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Essential new roles for peers and service recipients in the whole-health era

December 29, 2013
by Ron Manderscheid
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The whole-health era being ushered in by the ACA will bring dramatic changes to the roles of peers and service recipients. We need to implement these new roles in the incubator of emerging medical and health homes.

Much attention currently is devoted to the dramatic changes that the Affordable Care Act (ACA) will bring to behavioral healthcare providers. The major ACA change agents are insurance expansion with parity and service reconfiguration due to integrated care. By contrast, virtually no attention is devoted to the equally dramatic changes that the ACA will bring to the roles of peers and service recipients. I would like to explore these latter changes here.

How the ACA will Produce Change. As a framework for this discussion, several features of the ACA need to be described. The ACA promotes whole health--considering all aspects of a person's health together--through person-centered care--considering the person to be the "true north" of their own care. In turn, person-centered care requires shared decision-making between a person and their provider, and shared responsibility both for one’s care and one’s health.

These important goals can be achieved through integrated care systems that combine primary care and behavioral healthcare. Such service systems may be organized either through medical homes operated by primary care entities or health homes operated by behavioral health entities. It is in the incubator of these new service contexts that we need to implement the new roles for peers and service recipients.

In behavioral health, either for mental health or substance use services, the traditional peer role has been to engage and support a person with a behavioral health condition while that person receives behavioral health services. Frequently, this has occurred in public sector specialty service systems, particularly for persons with very severe conditions. Over the past decade, this effort has served to solidify the definition and range of actions of a peer supporter. The result has been funding of peer support services by the majority of states through the Medicaid Program.

New Peer Role Beyond Behavioral Healthcare. With the implementation of the ACA and integrated care systems, the role of peer supporter has the potential to undergo very significant expansion. Most dramatically, an opportunity will exist for a peer to serve persons who have no behavioral health conditions. Some will be persons with conditions ranging from simple medical ailments to diabetes or heart disease. Others will be people without any disease condition who are seeking to facilitate their own wellness through prevention and promotion services. Perhaps almost as dramatic, an opportunity will exist for peers to help improve wellness interventions for persons who do have behavioral health conditions, especially in a whole-health oriented integrated care system. 

Emerging Service Recipient Role. Similarly, the ACA will provide an opportunity for all service recipients to take on a new role by seizing the initiative to help define and shape their own care. Very clearly, key concepts, such as person-centered care, shared decision-making, and shared responsibility, will be integral to these revolutionary changes in the service recipient role. One simply needs to imagine a person with a severe heart condition taking on this new role to actually see how revolutionary these changes could potentially become.




I greatly admire Dr. Mandersheid. He pointed out recently that the major innovations in mental health over the last 30 years have been by persons with lived mental health experience. However, I take issue with his premise that peers should be renamed health supporters. If stigma and discrimination no longer existed, I would agree with such a broader designation for peers. But we will continue to need peer supporters, with the shared experience of recovery from mental health conditions as long as those without lived experience treat us as second class citizens. There still can be an expanded role of health supporter for others with a variety of health conditions.


Ron Manderscheid

Exec. Dir., NACBHDD and NARMH

Ron Manderscheid



Ron Manderscheid, Ph.D., serves as the Executive Director of the National Association of County...

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