2 stakeholders cited the increased costs of delivering and grading exams with an observational component as the reasons many states use written exams only, 1 stakeholder noted that including an observational component is a more accurate assessment of whether or not people have developed needed skills. Another stakeholder commented that using a written test alone may allow individuals who are good test takers to become certified, even if they lack the interpersonal skills needed to be a peer support specialist. Leading practice three: Incorporating physical health and wellness into training or continuing education. Program officials from five of the six selected states cited the importance of emphasizing to peer support specialists that they should help others manage their physical health—in addition to their mental health—during core training or continuing education as a leading practice. All six of the selected states incorporated managing physical health conditions into their core training or continuing education. (See text box.) In these trainings, peer support specialists learn how to help others with access to needed care and prevention services, set personal health goals to promote recovery and a wellness lifestyle, and adopt healthy habits to prevent disease or lessen the impact of existing chronic health conditions. The need for physical health- related training was identified after a 2006 report found that individuals with serious mental illnesses were dying 25 years earlier than the general population, largely due to treatable medical conditions caused by modifiable risk factors, such as smoking and poor nutrition or obesity. SAMHSA identified educating peers about health, wellness, recovery, and recovery supports as a core competency. All 10 stakeholders we interviewed confirmed that emphasizing the importance of physical health was a leading practice, though 2 stakeholders commented that incorporating physical health and wellness into trainings should only be done as continuing education. Example of Leading Practice Three: Georgia Peer Support Whole Health and Wellness Georgia determined it was important to incorporate physical health and wellness into training for peer support specialists and was the first state to have related services— which it calls Peer Support Whole Health and Wellness—provided by certified peer support specialists covered by Medicaid. These peer support specialists—who complete additional training and are certified in Whole Health Action Management—receive medical technical support from registered nurses and are trained to work in both primary care and behavioral health settings. Georgia created the service using a SAMHSA- funded Transformation Transfer Initiative grant, which was designed to give states the opportunity to increase their efforts to make their state behavioral health delivery systems more consumer driven, among other things. The SAMHSA-Health Resources and Services Administration Center for Integrated Health Solutions adapted Georgia’s training, along with a training developed by New Jersey, to publish a Whole Health Action Management Peer Support Training Participant Guide in 2015. This adapted 2-day training aims to teach peers to use a person-centered planning process to create a whole health goal and how to engage in peer support, including Whole Health Action Management peer support groups, to meet that goal. Leading practice four: Preparing organizations to effectively use peers. Program officials from four of the six selected states cited efforts to ready provider organizations—such as hospitals or drop-in centers—to employ certified peer support specialists as a leading practice. State program officials told us that organizational readiness includes making sure staff understand the role of peer support specialists and can provide appropriate supervision. (See text box.) Five of the selected states have developed guidance or training for supervisors of peer support specialists. Nine of the 10 stakeholders we interviewed confirmed that this was a leading practice. SAMHSA identified using supervision effectively and engaging in problem-solving strategies with a supervisor as a core competency for this workforce. Example of Leading Practice Four: Michigan Peer Liaisons In order to help provider organizations understand the role of peer support specialists, Michigan created an informal peer liaison role at all 46 of the local Community Mental Health Services Programs tasked with coordinating mental health services. State officials told us that these peer liaisons have telephone calls and in-person meetings to provide informal feedback on technical assistance needs and share information on how certified peer support specialists are doing in their roles and responsibilities. According to state officials, peer liaisons have helped prepare mental health agencies to work with peer support specialists and have helped the state identify what new trainings should be developed to better help peer support specialists succeed in the workplace. Many of the stakeholders we interviewed highlighted the importance of having individuals in an organization who understand the peer support role. Eight of the stakeholders we interviewed told us that supervisors need to understand or be trained in the peer support role and skillset, with three stakeholders commenting that supervisors need to be specifically aware of the difference between peer support specialists and clinical providers. For example, to achieve this the training and certifying organization in Texas runs a twelve month program that helps provider organizations effectively implement peer support services. The program, which is designed as a learning community, focuses on changing organizational culture, defining and clarifying the peer support specialist role, and supervising these staff, among other things. Relatedly, three stakeholders told us that there should be more than one peer support specialist at each organization. One stakeholder noted that having multiple peer support specialists at an agency provides built in support and understanding of the peer role, which is important given that peer support specialists typically have the lowest level of power in an organization. Another stakeholder noted that putting a single peer support specialist in an organization can be isolating. Leading practice five: Continuing education requirements specific to peer support. Program officials from five of the six selected states considered it a leading practice to require, after certification, peer support specialists to take continuing education that is specific to the peer support role. This is to ensure that peers maintain their competency and are aware of new developments in the field. Five of the six selected states required certified peer support specialists to maintain their competence through continuing education, and all five of these states had a requirement that the continuing education be specific to the peer support role. (See text box.) All 10 stakeholders we interviewed confirmed that this was a leading practice. The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury similarly identified as a best practice enabling continued learning through structured training. SAMHSA identified seeking opportunities to increase knowledge and skills of peer support as a core competency for peer support specialists. Example of Leading Practice Five: Pennsylvania Continuing Education Requirement As an added step to ensure that the peer support specialist workforce is competent, Pennsylvania places some of the burden on provider agencies for ensuring that certified peer support specialists meet continuing education requirements. The state requires its licensed provider