MIKE BACHHUBER: Okay, we're going to talk about certified peer specialists, and this is a relatively new concept that's been spreading around the country pretty quickly.

It kind of started with some folks realizing that peer support, which is not a new concept, is helpful to a lot of folks, in trying to find ways to make peer, oh, oh.

Hit the wrong button again.

Trying to make peer support more accessible to more people.

I think Georgia was the first state that initiated a peer specialist program, and they got it approved by their Medicaid program, and approved by the federal government.

And it has now been spreading from here, so this is the kind of official definition from the, whatever with CPSs, something about certified peer specialists.

The organization naturally that I'm aware of is INAP.

International Association of Peer Specialists.

And so it's defined as a person who has not only lived experience of mental illness, but also has had formal training in the peer specialist model of mental health supports.

They use the unique set of recovery experiences in combination with solid skills training to support peers who have mental illness.

Peer specialists actively incorporate peer support into their work while working within an agencies team support structure as a defined part of the recovery team.

This is a very general description.

You'll notice that they use the term mental illness several times, so it's not particularly a definition that's coming out of the activist community.

But in order to get peer specialist funding, they work through Medicaid programs, and Medicaid programs generally require medical supervision, doctor, psychologist usually, and so this fits closer within that paradigm.

In Wisconsin, about a dozen years ago, folks had been hearing about certified peer specialist programs around the country.

And came back and tried to get a program in Wisconsin, and there was some support from the State Mental Health Agency, and there was also building some of the organizations our Statewide Mental Health Consumer Network started training some of their staff in developing peer specialists around the state. 

Our state NAMI chapter developed a peer specialist training program and there were one or two other training program and there were one or two other organizations that started training peer specialists.

And so the state was trying to figure out if we're going to develop this, how do we proceed, and we don't want any of the organizations that already have a stake in a particular methodology, training method, to be controlling the process, and so they decided to work with independent living centers to help develop the program, since we had a long term history in providing peer support.

And so basically, they contract with the independent living center that I was associated with at the time, to develop a peer specialist certification program in Wisconsin, and we worked with various stakeholders to make that happen.

In the process, we were able to work with the other centers in the state, and get some real buy in, into making peer specialists and peer support services available more widely around the state.

So in Wisconsin, the centers do peer support in a number of ways.

The, there are several different training programs, and a couple of different ones are used by different centers.

For all of the peer specialists in Wisconsin, there's actually then a test that's administered by one of the colleges in Wisconsin to get the peer specialist certification.

So it doesn't matter which training you have, as long as you can meet the competencies and pass that test, you can get certified, and once you're certified, services are billable through Medicaid, through several different Medicaid programs and sometimes through private insurance.

One of the Wisconsin centers was working with OPTIM Health, a national HMO to do a, they were providing peer support to keep people out of repeat hospitalizations, and showed effectiveness through a study methodology in providing peer support, peer specialist services.

Okay.

Centers provide CPS services as a fee for service basis, so they're able to bill Medicaid or private insurance for that and supplement the IL funding.

Most of the Wisconsin centers do have peer specialists on staff.

I think we have, we have eight centers in Wisconsin and I think seven of them have peer specialists on staff.

Several of them only have one or two peer specialists.

One has, I think, 20 some peer specialists who work for the center, and some of the peer specialists are employed at the center or directly by the center.

Other times they're employed by the center and work for mental health programs.

We also have tried to promote the concept that peer specialists need to be supervised by people who have peer specialist training, and, because they're using medical systems, they still need to have the medical supervision, but that's not usually their direct supervisor.

I think that's pretty much what, the part I wanted to talk about.

Move over to the rest of our team now.


RUTHIE POOLE: Thanks Mike.

I wasn't going to do this part but who I work for and what I do now is train certified peer specialists in Massachusetts.

Massachusetts was one of the first states to pick up the CPS.

Not through our IL movement, but through our consumer survivor movement, we were calling it then, and we call it the peer movement now.

And so in 2006, in the springtime, a group of folks, a couple of my co-workers and a few other people went down to Georgia, where Larry Fricks, who is one of the heads of the national movement, Larry and Ike Powell, they are with, Larry is with Appalachian Mountain Consulting, you can find him on the internet, Larry F-R-I-C-K-S.

Anyways, they were trained in the Georgia model of CPS and so they brought it back to Massachusetts.

They helped Larry and Ike and Beth Filson, who is a trauma expert nationally who since moved to Massachusetts.

We like all the people who are really good at this stuff move to Massachusetts and eventually they all do.

But Larry, he loves that Georgia life-style.

He's never moving north, so he has a wonderful Georgia accent, he's never moving north.

But Beth, we got her up to the north from Georgia, and so anyways, they trained us, we had a class the summer of 2006, and then I was their second class.

So Larry, Beth, and, and Ike were doing it side by side when I took it with those of us who are trainers, I wasn't a trainer at that point.

So since then, we've certified over 400 people in Massachusetts.

This year we did six trainings.

It's very intense.

It is much more intense than what Georgia did, frankly.

You know, we think we're smarty pants in Massachusetts.

It's all those colleges and universities.

So if people do things, we have to do it that much more academically or whatever.

It's not academic.

It's tough, and the reason it's tough is people are not usually going to work at an IL, like what you are talking about.

