Many who seek services for mood, anxiety, or substance use disorders look for support from others who had a similar experience and are now in recovery.1 This type of support can be critical to success when trying to adopt healthy and positive behaviours.1 In short, people with lived experience can play an important role in helping others achieve recovery from mental health problems and addictions.
In this issue of Promising Practices, EENet's Howard Fruitman looks at Mississauga-Halton's Centre for Innovation in Peer Support.
Read it below or download the PDF.
More than 10% of Canadians experience mood, anxiety, or substance use disorders.1 Many who seek services for these problems look for support from others who had a similar experience and are now in recovery.1 This type of support can be critical to success when trying to adopt healthy and positive behaviours.1 In short, people with lived experience can play an important role in helping others achieve recovery from mental health problems and addictions.
Peer support can come in a variety of forms, including groups and one-on-one support, recovery education, social enterprises, and advocacy services.1
How Mississauga Halton LHIN integrated peer support
While more peer support workers are available now than in the past, there’s still a gap between their availability and the needs of those with mental health problems and additions.1 The Mississauga Halton Local Health Integration Network (LHIN) decided to do something about this gap.
Since it was established, the LHIN has had people with lived experience, family members, and caregivers sitting at the planning table for mental health and addiction services and programs. And in 2014, they became pioneers in the province by making peer support for mental health and addiction a sustainable funding priority.
To ensure that peer support would serve the needs of those who are accessing services for mental health and addiction problems, the LHIN brought together more than 70 persons with lived experience, families, caregivers, and peer workers to identify the core elements of effective peer support. These elements include support groups, social activities, recovery education, infrastructure, and advocacy services.
Based on this input, the LHIN created a funding framework for multiple agencies and hospitals to meet those identified needs, and funded 40 new peer support positions. The Mississauga Halton LHIN Consumer Survivor Initiative—called TEACH (Teach, Empower, Advocate for Community Health, part of Support & Housing-Halton)—received funding to oversee the sustainability of these new peer positions through the creation of two system lead positions.
Participating organizations include hospital psychiatric units, residential treatment programs for addictions, supportive housing programs, a central intake organization, employment support programs, community mental health and addiction providers, and self-help education and support groups.
Growing peer support in the region
During the winter of 2014 the region’s existing peer workers and peer supervisors started to identify the competencies and components of job descriptions needed to hire peer support workers. The 11 agencies funded by the Mississauga Halton LHIN worked together to train all hiring staff on guidelines, coordinated promotion of the new roles, and hosted community workshops and jobs fairs for potential applicants.
During the fall of that year, there was a push towards capacity building, so the Initiative developed ongoing core skills training for peer support workers. In addition, a knowledge exchange event brought together a diverse cross-section of individuals to share their knowledge on the current and future state of peer work. A panel of peer workers also spoke about their experiences.
The second annual exchange event, held the following year, had 125 people in attendance, and the third event, which took place in December 2017, gathered about 200 people.
Building a centre for innovation in peer support
To better reflect the work, the initiative has been renamed the Centre for Innovation in Peer Support and continues to be embedded in Support & Housing-Halton, working closely with TEACH and funded by the Mississauga Halton LHIN.
The Centre’s main focus is to ensure peer support services are integrated into mental health and addiction services in a way that honours the values of peer support. These values, drawn from the Mental Health Commission of Canada, are:
- Hope and recovery;
- Empathetic and equal relationships;
- Dignity, respect, and social inclusion;
- Integrity, authenticity, and trust;
- Health and wellness; and
- Lifelong learning and personal growth.
The Centre aims to demonstrate the value, impact, and importance of people with lived experience, family members, and caregivers—and their work—to the healthcare system. This is done by:
- Supporting and empowering people with lived experience to build their capacity as peer support workers;
- Fostering a coordinated and integrated mental health and addiction system by shared information, recognition of the peer support received by individuals, and personally connecting people moving from one service to another;
- Recognizing and integrating peer support work into addiction and mental health treatment and recovery services; and
- Increasing the capacity of peer support networks and their connection to other regional, provincial, and national initiatives.
The governance model
The Centre for Innovation in Peer Support has used a “constellation governance” structure to promote the flow of information and sharing of knowledge about system changes (Figure 1). This structure has changed over time to reflect its evolving role.
Two directors share leadership and communication. They facilitate trainings and network meetings with peers and their supervisors, and liaise with regional, national, provincial, and international stakeholders and other similar initiatives. They have four critical connections:
- The directors communicate regularly with all peer workers in the region through monthly networking meetings. This network of peers is considered a community of practice and includes peers funded by the LHIN and, increasingly, those funded by other sources. These meetings include debriefing scenarios, training, problem-solving, and the exchange of resources. Key challenges and opportunities that arise during these meetings are communicated to others through the channels noted in Figure 1. New peers who join these meetings participate in the Centre’s Peer Position Core Skills training.
- The directors facilitate monthly Peer Position Supervisor Network meetings for those who supervise peers funded by the LHIN and, increasingly, those who supervise peers funded by other sources. This network is also considered a community of practice and its meetings focus on practical issues such as how to balance peer philosophies with the demands of health service providers for service delivery and outcomes. The group helps to create documents to further integrate peer work, such as guidelines on how to document peer work and how to create promotional and education materials, as well as Frequently Asked Questions about peer work for staff teams. Everyone who supervises a peer in the Mississauga Halton region is included in this network and is trained in Peer Supervision. The training is provided by the Centre.
