As we stand at the nexus of health care reform, Olmstead requirements and budget pressures, national, state, managed care and health home systems are seeking innovations that provide recovery supports, rights protection, transitional supports, outreach and engagement, crisis diversion and health literacy.
Across the nation and New York state, peer services have so grown in sophistication, effectiveness and reach to be a powerful force in this environment. New York State's Medicaid Redesign Team's Behavioral Work Group recommended that New York State should "promote acknowledgement and respect for the unique contributions and value of Peers in delivering services that help people, promote wellness and decrease costs." The recommendations also urge new systems to incorporate peer services into health homes as a required element in health home applications, given the recognition that peer services are evidence-based practices which can improve outcomes while being cost effective.

Accordingly, there is a great increase in the awareness, valuing and interest in expanding peer services among new payers. However, payers appear confused about what services are available (different terms, different models and approaches), what constitutes "true" peer-run services, who should operate them, at what cost and with what expectations around health care and other outcomes.  This paper proposes to provide some clarity and guidance in these areas.

Judi Chamberlin's seminal 1978 book about "Patient-Controlled Alternatives to the Mental Health System" galvanized the self-help and advocacy movement and led to the rise of peer support, whose key elements include:

  • Sharing, validating and normalizing similar experiences
  • Building empathy, sharing opportunities for connection and knowledge
  • Building honest mutually responsible relationships
  • Based on the intention to change patterns and get unstuck
  • Full respect for each person's unique process of change
  • Willingness to challenge each other

Peer support offers people an alternative to traditional treatment relationships peers have often found pathologizing, distancing and alienating, judgmental and/or artificial, culturally unaware and/or insensitive, controlling and/or rescuing, infantilizing and disempowering. Too often, a person's "story" is defined and mirrored back by our system as a "snapshot of me at my worst moment" and one that neither promotes hope, dignity and full citizenship or healing and spirituality.

Authentic peer-operated services embody values, which include:

  • the sharing of a common bond among persons providing services and persons using services rooted in their common experience.
  • giving persons participating in service programs a significant voice in the planning, development and evaluation of the services they use.
  • mutuality between staff and volunteers providing services and persons using services.
  • an environment distinguished by voluntariness, openness, personal choice, the sharing of common experience, respect for individual dignity and a spirit of liberation.
  • a governing and operating structure typified by shared decision-making, flexibility, ethical integrity, and confidentiality.

To qualify as an authentic peer-run program, organizations must meet the following criteria:

  • At least 51% of Board members must be peers;
  • All Boards of authentic peer-run organizations, regardless of the percentage of peer membership must have a quorum made up of peers for voting purposes;
  • Peers must hold the majority of staff positions in a peer-run organization, including all the leadership and program management positions.  Peers must supervise non-peers working for the organization;
  • Peer initiatives that contract with a fiscal sponsor or fiduciary qualify as peer-run if the following conditions are met:
    • the program is staffed by a majority of peers, including all the leadership and program management positions; peers supervise all non-peers.
    • all personnel decisions are made solely by the peer program.
    • all program decisions are made solely by the peer program.
    • all financial decisions, except those dealing with the administrative needs of the fiscal sponsor (e.g., costs for accounting, administering program funds, yearly audit, reporting) are made solely by the peer program.

To meet the criteria of peer-run organizations, programs must be governed, led, and staffed by individuals who qualify as peers. A peer is someone who has been affected by:

  • a psychiatric label and the prejudice associated with it.
  • determination by others (e.g., relatives, service providers) to lack competency and negative valuation as a result of diagnosis.
  • discrimination from family, friends, treatment providers and society in general.
  • major life disruptions such as homelessness, repeated unemployment, extended isolation, loss of important relationships, childhood and adult trauma and/or abuse, problems in pursuing dreams and personal goals, loss of civil liberty through institutionalization or other forms of confinement.
  • major, protracted experiences such as disabling fear, anxiety, depression, hopelessness, helplessness, stemming from having a diagnostic label or from traumatic life events and inhumane mental health treatment.
  • significant, positive altered states associated with energy, creativity, spirituality, and other like phenomena.

Peer staff are specially prepared to serve people with psychiatric diagnoses because of their background, which typically includes:

  • being labeled with a psychiatric diagnosis
  • being subjected to treatment over time that did not fit our needs, and which, in many instances, has been inadequate, disenfranchising, defeating, coercive, disrespectful and harmful; which has created dependency and failed to provide choice and promote selfdetermination
  • being denied choices of where to live, how to spend our time, and who to spend it with
  • being detained against our wills in hospitals, jails, other types of institutions and even in private homes
  • severe and prolonged abuse and trauma
  • poverty and homelessness, and the accompanying degradations.