In fact, they do, Pat who is sitting over there, she's not there right now, is a certified peer specialist at the Metro West Independent Living Center outside of Boston.

Justin is staff at Northeast Independent Living Program, are almost all certified.

But most people are going to work in a hostile mental health environment.

A hostile workplace.

Not people like you.

And so we have to make the training very, very tough.

It's basically an eight-day training, once a week, there's homework.

There's a three hour written exam at the end, and a half hour oral exam.

My job, I'm not on the training team currently, is to test people and interview them for the training.

You must be interviewed.

And you must pass the test.

Our pass rate used to be about 50%.

It's very difficult.

But now we're doing a better job with the ruberics and all of that.

I'm not a teacher, so I don't understand all that.

But we're doing a better job.

Our pass rate is now about 80%.

And the reason why it's so tough, it is a state-recognized certification.

Because as I said, you're going to be working with people with all these big letters behind their name and they spend a lot of money for medical school, and PhD programs, so you want to be tough.

We develop the curriculum.

We've gone much further.

The three core principles in the curriculum are, one, we do a whole triangle thing, and one side is peer support.

The second side is we stress the most, is change agent.

You are making social change.

We're talking about system advocacy.

You are making change within your mental health service provider, and you're making change in the bigger mental health system.

That's not about changing people, the individuals.

We support them.

And in, but not of the system.

You are working in the mental health system, but you're not part of that system.

We have our own code of ethics, and it's very important, we do not participate in forced treatment, of course.

We do not participate in giving meds out, because that's a power relationship.

We're based on mutuality, and if I hold your meds, you better believe, I have power, even if you have the right to refuse there's a lot, there would be a lot of pressure on me to make you take those meds.

So certified peer specialists are embedded in Department of Mental Health, as I said residential and community outreach services.

Mostly through our residential program, we use a lot of private vendors.

We're union state that's been deunionized, basically, like many states.

Some people still work for the state as CPSs.

Their starting wages are 40 to $55,000 a year.

Those of us who are CPSs who work for private nonprofits, our starting wages are about $13 an hour.

So the death of the unions has been really hard on us human service workers in Massachusetts.

There's a day rate for rehabilitative services that some of the stuff Mike would know much more about that, he was talking about.

As he said, because right now, they're billed under rehab option.

Probably lots of people in the room who understand that.

I don't, so don't ask me.

So CPSs are, must be, for Medicaid billing and why Massachusetts, as I said, doesn't have Medicaid billing for a lot of reasons.

One reason is, we do not believe a clinician should sign off on the work we do.

Clinicians' roles are important and very different from what we do.

So what's exciting to me is, it looks like the feds are going to recognize people who are CPRPs and I'm going to need some help knowing what those letters stand for.

Certified Practitioner of Rehab Profession.

Does anyone know in this room?

It's, it's a rehab, the USPRA,

U.S. Psyche Rehab Association, psyche is part of that, psyche rehab.

So it's the psyche rehab model.

Do you know what that is, Dan, CPRP?

AUDIENCE MEMBER: Certified Psyche Rehab Professional.

RUTHIE POOLE: Certified Psyche Rehab Professional.

It's a nationwide certification.

CPRP, and so Medicaid, the feds are open to having a CPRP sign off.

a CPRP sign off.

And lots of us with lived experience are CPRPs.

I'm not, are you guys?

Okay.

Anyways, but that gets away.

Too often CPSs in Massachusetts are supervised by clinicians and if you're trained and supervised by a clinician, it's really tough.

So we really stress, like Mike said, that people should be supervised by someone in the field themselves.

SARAH LAUNDERVILLE: Oh, that was my cue.

I just wanted to draw attention that we were on slide 72 and we're going to flip back to slide 43, just to help with context, we thought it fit better in that section.

Okay.

So I'm going to talk a little bit about in Vermont this newer group that we've begun over the last couple of years called the Wellness Workforce Coalition.

And this all started, so after, when we had tropical storm Irene hit Vermont, our state hospital was flooded, so what a great problem that was to have in some ways, but what a horrible experience as well in terms of relocation and trying to figure out where people were going to go who were, in Waterbury, so people were moved to various different residential homes throughout the state, and some people were moved to one of our prisons for quite some time, and so we had these problems around trying to figure out how do we connect to people who are now dispersed all over in the community?

But I always like to share this story that happened around tropical storm Irene, there were some people moved to a group home in Williamstown.

The town I live in.

They had escaped from the floodwaters actually rising at the state hospital.

It was very dramatic and scary experience for a lot of people.

And so they got settled into their new living arrangement, and they were treated differently because they were in a different location.

They were called residents or guests all of a sudden.

They weren't called patients, and at that point, some of the state hospital workers had to come down to the new facility, cause they were all being reassigned, as were all of our complex of all of our state workers, the whole complex was flooded, so it was not just the state hospital, but all the state workers that worked out of Waterbury.

So we had some real relocation issues.

But we saw that people were being treated a little differently in this setting and they were responding differently, and always want to sort of rise up that story.

Part of it included the folks who had previously been patients the day before saying, I want to go and help some of the elders over in Northfield, which is the next town over, help dig out from the flooding, and so a group of people from, who were patients in the state hospital the day before were brought over and helped do volunteer work to help recover the flood, as many Vermonters did during this horrible time.