- The Centre’s directors are connected with the Mississauga Halton LHIN through Support & Housing-Halton. They are part of the LHIN’s leadership planning table, which includes the executive directors, CEOs, and clinical managers of mental health and addiction agencies funded by the LHIN. This planning group, called the System Integration Group for Mental Health and Addiction (SIGMHA), has monthly meetings that includes discussion on the Centre and its work.
- The Centre’s directors are also connected to other stakeholders and allies in the development of peer work and the engagement of people with lived experience, families, and caregivers through a stewardship group. They provide expertise to other groups that are working to integrate peer support into regional initiatives Members of this stewardship group include representatives from the Ministry of Health and Long-Term Care, Evidence Exchange Network, Ontario Peer Development Initiative, Addictions and Mental Health Ontario, LHIN Leads, Trillium Health Partners, Self-help Services, and Peer Support Canada.
The Centre’s directors are also engaged in a wide variety of provincial, national and international initiatives, ensuring the Centre can share and receive information through a broad network.
Evaluation and quality improvement
Developing an evaluation plan
In general, it’s difficult to find recovery-oriented data, let alone data specific to peer roles; this means there is no usable baseline data, which makes it difficult to evaluate the effect that peer support programming is having, or to encourage the community to adopt it as a practice. (You cannot track change over time without baseline data.)
For this reason, the Centre’s leadership team invested considerable time and effort to develop an evaluation plan, using an approach called “developmental evaluation.”
The evaluation will consider six levels of influence in the mental health and addiction system, which impact the delivery of peer support (Figure 2). In addition, an evaluator joined the leadership team early on, to ensure a consistent approach.
The team also put quality improvement processes in place to help evaluate the program and make decisions on next steps, tools, and processes. They were able to do this thanks to their involvement with the Excellence through Quality Improvement Project (E-QIP), a partnership between Healthy Quality Ontario, Addictions & Mental Health Ontario, and the Canadian Mental Health Association, Ontario branch.
These diagnostic tools and processes helped identify a critical issue that was causing significant challenges—a lack of clarity about the roles and responsibilities of peer support workers. Currently, the team is developing a tool to assess the degree to which the peer support that people are receiving actually reflects the values inherent to peer support work (the team calls this “service integrity”). Only then can an assessment of impact begin in earnest.
If there are gaps between the theoretical values and the peer support that is being provided in practice, quality improvement tools and processes will help determine where changes will need to be made to ensure that values are reflected in the work. For example, there may need to be a change to how peer workers are trained and supported.
The evaluation tool is also assessing the quality and impact on recovery-oriented outcomes from the perspective of those receiving these services.
There are, of course, complex challenges to evaluating certain outcomes, which contribute to the success of this work. These include:
- Trying to bridge the medical and recovery models of practice;
- Gathering system-level information for system planners and policymakers that does not necessarily speak to recovery-oriented practice;
- Working to have lived experience viewed as expertise and evidence at the systems level.
- Knowing that innovative and value-driven peer support requires change to the mental health and addiction system, while recognizing it’s complex (Figure 3).
The Centre will continue to evolve to meet the complex needs of those receiving services and of the healthcare system. To build on their success and implement quality improvement measures, the Centre’s leadership team has grounded its work in four principles.
- The importance of the voice of people with lived experience and their families. When we make decisions, the perspective of people with lived experience and their families will be the primary lens through which we evaluate options.
- Inclusion and diversity. We will develop and support relationships that promote equity and diversity, and that honour each individual’s option to choose their own recovery journey. We will encourage the involvement of our colleagues in all of our initiatives.
- Moving toward clarity. As a ground-breaking initiative, we recognize and appreciate the need to function and succeed in an environment that is complex and dynamic. While challenging to navigate, this environment can offer excellent opportunities for us to build a new reality using evidence-based decision making for peer support in the Mississauga Halton LHIN Region.
- Transparency. In order for this initiative to be successful, we will make every effort to be transparent as we collaborate with a diverse set of stakeholders. This transparency will extend in all directions, to all stakeholders, and to the larger community.
Over the first three years, the application of these principles has resulted in the growth of seven areas of reflective practice for the people involved with the Centre:
- Person-directed services
- Developing a new role in the system
- Service integrity
- Communities of practice
- “Marrying” all of these
As the Centre continues to mature, these areas of reflection will continue to help shape the activities that it takes on and supports:
- Evaluation and research
- Capacity building
- Knowledge brokerage
- Quality improvement
A peer support service delivery model adds value and fosters the ongoing evolution of the mental health and addiction system. The Centre for Innovation in Peer Support has begun to lay the ground to implement and sustain this model. People with lived experience bring their expertise and first-hand accounts to service delivery. This will help the mental health and addiction system better serve communities.
In the end, as Betty-Lou Kristy notes, “the lived experience of people, families and peer support is shaping the cultural shift from ‘storytelling’ to evidence. It provides a road-map to affirmative change.”
Author: Howard Fruitman
- Cyr Céline, McKee Heather, O’Hagan Mary and Priest Robyn, for the Mental Health Commission of Canada (2010 first edition / 2016 second edition). Making the Case for Peer Support: Report to the Peer Support Project Committee of the Mental Health Commission of Canada.