agencies to develop a staff training plan to ensure that each certified peer specialist receives the continuing education they need. Pennsylvania also requires these agencies to provide opportunities for certified peer specialists to network with other certified peer specialists both within and outside the agency. The state monitors compliance with these requirements through annual inspections. State officials told us that this requirement serves as a safety net and assures them that certified peer support specialists are up to date in their training. Leading practice six: Engaging peers in the leadership and development of certification programs. Program officials from four of the six selected states cited having certified peer support specialists lead or participate in the certification process of applicants as a leading practice. State program officials told us that peers should lead in a variety of ways, including helping screen applicants, developing curricula, providing training, and serving as mentors or supervisors to other certified peer support specialists. For example, Michigan concurrently runs its continuing education courses and core training in the same location so that experienced peer support specialists can mentor new peers. Officials from all six selected states told us that certified peer support specialists in their states participate in some part of the certification process. (See text box.) The Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury similarly identified as a best practice leveraging the unique experiences and benefits peer support specialists offer as peers throughout a peer support specialist program, including in positions of leadership. All 10 stakeholders we interviewed confirmed that this was a leading practice. Example of Leading Practice Six: Oregon Traditional Health Worker Commission Through service on a statewide commission, peer support specialists in Oregon have a leadership role in developing the education and training requirements for certified peer support specialists and others. The Oregon Health Authority’s Traditional Health Worker Commission promotes the role, engagement, and utilization of traditional health workers—health workers who are certified by the state—in Oregon’s health care delivery system. The commission includes member representatives of each type of traditional health worker, including peer support specialists. In addition to developing the education and training requirements for peer support specialists and other types of traditional health workers, the commission developed the scope of practice to be used by provider organizations that employ peer support specialists. On an ongoing basis, the commission advises the Oregon Health Authority about the traditional health worker program and ensures that the program is responsive to consumer and community health needs. Oregon state officials consider having this advisory body with representation from the peer community to be a best practice, commenting that the commission provides the hands-on knowledge that the state can then implement through policy and rules. We provided a draft of this report to HHS for review and comment. The Department did not have any comments. We are sending copies of this report to the appropriate congressional committees, the Secretary of the Department of Health and Human Services, the Secretary of the Department of Defense, and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staff should have any questions about this report, please contact me at (202) 512-7114 or DeniganMacauleyM@gao.gov. Contact points for our Office of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix IV. Recovery experience Must have lived experience with a mental illness or substance use disorder and have been in recovery for a minimum of 2 years. Must have been in recovery for at least 1 year between diagnosis of mental illness or substance use disorder and application for training program. Must have been diagnosed with a mental illness and been in recovery for a minimum of 1 year. Must currently be or formerly have been receiving services for mental illness or substance use disorder. Must currently be or formerly have been receiving services for a mental illness. Minimum of 12 months of work or volunteer experience within the last 3 years Not required 2 (type unspecified) Must self-identify as being in recovery from a mental health challenge. For the purposes of this report, we use the term “peer support specialist” to describe individuals who use their own lived experience recovering from mental illnesses to support others in their recovery; however, each state may have different titles in place for the certified role achieved through their peer support specialist programs. The training schedule below, developed by the Appalachian Consulting Group, illustrates the content areas that may be included in core training curriculum for peer support specialists seeking certification. The Appalachian Consulting Group’s curriculum was used in the first Medicaid-billable peer support specialist program in Georgia in 1999, and since then the curriculum has been used to train peer support specialists in 25 states. This training schedule is an example of the types of content that could be included in such training, and is not an endorsement of a particular training curriculum. In addition to the contact named above, Tom Conahan (Assistant Director), Summar Corley (Analyst-in-Charge), JoAnn Martinez (Analyst- in-Charge), Kaitlin Asaly, Muriel Brown, Krister Friday, and Emily Wilson made key contributions to this report.

Summary: As the peer support workforce has grown, there has been increased attention to standardizing the competencies of peer support specialists through certification. The 21st Century Cures Act included a provision for GAO to conduct a study to identify best practices related to training and certification in peer support programs in selected states that receive funding from SAMHSA. This report, among other things, describes leading practices for certifying peer support specialists identified by program officials in selected states. GAO interviewed state program officials in six selected states and reviewed online, publicly available information about their peer support programs. GAO selected the states in part based on the state's certification program being well-established (at least 2 years old), use of SAMHSA funding for peer support, and stakeholder recommendations. The six selected states—Florida, Georgia, Michigan, Oregon, Pennsylvania, and Texas--are among the 41 states and the District of Columbia that, as of July 2016, had programs to certify peer support specialists. In addition to the state program officials, GAO interviewed SAMHSA officials and 10 stakeholders familiar with peer support specialist certification, including mental health researchers and officials from training organizations, among others. GAO provided a draft of this report to HHS for review and comment. The Department did not have any comments. According to officials from the Substance Abuse and Mental Health Services Administration (SAMHSA) within the Department of Health and Human Services (HHS), shortages in the behavioral health workforce are a key reason that individuals with mental illnesses do not receive needed treatment. In recent years, there has been an increased focus on using peer support specialists—individuals who use their own experience recovering from mental illness to support others—to help address these shortages. Program officials GAO interviewed in selected states generally cited six leading practices for certifying that peer support specialists have a basic set of competencies and have demonstrated the ability to support others.