It's a story that's really important, right, because we have so many stereotypes around those of us who have been hospitalized, those of us who have been involuntarily committed or, treated I use with air quotes, medicated.

There's so many stereotypes that go along with that, and to think of folks in a role that you wouldn't traditionally think of folks in that role, right?

It's really important, if you're coming from a space where you don't know a lot of people who have been through that process and who are hospitalized, you may have an image of what that looks like in your head until you start to meet people who have been in that situation.

With the hospital shutting down, we had to figure out some new solutions.

We need to, you know, the first, well, you know, the governor had gone out campaigning, I think the year before, a couple years before, telling all the state employee association workers that we're going to build a new state of the art state hospital, we're going to make it bigger, we're going to make it better, we're going to make it all of these things, so we had some resistance from workers who wanted this really large hospital to come up, you know, and we had, our hospital was about 52 people in it, so I know in scale to some of your other states it's very different.

And so we worked and advocated around that whole system, around what's this going to look like, and Dan came to our state and helped with that fight, and we ended up with a facility that has about 21 beds and then we have, we're working to community hospitals and those sort of solutions.

But a million dollars became available for peer services.

We had, at the time, our secretary, deputy secretary of the agency of human services, he became our commissioner of mental health and his name is Patrick Flood, and he read Robert Whitaker's book, advocates, and he heard from advocates and he invited Dan to come and talk to folks and he started saying, this is really important that we invest in peer services.

Prior to that, he had been the commissioner of the disabilities, aging, independent living and worked on all, he promoted the duals project, he really looked at, how do we collaborate and look at systems?

He was the first commissioner to give our Center for Independent Living $100,000 for home modifications because he knew when we were transitions folks out of nursing home that we were saving money so by investing and some of these other services, that is where it went.

So having an ally in relationships with state folks who are going to bring that message forward is important.

So when it struck, when the time happened, all of a sudden we had a million dollars to spend in peer services around mental health.

We had lots and lots of meetings around how that was going to look, and through that process, we worked with the Department of Mental Health and we decided, we wanted to bring together in coalition all of the different peer groups that are doing work around mental health issues across the state.

And so we, at the time our longest running group Vermont Psychiatric Survivors was kind of going through their own organizational turmoil and they weren't ready to, or able to accept funds and really kind of guide this process along.

The only other groups that were stepping up to the table were groups that were not, or organizations and agencies that were not peer directed.

So they had a focus on mental health issues or recovery issues, but the majority of their Board of Directors were not us, so VCIL was one of the, the applicants for this, and that was one of the, the reasons that we were able to help sort of formulate and start that funding going forward.

So we were the Vermont's peer network at first because we were a small group of people and we didn't really know what to call it.

We wanted to call it something, and we've transformed into the Wellness Workforce Coalition and you'll see our mission is to create a statewide coalition of peer-run organizations that support training and advocacy for Vermont's peer work force while preserving the autonomy, character and contributions of each member organization.

Which is not easy work.

You think it's going to be easy in some ways.

Here are, here are the members of our coalition.

So Alyssum, Dan talked a little bit yesterday about the facility that we have.

Friends of Recovery we brought in.

It was really important we brought in the addictions community, the recovery centers, turning point centers throughout Vermont are a part of this coalition, and when you start to cross-pollinate, there's a lot of really good that can come from that, and there's a lot of challenges that are met with that.

We have a lot of folks that still believe that the medical model is really the way that they wanted to push forward and so we have some conversations around that.

NAMI Vermont is a coalition member.

I wanted to stress that it's a portion of NAMI Vermont, so NAMI Vermont is not a peer led organization.

It was really important all of our partners were peer led, so they have some groups that are peer led and those are the groups that are represented at the table for our coalition.

Vet to Vet.

Vermont Psychiatric Survivors.

The Vermont Foundation for Recovery.

Our turning point centers.

There's a Northeast Kingdom Youth Services Peer Wellness Program and unfortunately that program has been cut this current year so we're not sure how the youth services program is going to continue with us.

The Vermont Federation of Families for Children's Mental Health.

VCIL is a member.

Another Way is a drop-in center in Montpelier.

Green Mountain Self-Advocates, which is a self-advocacy group in the state, it is run by folks who have intellectual disabilities, and The Wellness Co-op, which is a group up in Burlington and the Vermont Support Line, which is part of that.

The Wellness Co-op and the Support Line, are all part of our Pathways to Housing work being done in the state.

Well connected to that.

And then we have folks at the table who work within designated agencies, and like Ruthie was talking, I think those are the pioneers right now.

People who are working in these environments that, you know, they're being sent out to trainings and we want you to come back with your peer message, but then they're met with a lot of resistance by leadership and we have some designated agencies within our state and those are folks that, that receive money from the Department of Mental Health and they, for folks that don't know what a designated agency is, and provide services around mental health services in our state.

And so these guys go out, they get the trainings and they're coming back to environment that not always is met with friendly peer to peer work, so it's important to know.

I'm going to talk a little bit about the work of our coalition and the path that we've been on around sort of where we're going.

So our coalition meetings began with writing our vision and mission.

And it was really important in those early, in the early conversations, the turning point centers and Green Mountain Self-Advocates were not at the table and it was important to us as a cross-disability rights organization that we were being really inclusive, in coalition, so we include that broader community into the peer work force.

