Where Do Peer Providers Fit into Newly Integrated Behavioral Health Care Teams? a Mixed Method Study

Background: Peer providers use lived experience of mental health recovery plus professional skills to deliver mental health services. Peer providers have been increasingly used in the public mental health system, with roles including wellness coaching and health navigation.  Yet some mental health agencies are still reluctant to implement peer-support programs even though a recent systematic review suggests that peer-based services are equally or more effective than usual care. Further, there is little known about the level of involvement of peer providers in behavioral health care teams that provide integrated primary care.  This mixed method study evaluates where peer providers fit within newly integrated primary and behavioral health care teams using social network analysis coupled with qualitative field work. Integrated teams are part of a policy initiative that is being conducted by the Los Angeles County Department of Mental Health.

 Methods: This study used a convergent parallel design to understand the roles of peer providers on integrated teams.  An online survey collected sociometric data from staff members of 24 integrated pilot programs during 2014. Survey respondents nominated individuals with whom they regularly coordinate client care from a roster. Structural analyses (network size and density) and positional measures (indegree centrality and betweenness) were calculated to understand the network positions of peer providers.  CONCOR procedures were conducted to identify the roles of peer providers within network subgroups. Qualitative interviews were also conducted with peer providers themselves to discuss their role within the team. Qualitative interviews were audio recorded, transcribed, and then analyzed using constant comparative methods informed by grounded theory. Consistent with a our mixed methods design, results from social network and qualitative analyses were triangulated to determine if the findings were convergent, expansive, or discrepant.

 Results: Fourteen integrated programs included peer providers on their integrated teams.   Network sizes ranged from 8-23. CONCOR analyses revealed substantial variation with respect to implementation of peers across models.  Four programs’ peer providers were included in the highest status network subgroup, while 3 programs’ peer providers were included in the lowest status network subgroup.  Qualitative analysis provided nuanced understanding of differences in the professional roles of peer providers in these groupings.  Qualitative data indicated that variation in CONCOR groups was related to the conceptualization of a peer provider, namely whether it meant to have a shared mental health condition or cultural background.  In fact, peer providers in the highest status network sub-groups had lived experience of mental health recovery and reported being were directly involved in care management of clients, while those in the lowest status groups shared a cultural background and conducted community outreach rather than care coordination.

Discussion:  Social Network Analysis is useful for understanding whether and how integrated health care teams implement peer providers.  This analysis reveals that peer providers do not fit uniformly into integrated teams.  Targeted efforts are needed support the implementation of peer providers in integrated care programs both at the individual program and system levels, while accounting for agency-specific roles of peer providers.