Challenges and Opportunities: Workforce Development for Behavioral Health “Peer Support Workers”
By Antoinette ‘Toni' Gingerelli (MPP 2022), Kelsey Pukelis (PhD Student in Public Policy), and Priscilla Liu (MPA 2022 & MIT Sloan MBA 2021)
Across the United States there is a shortage of behavioral health workers. These workers play an integral role in supporting those struggling with mental health conditions or substance use disorders, a role with even more importance in the wake of COVID-19. Against this backdrop, the Massachusetts Healthcare Collaborative sought to identify and address challenges in the state’s healthcare workforce pipeline, starting with peer support workers.
Peer support workers are individuals with direct or indirect lived experience of a mental health condition, substance use disorder, or both, who provide non-clinical support to others undergoing the recovery process. They bring their personal knowledge of mental health conditions and substance use disorder and share experiential information to support people’s progress towards recovery. Peer support workers play a critical role in helping to reduce hospitalizations and other high-cost services by helping those they support to stay engaged in the recovery process. Though they offer a high return on investment in behavioral health services, peer support workers are often stuck in low-wage roles with limited opportunity for career progression. To best leverage the power of peer support, it is critical to standardize and formalize the field of peer support and bolster career pathways.
During Spring 2021, our team from the Cross-Harvard Future of Work Study Group collaborated with the Massachusetts Healthcare Collaborative to understand peer support certification and standardization of their career ladder in behavioral health. Our team’s methods included conducting interviews with employers and peer support workers, analyzing labor market data from Burning Glass Technologies (now Lightcast), and reviewing the literature of peer support work in similar states.
There is a growing need for peer support roles in behavioral health, but the sector faces stark labor shortages
In Massachusetts, more than half of adults received mental health services and one in twenty adults have had serious thoughts of suicide in the preceding year. Substance use disorder is also prevalent: 8.7% of adults in the state have had substance use disorder in the prior year—17% higher than the national average—and even pre-COVID, reported opioid-related mortality had more than tripled between 2011 and 2019. Against this backdrop, the behavioral healthcare sector is innovating to address growing need for its services and reduce the use of high cost services like hospitalization, in part by expanding the use of peer support workers.
Figure 1. Continued Trend of High Deaths from Opioids (MA)
Source: MHA 2021, Mass.gov 2020, MA Employer Interviews
Supply for peer support workers lags behind demand substantially, based on labor market data on peer support workers. However, data is scarce because these positions are not yet categorized in labor statistics databases. In a 2020 report, the Substance Abuse and Mental Health Services Administration (SAMHSA) projected the U.S. would need over 1.1 million peer support workers, with 70 percent focusing on mental health and 30 percent on substance use disorder to address rising behavioral health needs.¹ An estimate of total certified peer support workers across the U.S. from April 2016 was just over 23,500.² Scaling this by an estimate that approximately one-third of positions require a certification still only results in approximately 74,000 current workers.³ Our estimate of total peer support job postings from Emsi Burning Glass Technologies data, including non-certified positions over the last decade, is almost 48,000. Even though these samples are not perfectly comparable in terms of time, certification, and coverage, the difference between supply and demand is stark.
Figure 2. Supply/Demand Mismatch in Behavioral Health
Source: Project on Workforce analysis of Emsi Burning Glass data (Spring 2021); SAMHSA 2020, Kaufman et al. 2016
Part of the challenge in expanding the supply of peer support workers stems from norms about how their services are typically reimbursed. Namely, insurance coverage of these services has lagged behind need. Historically, peer support roles were funded through a combination of federal, state and philanthropic grants.⁴ As of 2018, thirty-nine states allowed Medicaid billing for any type of peer support services. For example, MassHealth⁶ only began to reimburse for peer support services in 2018. Commercial insurers have not yet followed suit for all peer support services.⁵ Hence, the development of a standardized certification process is critical to feedback into the growth of peer support positions.
To grow the peer support workforce and bolster career trajectories, we assessed the following stages of the talent management process: recruiting, hiring, training, and upskilling.
Recruiting and Hiring Criteria
The vast majority of recruiting for peer support workers is informal, largely through word of mouth. Employers rely on referrals from existing clients, staff, and community members with lived experience. Other recruiting sources include graduates from local substance use disorder programs, recovery networks and newsletters, and traditional job boards. In the hiring process, candidates are vetted to ensure their commitment to the peer support role. Unique to this setting, positions require lived experience of substance use disorder or mental illness with at least a year or two of sustained recovery. Formal counseling qualifications, past experience, or certification are not required, but preferred. In Massachusetts, employers typically provide the training and certification needed through in-house training and sponsoring of training for certification.