We had our name changed.

We developed a website, which is not quite live yet.

And there was already some SAMHSA money within the Department of Mental Health to provide IPS, Intentional Peer Support training, and WRAP, the Wellness Recovery Action Plan trainings, so those trainings were happening so we helped coordinate those.

Advocacy and legislation was part of like that original work that we hoped to do, and the conversation has now shifted to peer certification.

The other major thing that we did in the beginning is provide technical assistance, so a lot of our members of our coalition are small nonprofits, and some of them don't have, or didn't have really active engaged Board of Directors, some of them had financial issues, and so VCIL, as the organization sort of helping coordinate all of this, we were out providing technical assistance to our members, and sitting one on one with their financial people, sitting with their Board of Directors, and helping promote and bring them up to capacity, and while that, I think we're going to do a little bit of that this year with one of our members.

That's really changed.

Because we've been able to change that system from within at this point and we have some really great thriving boards and responsible organizations throughout the state, so we're excited about how that's shifting for us.

So we had a lot of meetings, a lot of planning groups, and it does take a lot of time and investment to do this sort of coalition building, and this is just one model.

It might not be something that, you know, you go on this path, but I encourage you to look for ways that you can be in coalition with other groups.

So we looked at our pros, our strengths, opportunities and what you'll find is, because of the real vast differences in some of those groups that we have up on that board, we had some really vast differences in some of our discussions around these things, so some of our strengths.

One of the big reasons that people say we want to do some either peer certification or core competencies or whatever, is around doing it before it gets done to us.

You know, there's a real fear from some of the folks in Vermont that SAMHSA is going to come in and say, this is how you're going to do it and they don't want that to happen, so there's a lot of conversations around us really making it what we want to make it.

There is opportunities for additional funding streams.

Our groups wanted to be accountable, that if you were working at one of these organizations and you decided to move on to another organization, there was some consistency and accountability around that.

We wanted to develop what an ethical code would look like.

We also wanted access to finding qualified people, and a sustainable movement within Vermont.

Some of the cons that we talked about include the whole peer certification process could be stigmatizing, could be prescriptive.

It might not have any teeth.

We might go through this entire process, this is what we're going to do and it might not go anywhere.

It can create an atmosphere where some aren't going to be able to do it.

We see it already with some of the training.

Through intentional peer support, people will write, their plans of how they might want to be an advanced facilitator, and they might not be accepted to that, and so we're creating an us and them environment again, so those are things we really need to consider as we're moving forward.

And some people said it was too radical and some people said it wasn't radical enough.

So that's complicated.

So I'm definitely, as a person that's been around, you know, for 18 years, kind of on this old school track, and have that voice at the table where we have some folks that have, you know, joining the movement who are, like, peer is not the word they want to hear.

That was something that was incredibly embracing, I felt embraced by that word.

We're starting to see some of that, so we have these really incredible conversations and in some ways, we got to a point through that disagreements that maybe core competencies is where we start, in terms of, what can we have conversations around with core competencies, so at this point we haven't agreed as a coalition we're going to have peer certification.

We haven't actually agreed that we're going to have core competencies even but we're having conversations about it.

So really finding where the different groups are and moving through that process is really important.

We also feel that it's really important that all of the trainings that we're sending our members to are accessible and they're not.

So folks who have intellectual disabilities, for the most part, are not finding it easy to navigate some of the trainings that are out there around peer to peer work.

So our self-advocacy group, Green Mountain Self-Advocates who is a member, provides technical assistance around that, and so they are working with some of the leaders who provide some of these trainings on that.

So we talked briefly about intentional peer support and the Wellness Recovery Action Plans, and if you don't know about these different trainings, I'd encourage you to look them up on Google or connect with some of the presenters that really know a lot more about those training opportunities.

And they can be very expensive, right, so the intentional peer support training, when we brought in, in, the trainers, it was $15,000, so you have to really be thoughtful and mindful around looking at the trainings, deciding if it makes a lot of sense for your state or not, but I can tell you that, that WRAP, some of you might have been trained in, those, while expensive can really fit the needs of cross-disability community, and so to look at those with those set of eyes, as you look at it.

Members wanted crisis training, cultural competency training, advocacy training, training on nonviolent communication, self-care, the history of our movements, history of the medical model, history of all the movements, the Hearing Voices Network does some trainings, and there was just a grant opportunity through that, so you can check out Hearing Voices Network, if you're interested in that.

They were interested in alternatives to suicide trainings, which I think we just did.

Some of our members were interested in Bridges Out of Poverty training, which has, have folks heard of that training before?

AUDIENCE MEMBER: Yeah.

SARAH LAUNDERVILLE: Some people love it, some people don't love it, we've heard.

There's some mixed bag around that, so we provided the Bridges Out of Poverty for folks that really want to talk about economic justice and I was telling folks last night, I was talking to a person the other day on the phone and he said, you know, Sarah, I'm sick of people trying to deal with my poverty issues by referring me to a mental health agency.

That is really what it comes down to for a lot of folks.

So understanding, economic injustice, all of that is a good training.

Some people find it doesn't go far enough and there are now alternative trainings that are out there as well.

Antioppression.

Documentation training.

Some of those basic things that we talked around fiduciary experience and all of that.

