Best Practices: Level-of-Care Criteria for Peer Support Services: A Best-Practice Guide

Abstract

Peer support services (PSS) are an expanding part of the continuum of care provided for behavioral health conditions. These services have been deemed an evidence-based reimbursable model of care by the Centers for Medicare and Medicaid Services. States, counties, employers, and health plans are increasingly covering PSS in benefit plans. Controlled and experimental studies are building the evidence base for these services. Medicaid and the states have not developed level-of-care or medical necessity criteria for PSS, even though these criteria are standards for determining coverage and reimbursement. This review of emerging level-of-care criteria for PSS provides a framework for the further development of these resources.

Unique and common elements of the role of peer support in the context of traditional mental health services.

“…In 2009 through 2011, stakeholders from states that had made the most progress in pursuing Medicaid reimbursement for peer support were convened, through the Pillars of Peer Support Initiative, to develop core principles for the certified peer support (CPS) workforce and provide guidance to states regarding peer support education, certification requirements, employment, professionalism, and community advocacy (Daniels, Bergeson, Fricks, Ashenden, & Powell, 2012). Most recently, standards for coverage and reimbursement for peer support services were proposed to assist states and private insurers in establishing level-of-care criteria over the course of treatment for individual conditions and determine when peer support is appropriate on the basis of individuals’ needs, preferences, and goals (Daniels et al, 2013). Peer support is now a core element of emerging health care delivery models that embrace the concept of recovery, person-centered care, and integration of behavioral health and primary care (del Vecchio, 2012; Salyers et al, 2010).…”

The role of peer support specialists for patients with medical and behavioral health needs – Challenges and opportunities

“…Level of care criteria for peer support services have been established by health insurers to guide medical necessity and coverage determinations. 6 The role of the Peer Support Specialist in the integration of care for physical and behavioral health conditions has also been demonstrated through the SAMHSA-HRSA Center for Integrated Health Solutions Whole Health Action Management program which helps establish health improvement goals and fosters activation for their achievement.…”

A Scoping Review of the Role and Training of Para-professionals Delivering Psychological Interventions for Adults with Post-traumatic Stress Disorder

“…This role involves designing and managing mental health treatment programs, building clinical capacity in primary care settings, supervision and quality assurance of mental health services, and providing consultation and referral pathways that support self-management and skill building through stepped care [26]. To complement this change, licensed non-mental health specialist professionals (teachers, nurses) or unlicensed paraprofessionals would take on more aspects of direct mental health service delivery, a practice that is increasingly legitimized through expanded insurance coverage for peer and allied health professional programs [27,28].…”