Community-based care management services are vital in helping New York City’s most vulnerable members navigate an evolving healthcare landscape. CBC’s Pathway Home™ (PH) program is an evidence based multidisciplinary care transition intervention, tailored to walk side by side members from institutional setting back to their communities, providing emotional and practical support every step of the way. Pathway Home™ specializes in care transitions from a variety of institutional settings such as State Psychiatric Centers, Adult Homes, Hospital Inpatient Units, and transitional living residences. Pathway Home’s™ unique approach builds trust and rapport to mutually design a transition plan while inpatient, segueing into intensive supportive community-based visits. Through modelling and active linking from the PH multidisciplinary team, members strengthen skills for independence and take active ownership over their healthcare needs. The multidisciplinary team is comprised of Licensed Mental Health Clinicians, Case Managers, Registered Nurse, and Peer Specialists. Pathway Home™ utilizes several evidence-based practices such as Critical Time Intervention (CTI), Harm Reduction, Motivational Interviewing, and Peer Support. Peers are those with shared lived experience of mental illness, substance use, or homelessness who utilize disclosure to engage, develop, and strengthen rapport with the members.
This article highlights the important peer role within CBC’s Pathway Home™ team including the influence on the care team relationships and member/provider relationships. It’s well known that the peer is meant to build a connection using disclosure and comradery to establish a safe space for recovery, wellness, and growth. Traditional multidisciplinary teams have established robust structures for community-based services but often have limited experience in adopting a meaningful place for peers. The mental health clinicians provide clinical and therapeutic support and registered nurses use medical expertise to provide health education and linkages to medical care. However, the peer specialist position, can feel vague and arbitrary. The function of the peer specialist is inconsistent across providers and has been challenging for peers to establish their legitimate role in a care team.
Peer Amongst Peers
The perspective of an individual with lived experience is an important team-based tool just like a nurse providing a medical perspective to inform the team around physical health. Some members have histories of poor experiences in care and when offered services may find that these past experiences are a negative anchor and decline services. Staff desensitization, compassion fatigue, and burn-out create unintended therapeutic relationship barriers. The peer helps to remediate and heal this by building the member and team connection. They purposefully share their own experience of receiving care with the goal of increasing the intervention’s acceptance. The peer’s perspective on the receiving end of empathy fatigue can point this out to team members and remind them that the individuals have valid experiences and voices.
In a more active way, the peer will use language to help guide the Pathway Home™ team. In their training, peers are encouraged to use conversational speech rather than clinical language. This is with good reason as the peer embodies the person-centered approach especially in the language they use when discussing a member. Established clinical language is a refined and convenient short-hand form to communicate information in a field where time is limited, but it has its deficits, e.g., stigma, lack of clarity, barriers to empathy. There are so many ways to reframe a mental health experience, to shed preconceived notions and stigma that are often associated with them. The peer specialist, who has first-hand knowledge of how language impacts treatment, is best placed to guide the team in broadening their vernacular by circumventing stigmatizing language and activities. Through dialogue and a person-centered approach, the peer minimizes repetitive language, energizes the team, and reminds colleagues of basic truths; we do not have issues, we have challenges, we do not have weaknesses, we have barriers, we are not clients, we are members.
Bridging the Member/Provider Dynamic
Building trust between a member and their various healthcare providers is innately challenging. A common issue is the power imbalance between members and their providers. The provider who takes on the role of expert often results in member’s self-doubt and acquiescence. Unfortunately, and unintentionally, that dynamic can breed distrust and create an “us vs. them” dynamic where the provider is perceived as ill-intended. This is exacerbated in times of crisis that end with an adverse event such as hospitalization where members experience the process as punitive and/or threatening. A core element of the peer role is to validate member feelings, experiences, and circumstances. They connect to members and establish trust that encourages discussion about the recovery journey. While other disciplines can provide validation and use disclosure, the peer role is invaluable, as it involves trust through mutuality.
The peer embarks on a conversation fostering a different kind of relationship. They share their stories and actively listen in return. There is reciprocity, transparency, and mutuality to provide comfort in situations that can feel very isolating. In other words, it’s an organic conversation between two people. I am not a clinician; I am not here to assess you. I know how scary being hospitalized can be, I’ve been there too. Let’s see how we can put our heads together and figure out how to best support you. The hope is to build trust which encourages the member to be more open to sharing their concerns with treatment and their requests about how to move forward.
When this conversation takes place on a psychiatric unit, (a common occurrence with Pathway Home™), education and advocacy can then play a key role in building trust. Residing in an inpatient unit can be traumatic in its own way and elicit mixed emotions. Sometimes a member needs more clarity on their discharge plan, doesn’t understand their rights as a consumer, or is too afraid to ask questions. The peer can help bridge that gap by being a trustworthy person that provides feedback, clarity, and suggestions based on their own experiences in treatment. This knowledge then allows the peer, along with the PH team, to advocate for the member and provide education.
Implications for the Field: Sharing with Intention
The behavioral health sector has focused on increasing awareness and education on person centered care, strength-based language, and ensuring members are the drivers of their own recovery. The peer specialist role was/is most prepared for this movement. When utilized well the peer specialist both assists the member and equally important educate staff from other disciplines. The lived experience and the comradery are just the tip of the iceberg when it comes to the underlying context and plethora of care that a peer specialist can provide. The peer has a story, the member has another, both are equally valid, and they can learn from each other, guiding others within the healthcare system through their humanistic lens.
Angelo Barberio, MA, CASAC II, is Director, Pathway Home™, at Coordinated Behavioral Care, Inc. (CBC). Maynor Alas is a Peer Specialist/Care Manager, Pathway Home™, at Samaritan Village. For more information about Coordinated Behavioral Care, inc. or Pathway Home™, please visit www.cbcare.org. For more information about Samaritan Village, please visit www.samaritanvillage.org.