Burn out.

Supervision with peers, supervision with clinical.

Vicarious trauma.

Business and administration skills, soft skills, team building skills.

So there's a lot of things.

This is our beginning conversation, and that's a lot of stuff to really, we definitely had to whittle it down to what could be achievable for us.

But we spent a lot of time on values and ethics as well and that's really where it comes down in the heart of some of us, when we're, when you're doing coalition building, there's so many different values and ethics that really need to come into play, so we talked about integrity and safety, mutual respect, empowerment, pro-individual choice, harm reduction, non-judgmental, informed decision-making, person-driven, non-prescriptive, self-directedness, social justice oriented, we wanted to be change agents.

We wanted to make things better, not only with individuals but with the entire system.

We want to look at crisis as an opportunity, we wanted to look at being well.

That was really important in self-awareness.

We had lots of confidentiality conversations, conversations around supervision, feeling connected, you know, as you're doing this work.

Communication and civil discourse and positive regard.

So then we came up.

Here's our 12 core competencies that we decided on that we're, and we're kind of at this point where here's what we're going to work on next, you know.

So skills, abilities, knowledge and values, so we wanted to really develop lived experience and what that means.

What are the conversations we want to have about it?

How do we want to talk about that?

You know, we talked yesterday a little bit about, what does that mean, even?

Lived experience.

And as you can imagine, with such a large group of members, we have a lot of wonderful conversations about that.

Ethics are really important to our group.

Confidentiality, communication, self-awareness, our own intentions, moving from self to systems, all of that stuff.

Empowerment, learning instead of helping and fixing.

Boundaries.

Mutuality and empathy, really important to our group.

Authenticity, using our own language.

We've talked a lot about language.

Looking at things through different lenses, our world view, our gender cultural awareness, having lots of conversations about the different lenses that we kind of approach folks with.

Safety, internal and external, and the safety really came around safety to ourselves, you know, mainly I don't want to give this impression that I was fearful of folks, although there were some safety issues in some settings.

And wellness and self-care, natural supports are really important.

So we're still working on a model that works for all of our members, as I said and I think there's going to be a lot of time spent on what that looks like.

And as I said, the challenge to the historical thinking of not having a certification process and working with respect to honor the work in our past and to look at what the peer work force is asking for is sort of what we're going up against, and it's an important thing to kind of connect with, so that's where we are.

[ Applause ]

SARAH LAUNDERVILLE: I have five minutes, questions on any of this stuff that we had just talked about.

Comments.

RUTHIE POOLE: You have to love Vermonters, they're so like, intentional.

It just, in Massachusetts, we were not intentional like that.

And I just really love it, and I mean that, like really like gratefully.

I kept whispering in Justin's ear, we need training in that, we need training in that, we need training in that.

He's, like, yep, yep, yep.

And I really love that, that you're doing it with all these voices at the table.

And what really wows me is that they have self-advocates there.

Because it's funny, when we were talking about hierarchy of disability, I always say, well you know, many of us with lived experience are feisty enough to like elbow our way at the table, but the self-advocacy community, people go around, sorry, Justin, and they go, we'll just keep speaking for you, you're 65 but you have an intellectual disability and I'll keep speaking for you, and you're very sweet, we hate Ruthie because she has mental health condition and she's uppity, but Justin, he's very kind.

So I think that you included those folks, because very often, they're not even at the table.

I mean, maybe I had elbowed my way and my community elbowed our way there but nobody even invited the folks with intellectual and cognitive disability.

So I love that you did that.

SARAH LAUNDERVILLE: Thank you.

One thing I'll share, when my former executive director, Debra Lisi-Baker, she thought it was really important that coalition building and relationship building, was a part of the heart of what we do and I try to continue that as director.

One of the things that she did during her time, was develop statements of solidarity, anyone ever done that with other groups within your center?

I can share with you our statements of solidarity.

We have one with Greenmount and ADAPT.

Greenmount and self advocates, and Vermont Psychiatric Survivors, and VCIL, where we came together and basically, it's a we've got your back sort of statement, that if one of those groups is not at the table, then we're going to rise their voice up and make sure it is.

And so after that, we moved on to, we have this human rights council that I talked a little bit about earlier, and it's a large member of groups, and we've had some, one people's convention, we're going to have another one this September, and it's all about that coalition building, and we have some principles that we've come up with, and I think making those relationships, and not just with like-minded people, really reaching across, for us our advocacy issues really go across liberal to conservative, right, so it's important to build relationships across the board.

Any other questions?

Go ahead.

AUDIENCE MEMBER: Yeah.

This, my question may be kind of involved.

When you say that Massachusetts doesn't do Medicaid, does that mean that Massachusetts has a program that is like Ten Care, from Tennessee, and that it's funded through the state general fund, or are there federal dollars that are passed through?

RUTHIE POOLE: I'm sorry, I probably confused everyone, and thank you for that question.

So our Medicaid is called Mass Health, you know they have changed the name depending on where you are, and we have very extensive Medicaid.

We take almost all the options.

We used to have chiropractic and podiatry.

Those are gone.

Dental usually goes and comes.

They like to protect our front teeth but not our back teeth because we can get a job if we have front teeth.

It's like really bizarro.

And so the, they were talking about OneCare, which is a dual eligible project, a lot of your states probably have that.