Peer-run organizations are uniquely prepared and capable of providing effective and authentic peer services.
Accordingly, managed care organizations, health homes, provider networks and providers should contract with an outside peer support agency to provide services.

Any contract or RFP must identify how peer services will be incorporated into the managed care, health home or other service designs.

Peer support services should appropriately and effectively be extended into more situations, such as hospitals and nursing homes, to augment transitions to the community.”

Critical Components of Peer Support Services


Ensures a practice of reasonable accommodation, supported decision making, and attempts to establish, expand, protect, and enforce the human, legal, and civil rights of people engaged by the mental health system.

Examples of Tools & Services:
Peer Advocacy Services
Advance Directives
Systems Advocacy
Benefits & Entitlements Education
Rights Education

Practices that seek to build a relationship of trust and support with people who are experiencing significant challenges in their lives, including being homeless, disenfranchised and/or experiencing co-occurring health issues. These services should be offered in the spirit of choice, companionship, partnership and mutuality.
Examples of Tools & Services
Advance Directives
Peer Wellness Coaches
Drop In Centers

Information & practice of Alternative healing approaches like Acupuncture, Reiki, Aromatherapy, Meditation & Self Help.
Examples of Tools & Services:
Group Acupuncture
Workshops on alternative topics
Partnerships with alternative healers
Referrals to alternative healing practices

Recovery is a process of change whereby individuals work to improve their life by living a meaningful life in a community of their choice while striving to achieve their full potential.
Examples of Tools & Services:

Recovery Centers
Peer run Supported Housing
Peer Support Groups
Creative  expression and exploration
Community exploration
Education & skills development

Work with a person to build a bridge to their community by working with them to develop critical personal supports and linkages to essential resources that enable successful transition.

Examples of Tools & Services:

Bridging from jail and prison to home
Bridging from institutions to home
Bridging from home to the community

Working with a person to examine their experience with crisis and help them to decide what might be useful when in the midst of a crisis.  

Examples of Tools & Services:

Wellness Recovery Action             Planning (WRAP)
Intentional Peer Support
Peer Run Crisis Respite  programs
Peer Support Phone  Lines    


  • Peer Wellness Coaching and Centers
  • Peer Bridger: hospital, adult home, jail/prison to community
  • Peer Crisis Support and Diversion
  • Peer-run Housing
  • Peer-run Employment Services
  • Peer Independent Living Services (advocacy, entitlement, community linkages)
  • Peer-run Recovery Centers


    • A 2002 University of Pennsylvania study found supported housing produced an average of $16,282 in savings from reduced use of hospitals, ERs, shelters et al.
    • Housing Options annual recipient surveys for the past ten years have shown that 90% or more have less need for crisis intervention, 99% have found their housing stability has improved, 96% state that their ability to live more independently has improved, 94% indicate improvement in daily living skills; and 90% have reported an improvement in social and personal relationships.
    • More than 70% of the individuals who have transitioned by Housing Options from state psychiatric centers to the community have remained there for over one year (estimated annual savings $12,000,000).
    • A 2010 study by OptumHealth found that peer bridger hospital-to-community support services reduced Medicaid hospital days by 73% in Tennessee, 44.1% in Wisconsin;
    • a 1998 study by National Health Data Systems found a 72% drop in hospital readmissions by people who received NYAPRS Peer Bridger state hospital to community services.
    • A May 2006 Mathematica study found that working Medicaid beneficiaries dropped their Medicaid dollar utilization by 40% and a similar 2011 study conducted by the NYS Office of Mental Health found that utilization dropped by 50% for the same cohort.
    • For 2010, the annual cost for Rose House to provide care for 227 guests, for 748 resident days was $264,000 compared to $1,047,200 based on the average cost in local hospitals. Unspent Medicaid/Insurance cost $783,200.
    • College of St. Rose study on Rose House: In a two-year look back survey conducted in 2009, 90% of Rose House Alumni have reported no hospitalizations since the diversion house experience.
    • CSR also looked at the experience of receiving Rose House services and found that "64% of respondents indicated that they experienced these elements of treatment at Rose House compared to 22% at inpatient hospital settings" (e.g., being greeted warmly, orientation to the program, non-judgmental staff, explanation of program, expectations, involvement in treatment planning, understanding of the risks/ benefits of treatment, use of recovery based language, trauma sensitive treatment).