Though employers did not report major challenges in recruiting peer workers, the most salient challenges include low wages for peer workers, the lack of clear career pathways, and concerns about diversity. Across behavioral health roles, wages are not competitive and senior peer leaders are not accounted for within the reimbursement system. Based on our analysis of peer support job postings from Burning Glass, two-thirds of postings are full-time,⁷ 60 percent are paid hourly, 37 percent are salaried, and the median pay range is $14.00-$16.50 per hour.⁸ In exploratory analyses, we found that certification is not associated with higher pay, although this does not tell whether or not expanding certification would increase wages. Additionally, there is not a clear next step for peer workers who want to take on additional responsibility while also continuing the aspects of the peer role—mentorship of those in the recovery process—that fueled their initial passion for the role. The most common next steps in the career ladder are to pursue managerial roles or clinical roles, both of which maintain the core responsibilities of peer workers. Finally, employers often highlighted the importance of equity across demographic groups and increasing diversity in the role. Unfortunately, data is lacking about the demographic composition of the peer support workforce, so whether the workforce is representative of populations served is unknown.
Figure 3. Top 30 Skills in Peer Support Job Descriptions
Source: Project on Workforce analysis of Emsi Burning Glass data
Upward Mobility Pathways
Employers of peer support workers emphasize the importance of providing training for employees to gain skills and progress through a career ladder. Multiple interviewees recommended standardizing continuing education for peer support workers through a state certification program with different levels of expertise, similar to certification levels offered in Kansas and Maryland.⁹,¹⁰ One provider organization described the opportunity for peer support workers career growth in three categories (Figure 4). The management category describes peer support workers becoming peer specialists, leads, or supervisors within their organization. The second category is lateral movement: transitioning to larger organizations where workers can take on more responsibilities. The last category describes moving to more clinical roles, often requiring additional formal education (e.g. Licensed Independent Clinical Social Workers, nurses).
Figure 4. Career Opportunities for Peer Support Workers
Source: Interviews with peer support workers and employers conducted by Gingerelli and Liu.
In Massachusetts, one provider organization developed their own internal career trajectory highlighted below:
The organization (Figure 5) created an internal structure where peer support workers start as “Recovery Support Navigators” who serve as “liaisons to care,” providing brief intervention and important connections to treatment for substance use disorders. With more experience and formal training they can progress to “Recovery Coaches,” working with individual clients and having the opportunity to progress to leadership and supervisory roles.
Figure 5. Interviewed Employer’s Internal Career Ladder
Source: Interviews with peer support workers and employers conducted by Gingerelli, Liu, and Pukelis.
One common emphasis across provider organizations is the importance of providing opportunities for upskilling. Providing additional education allows peer support workers to grow personally and professionally and allows organizations to retain employees.
Conclusion and Future Research
Our analysis found that there is a demand for peer support workers throughout Massachusetts and the United States, however, the supply of peer support workers lags behind. For this reason, it is important to create a more formal recruitment process for this role rather than relying on recruiting through “word of mouth” alone. Although some organizations that utilize peer support workers have created opportunities for upskilling, the career field would benefit from creating a more formal career ladder for peer support workers to advance and earn higher wages. It is important to note that our research focused on employers of peer support workers. In order to develop a comprehensive career ladder for peer support specialists in Massachusetts, it is important to seek their perspectives on hiring and advancement opportunities as well. Based on our findings, we recommend pursuing future research on the following:
Creating a peer specialist in training or peer specialist supervisor formal credential in Massachusetts
Developing continuing education requirements for peer specialist roles
Boosting employer understanding on potential advancement ladders within and outside their organizations
Developing processes to improve diversity and equity in recruiting and training
Acknowledgements: Thank you to Bledi Taska, Chief Economist, for his help in provision of Burning Glass data for this research.
Interested in more of the Project on Workforce’s research on the Massachusetts healthcare workforce?
For a landscape analysis of post-COVID healthcare workforce innovations in Massachusetts, see this post.
REFERENCES
3. Approximately one-third of BGT job postings mention a certification, though this proportion varies widely across states.
4. Substance Abuse and Mental Health Services Administration (SAMHSA), Massachusetts Department of Public Health Bureau of Substance Addiction Services (DPH BSAS)
5. Peer services are reimbursed an average of $13.08 for 15 minutes, with a range of $5.98 (SC) to $24.36 (GA). University of Michigan Behavioral Health Workforce Research Center. National Analysis of Peer Support Providers: Practice Settings, Requirements, Roles, and Reimbursement. Ann Arbor, MI: UMSPH; 2019.
6. MassHealth is the combination of Massachusetts' Medicaid and Children’s Health Insurance programs
7. Sample is 58% of postings
8. Sample is 33% of postings. Remaining 3 percent are paid monthly or daily. Median pay range includes hourly, annual, monthly, and daily pay frequencies, where salaries are converted to hourly pay equivalents.