I know Sarah was referring.

So what, right now, certified peer specialists, when Medicaid billing happens, is through rehab option through residential.

AUDIENCE MEMBER: Are your, I'm sorry, through residential?

RUTHIE POOLE: This community-based flexible support is what, it's not really flexible.

It is community-based.

AUDIENCE MEMBER: Community-based support.

For the signoff, is Massachusetts then different so, for example, if you're, if you're working in a community mental health center in Indiana, my frame of reference is Indiana, if you're working in a community mental health center in Indiana, by and large, most of the billing has to be authorized under a physician's signature.

They may not actually sign the billing, but it's done under the auspices of a physician, so

RUTHIE POOLE: No.

Not true in Massachusetts.

AUDIENCE MEMBER: So who, who indeed then signs off on the, on the MRO draw down that your peer support folks are doing?

RUTHIE POOLE: Sure.

They do have to have clinicians but what I was trying to explain is

AUDIENCE MEMBER: When you say clinician, is that a licensed community mental health center social worker?

RUTHIE POOLE: Some other Massachusetts person help me out with that?

Because I've never worked for a place where my work can be billed, that's always been my problem, like I'm always the next to be laid off, we can't bill for you.

So, so, but maybe there's, can you answer that?

JUSTIN BROWN: So I think what we want to do is distinguish between what happens in, for instance, our independent living center where by and large we don't bill Medicaid

AUDIENCE MEMBER: And I understand that.

JUSTIN BROWN: And what happens within the traditional mental health system where Medicaid is billed and peer specialists are embedded within the clinical team and those clinical teams develop a treatment plan that's often called person centered but it's not necessarily self determined.

AUDIENCE MEMBER: Sure.

JUSTIN BROWN: That's one of our objections, is that these treatment plans, these treatment teams, that the human being at the center of that is often way outnumbered and it's a tough, a tough situation.

AUDIENCE MEMBER: Yeah, no, I understand.

I'm trying to find out the sustainable funding piece for this, for you guys.

So for those folks who are embedded at the community mental health center level, are they drawing down a mental health center level, are they drawing down a fee for service for the work that they are performing?

And who is doing the signoff on that?

JUSTIN BROWN: The signoff is a licensed clinician, could be a social worker, could be an M.D., PhD

AUDIENCE MEMBER: Clinical nurse specialist?

JUSTIN BROWN: Anybody who is licensed, and you know, for mental health services in the state.

AUDIENCE MEMBER: By the state.

Okay.

JUSTIN BROWN: But this is a day rate, so it's not a hourly or a 15-minute rate, and the peer specialist can deliver what's called a rehabilitative service which then allows that day rate to be billed.

So the peer specialist signs off on I delivered a rehabilitative service today, and the clinician signs off on the overall medical necessity of the treatment plan.

AUDIENCE MEMBER: Okay.

Great.

I have one more question for the person

RUTHIE POOLE: Can I add to what Justin just said, because there's a one complicating factor that may be true in your state.

So that's the people, the rehab option stuff, the stuff that you guys (unclear)

AUDIENCE MEMBER: Right, an MRO.

RUTHIE POOLE: But we have a carveout for behavioral health services under Medicaid, and probably many states do.

Beacon Health, Value options, some of the big Magellan, so our carveout was to Value Options, who has just been bought out by Beacon Health strategies, they're humungous, and so that's our behavioral health, addictions and mental health services carveout, right?

And so that's called, they like to use Massachusetts name to make it seem local, which I think is hysterical, so it's called Massachusetts Behavioral Health Partnership, but they're owned by Beacon Health now.

They were owned by Value Options, who just got bought out.

And so those peer specialists, they're working on emergency services teams, and they also have some who work with intensive case management.


And so those folks, they, they have that carveout for Medicaid, and so it's a more, umm, what do you call it, an MCO kind of model, so that's a little different than the fee for service stuff.

AUDIENCE MEMBER: They'll draw down as a team.

I have a question for the Vermont person too as a follow-up.

MIKE BACHHUBER: If I could, I wanted to add, in Wisconsin it works fairly similarly to the way Justin was saying.

Social worker for the county authorizes the specific service and signs off for Medicaid.

AUDIENCE MEMBER: That is someone who would be licensed in Wisconsin then, right?

MIKE BACHHUBER: Right.

AUDIENCE MEMBER: Okay.

When you were going through your presentation about building the coalition in Vermont, one of the comments you made was that it had opened up additional funding streams for, I hate to be so focused on money here, but you had said it opened up additional funding streams.

Could you talk a little bit about what some of those additional, like community foundations or

SARAH LAUNDERVILLE: I think that the hopes are it opens up funding streams and it's exactly the Medicaid building streams, its the SAMHSA funds, all those sort of things that people are hoping for by doing peer certification, and so we haven't, it hasn't actually opened, the parts I was going over was like here's what the hopes are for that coalition.

AUDIENCE MEMBER: Gotcha

SARAH LAUNDERVILLE: And then that added to a lot of conversations of, is it worth it?

You know, do we want that sort of money coming in, because we've had lots of conversations around, for instance, Vermont we choose not to have a PCA program in our state, and we have lots of conversations about why as an advocacy organization we don't want to move forward on that, because it will bind us in our state around being able to push on certain advocacy issues, so you can see some parallels to that, when it comes to, like, Medicaid billing for mental health issues, things like that.

