In this post we reflect on the definition of success in a study measuring the value of peer support services administered through the HUD VASH program and discuss client-centered definitions of value. We propose designing and understanding programmatic success goals tailored to unique need categories within veteran participant groups.
With stay-at-home orders lifting all across the country and the economic effects of the SARS-CoV-2 pandemic becoming clearer, America’s next housing crisis is already upon us. A forthcoming flood of federal funding for shelter and affordable housing initiatives as part of the CARES Act congressional response makes our attention to housing support studies even more timely.
Peer Specialist Service Model
Peer specialist support plays a big role in a growing number of mental health and substance abuse treatment interventions. The model employs individuals in recovery from mental illness, including substance abuse disorders, to assist other recovering individuals with getting mental health or substance abuse treatment.
Libby Spencer, a Recovery Support Peer Specialist in Austin, Texas describes peer support as a “people business.” Peer support specialists are able to leverage their own experience on both sides of recovery to connect and engage with others in an authentic non-judgmental way. Spencer sees all different kinds of people in the peer circles she mentors and notes that an effective peer support specialist encourages peers to be open to multiple pathways to recovery.
Peer support programs are essential to the success of several successful criminal justice reform models, including innovative programs in family courts, mental health courts, and veterans courts across the county. The model has been integrated with many behavioral health clinics and shows promise as a tool to support recovering individuals and to facilitate community engagement. The VA embraced the Peer Support model [pdf] years ago, in an effort to involve individuals in recovery and their families to meaningfully engage veterans in programs and resources.
Case Study: Peer Support Services in the HUD-VASH Program
Researchers from the VA published a study in Medical Care in April evaluating peer support services. The program randomized clients to receive peer support services plus standard case management or just the standard case management services. Clients had all recently experienced homelessness and were enrolled in supportive housing provided by the VA (HUD-VASH). The supportive housing program provides federally funded Section 8 housing vouchers and requires veteran participants to have monthly contact with a case manager.
The clients were evaluated using “residential stability” (frequency of nights spent in housing provided) and self-reported measures of addiction severity and symptoms of mental illness [pdf]. The researcher’s use of length of stay in housing was an important measure in this study because it represents an evidence-based Housing First model. This model prioritizes housing which has proven positive impact for healthcare access, long-term stability, and quality of life.
Effective Peer Specialists Positively Influence Housing Retention
Comparing the group of participants randomized to receive peer support services to the whole (an “intent-to-treat” approach), the researchers detected no difference in stability or behavioral health over time. As is often the case in providing support programs to complex client populations, not everyone completed the full, structured peer support specialist curriculum from the Mission-Vet manual [pdf]. When researchers compared only the clients who saw three specific peer specialists (ones who more strictly adhered to treatment protocol) to the whole, participants with protocol-adherent peer support stayed in housing longer than those without peer support. Measurement began around 400 days after housing entry.
In other words, the study demonstrated that the addition of peer support kept veteran participants housed for longer – but only when the program was implemented according to protocol. If the analysis included everyone assigned to peer support services, the impact effectively disappeared.
Fidelity: Importance of the Program Dose
Implementation fidelity is the extent to which the delivery of a program actually adheres to the model as intended. For this study, the program was based on the Mission-Vet manual. However there are many ways to think about adherence to a program’s original mission, values, and design. Once again, we are faced with a complicated and dynamic issue to capture and quantify. Determining fidelity can often be a very subjective experience, depending on the clients’ or the staff members’ perceptions of the principles and objectives of a program [pdf]. Fidelity also relies on commitment to the principles of the intervention in question, as well as the nuances of implementation science [pdf].
The restriction of detectable impact in the study by Ellison et al. to just protocol-adherent cases should give us some pause. The authors are seemingly quite humble about this, since not everyone was able to see benefit from the program. Alternatively, this may actually demonstrate a stronger case for causation between the program and residential stability. If those receiving the full dose of the program see benefits not detected when program delivery is incomplete, it seems likely that the program is responsible for the increased stability.
Greater Engagement with Peer Specialists Reduced Behavioral Health Symptoms
The researchers concluded that peer specialist engagement was not influential in the self-reported behavioral health symptom checklists over time. However, the study discussion acknowledged that some program participants defined as “high peer specialist engagers … experienced a significant improvement in mental health and substance abuse symptoms, unlike those who were low peer specialist engagers.”
The study included only the role and participation of the peer support specialist in their measurable results, not the role and participation of the client. We need further research in this area. Ideally, studies should have a client-centered mindset and tell us more about the characteristics of veteran participants who engaged more actively with peer support.
In her role as a recovery peer support specialist, Libby Spencer sees some peers more engaged than others. She described a few variables that impact engagement: relatability and openness of the peer support specialist, how far along a peer is on their path to recovery, whether a peer is consistently taking prescribed medications or following a daily routine, and especially whether a peer has other sources of support in the community.
Engaging Complex Populations Requires Tailored Services
The veteran population studied was comprised of HUD-VASH program recipients in treatment for mental health and substance abuse. This is a small subset of the veteran population. The participant group randomized to receive peer support services included people with complex needs and an array of backgrounds. Despite expansive programs for mental health and housing stability, practitioners and peer support specialists will tell you: success in housing and stability is accomplished one person at a time. And no one intervention can meet the needs of every person. We can better understand and address the needs of each individual by studying which groups in a sample population participated more and which groups may require an alternative or modified intervention option.
The VA and its clients are unique in many ways. The standard of care resources and case management programs provided to the control group may be more extensive than other, civilian programs. It’s also possible that veterans benefit more from structured interaction with peers, given the potential for shared trauma or commonalities in life experience. The population cross section in this veteran population could reveal interesting insights about the shared characteristics which underlie a rich and complex array of need based groups.
Conclusion
Identifying the unique needs and characteristics of people who were highly engaged in peer support programming could provide insights about the specific needs peer support can meet. Even within the constraints of a small sample size, general information about age, gender, race & ethnicity of high versus low engagers could give insights into different need-based groups and could be useful to ensure that the service is meeting all veteran demographics. Even better would be information on whether engagers had a history of traumatic brain injury or family violence, how early a peer is on their path to recovery, whether a peer is consistently taking medication or following a daily routine, and whether a peer has other sources of support in the community.
There is also a need to reevaluate how we define value and impact in programs such as these. What defines success in this or that situation for a program? In light of the complex population and individual needs within the population, we recommend identifying characteristics of veterans engaged in peer support services so that practitioners can better meet individual needs.
Ben King
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Ali Foyt
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- Framing Success for Supportive Housing Services - June 11, 2020