That's the conversations we're having.

AUDIENCE MEMBER: Okay. Great.

Thank you very much.

AUDIENCE MEMBER: I think that Medicaid is definitely state specific on what your state chooses to do.

Any of you had experiences where you looked and researched what the feds say, and then said, okay, we need to make some changes so this peer model will work within our state, so the option opens up to other organizations besides just the state agencies.

RUTHIE POOLE: And I think the timing, and Dan, you're going to have to tell me, Cindy Mann still the held of Medicaid?

AUDIENCE MEMBER: No, but I could not tell you the new director.

RUTHIE POOLE: Anyways, do people know who the head of the Medicaid is, the feds?

So Cindy is actually a friend of mine.

And I could not believe, I am like Cindy Mann is the head of Medicaid for the whole country?

She is a legal services attorney who said, sang to me, Patsy Klein, Stand By My Man, because her husband, Steve Stavner was going to the Social Welfare Foundation in DC.

The next thing I know, she is the head of Medicaid.

I mean, she is like left of left, so timing is everything, so who knows who our next president will be, and I don't know if the head of Medicaid is still as liberal minded as Cindy.

Does anybody else know?

I couldn't believe, like, Cindy Mann is the head of Medicaid.

This might be the time.

SARAH LAUNDERVILLE: We're going to take a couple more questions or comments, if folks have them.

AUDIENCE MEMBER: I guess one more.

For those folks who are embedded at the community mental health center, you really spoke about kind of the hostile work environment, but Jeff and I were kind of talking about, off record, that's a, do they find that they're walking a real fine line between, you know, being a CMAC, a community mental health center employee and a peer support person and how do you live in both worlds?

RUTHIE POOLE: You know, it's a great question.

I have some incredibly sad, painful stories around that, not for myself but that I've heard.

For instance, one person on a community-based flexible support team, they're not at a mental health center, right, but Department of Mental Health provider of services.

So the people they provide services to 40% live in group homes, 60% live in their own apartments with supports.

Supports ends up being, here's your meds, let me watch you take them.

That's, to be honest, that's what it ends up being.

And that's not what peer specialists do, but that's what the bottom line ends up being.

One women, I'm not kidding, this just happened last year, and these people had had peer specialists for four years, she asked someone in administration, she was working on a project, she said, could I use your scissors?

She goes, are you safe with sharps?

This is a peer specialist who works with her.

She said that to her.

So you know, those really painful attitudes might be the person next to you.

And that's very, very hard.

I thought, oh, my God, she was making 11.50 an hour to be treated that way, which she was because out in Western Mass.

So I think it is a real challenge, when Sarah used the word pioneers, they are, I'm so grateful to those folks.

I would get my ass fired immediately because I can't, I don't know when to keep my mouth shut.

AUDIENCE MEMBER: Is there a special training component that you've put in place for your folks in Massachusetts to kind of help them with that?

RUTHIE POOLE: Yes. That's why.

When she was talking about intentional peer support, that's a peer support model, eCPR is a peer support model.

That's not what our certified peer specialist training is.

One of our most important modules, we do a little on that, is power, conflict, and integrity.

Because how do you keep your integrity?

How do you get the people in power at your agency to listen to you in a way that they can hear?

It's very hard to do.

I just, you know, these people are paid so little to do this important work, because you know, it's funny, because the whole person center planning thing, you guys might be familiar with that term in mental health, okay, so say you're my age, 53, and I've been in the mental health system, say, since I was 20, the public mental health system.

So I've never had any choices at all.

And now that we have person-centered planning, they say, okay Ruthie, you run your treatment meeting.

Well, no one has even asked me what I thought for 30 years.

So what peer specialists do is help an individual prepare for that.

One man I worked with, who is bilingual bicultural, he's Puerto Rican and they assume he wants to speak in Spanish.

He's much more comfortable in English, he moved from Puerto Rico when he was one.

They always talk to him in Spanish and he's really shy, so he can't say please speak to me in English.

And so I just sit there with my bad Spanish, I just listen and for a one hour treatment team meeting, he and I spent 12 hours preparing.

Because he is out about his mental health challenges.

He is not out about his intellectual disability, so we spent 12 hours to prepare for one meeting.

So it's not something that can be done quickly, frankly.

SARAH LAUNDERVILLE: And that just brings up another thought to mind around IL skill building.

So we were talking yesterday about like planned development and people don't know what they're necessarily looking for when they walk through the door and it's our job to elicit and talk and have conversations, right?

But it's also our job to start to think about, how many times are you hearing similar conversations that you should be providing skill building training to, and so it's another opportunity that if you're not thinking outside the box in terms of training, it's another opportunity to.

DARRELL JONES: I just wanted to go back to that article that Ruthie mentioned this morning, because we've had an inquiry about it.

That article had been shared with us at ILRU prior to the training, and it had been our intent to get reprint permission to distribute it to you.

We do things by the book at ILRU, and it is a published journal article.

The system for reprints is a clearinghouse kind of situation.

And what was involved was not that they would just tell us that, yes, you can run this off on your copy machine.

We had to tell them how many people, how many copies we would pay for those copies, they would ship those copies to us, and I could not find any option for an electronic version, an accessible version, or even a contact person to get in touch with, so this was one of those things that kind of fell into the cracks.

SARAH LAUNDERVILLE: One more comment or question?

AUDIENCE MEMBER: So some of you guys, Massachusetts, are very close to one another.

Massachusetts, are very close to one another.

Has there been any sort of regional collaboration, like some of the Vermont people closer to Massachusetts.

Massachusetts people maybe, or New Hampshire, or what not, the states are very small.

When I was in Delaware, I was part of an Asperger's group and some of the people that went to the Asperger's group they came from Maryland and Pennsylvania, or, to be part of it are in the states.

RUTHIE POOLE: So it's very funny, because like we don't do a very good job talking to each other, so the six recovery learning communities, to really talk to the director of one of them, I had to go to Orlando, Florida, to some stupid conference and run into her.

And so, like, we never talk to Vermont.

I've never met Sarah in my life.

It's very silly.

I hardly ever speak to Courtland, and he's, like, how far, maybe ten minute drive from Roxbury, would you guess, to your office?

Yeah, so, I just think it's human nature, yeah, yeah, so you live even closer to there.

And I think, you know, like I'm really glad a contingent came from Hawaii together because actually you're talking to each other.

So, and it probably took you coming all the way to Baltimore, I can't imagine how many thousand miles that is, but I think we get so busy that we don't take the time to do trainings like this.

I'm really grateful to Tim and Darrell and all the other folks who put this on, because, like, I've never met these guys, frankly.

And I, the people in Massachusetts,

Pat and I have known each other for years.

How often do we talk, Pat?

Not often.

And life gets busy.

AUDIENCE MEMBER: I will say there are some opportunities.

Each year we have a statewide independent living conference.

RUTHIE POOLE: They don't invite me, Courtland.

AUDIENCE MEMBER: I don't know what you did, but you have to work that out.

So that folks from around the state have opportunities to do that.

There's the mass rehab conference, consumer conference where folks from around the state come and participate and I know NCIL, I imagine still has regional reps that try to share and get out information to folks in the regions that they cover, and so I do cross paths with Ruthie, and I, we've actually worked really closely with another coalition called DAR, with one of her colleagues, actually awarded one of her colleagues at our center, so there are opportunities for us to talk.

I mean, but it's not what it could be.

You know what I mean.

SARAH LAUNDERVILLE: What we decided to do is have that time for questions, because we had gone through so much earlier, and we're going to take a break, and then we're going to go through, during lunch, the reviewing our organizations and then we'll move on to the other parts that Justin is going to take us through as well, right?

JUSTIN BROWN: We have a discussion for lunch.

mumbled conversation

JUSTIN BROWN: As you know, the price of lunch is work.

And the work is to take this material and see what we can do from it.

So tomorrow we're going to be mostly focused on going forward from here.

We'd like you to just think about these three questions.

We're going to lunch now, but getting back, take a little bit of time, and you know, one of the questions that people have asked is, when somebody comes through the door, how do we know whether they need support around mental health, mental wellness resiliency, but I'd like you to ask a different question, which is really leading into Sarah's later presentation around organizational change, and that is, in your Board of Directors, what representation do you have of people who identify as people living with a mental health challenge?

And then we want to ask you, what is the difference between a token presence of psychiatric survivors and true inclusion of the psychiatric survivor movement, of the peer support movement, of the, of those of us with lived experience, so I'll give you actually an example from my own independent living center.

We have some folks who identify who have been diagnosed with various psychiatric disabilities, but often they're people who are kind of, they're not especially outspoken, they're not connected to the advocacy that we've been talking about, and it's, in some sense, it's a way to have, as Ruthie was talking about earlier, somebody who kind of represents our community but doesn't speak too loudly.

And the other piece about a token representation, Dan said it yesterday, we could say it again and again, if there's one of us in the room, right, if there's one of us in the room, that's an impossible burden, right?

If you're black and the only black person.

If you're a woman, only woman.

If you are a person with lived experience, at least you're the only one out, that's a very heavy burden.

So there's a critical mass of two or three on the Board of Directors that makes it possible for people to speak out of our lived experience and not just be these kind of token folks on a Board of Directors who have little to say but kind of make everybody feel good because we've got some representation here.

So I'm putting it kind of harshly but I think it's often a reality, so what I'd like you to do is spend your time asking, what first step could your CIL take to begin the process of inclusion in a way that honors the history and values of the psychiatric survivor movement?

And who would your allies be?

So you know, really, Sarah talked about, it's not just developing this capacity within your Center for Independent Living, it's reaching out across all of the partners, all of the allies, so who would your allies be?

So those are the questions, so we're going to ask you to have, you know, a conversation.

We're going to ask you to designate someone as your spokesperson, and we're going to have a report back at the end of lunch.

And the more specific you can be, you know, who in your state can you reach out to, just like we haven't reached out to each other and we live as neighbors, neighboring states, who are those folks who you, when you go back home, are going to reach out to, to build some of those cross-disability alliances, advocates for inclusion.

SARAH LAUNDERVILLE: Can I add, if you feel like you're doing these things, you have already taken those first steps, I encourage you, what's your next step?

Where do you want to go?

So I don't, I would love to hear report backs from all the tables of saying, here's what we're going to do next, so even if you're doing a great job.