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Implementation of peer providers in integrated health care settings

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Implementation of peer providers in integrated health care settings

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1

Implementation of Peer Providers in Integrated Health Care Settings

by
Elizabeth Siantz, MSW
May 2016 Degree Conferral
Ph.D. (Faculty of the USC Graduate School)

University of Southern California
Dissertation Guidance Committee
Benjamin Henwood, Ph.D. (Chair)
Lawrence Palinkas, Ph.D.
Lourdes Baezconde-Garbanati, Ph.D.
With additional guidance from Eric Rice Ph.D.

IMPLEMENTATION OF PEER PROVIDERS 2
Dedication
This dissertation is dedicated to my husband, Mark McDowell, who joined me on this
journey out West so that I could pursue my aspirations. Thank you for caring for me and growing
with me during this massive undertaking. Also to my parents, the Professors, who saw me as
PhD material before I did, and for sharing two full careers worth of wisdom on the ropes of
academia, mentoring relationships, dissertations, grants, and work–life balance. To my sister,
Elena, for reminding me to lighten up. To the dear friends I’ve made along the way—those who
practice the philosophy of ‘sharing in the ride rather than defeating each other in the race’—
especially Amy and Liat, along with the many others who have kept me laughing. To my dear
doggies for demanding I put down the computer when it’s time for a break. Finally, to the
California wilderness for providing respite and escape, especially the spectacular Eastern Sierras
including Big Pine Canyon and the John Muir Wilderness, and El Dorado County and the
American River when I wanted less of a challenge.

IMPLEMENTATION OF PEER PROVIDERS 3
Table of Contents
Dedication ....................................................................................................................................... 2
Acknowledgements ......................................................................................................................... 5
List of Figures and Tables............................................................................................................... 7
Abstract ........................................................................................................................................... 8
Chapter One: Overview of the Three Studies ............................................................................... 10
Introduction and Rationale ...................................................................................................... 10
Study Goal and Structure ........................................................................................................ 14
Study Framework .................................................................................................................... 15
Methods................................................................................................................................... 15
Summary ................................................................................................................................. 21
References ............................................................................................................................... 22
Chapter Two: Study 1 ................................................................................................................... 29
Implementation of Peer Providers in Integrated Mental Health and Primary Care Settings .. 29
Introduction ....................................................................................................................... 29
Methods................................................................................................................................... 31
Study Setting ..................................................................................................................... 31
Study Framework .............................................................................................................. 31
Study Sample .................................................................................................................... 32
Data Collection ................................................................................................................. 32
Data Analysis .................................................................................................................... 33
Results ..................................................................................................................................... 35
Outer Setting ..................................................................................................................... 35
Inner Setting ...................................................................................................................... 36
Individuals Involved in the Intervention ........................................................................... 38
The Process of Implementing Peer Providers ................................................................... 39
Discussion ............................................................................................................................... 40
Limitations ........................................................................................................................ 44
Conclusion ........................................................................................................................ 44
References ............................................................................................................................... 46
Chapter Three: Study 2 ................................................................................................................. 56
Where Do Peer Providers Fit into Newly Integrated Behavioral Health Care Networks? A
Mixed-Method Study .............................................................................................................. 56
Introduction ....................................................................................................................... 56
Methods................................................................................................................................... 58
Setting ............................................................................................................................... 58
Study Design ..................................................................................................................... 58
Study Sample .................................................................................................................... 59
Data Collection ................................................................................................................. 59
Data Analysis .................................................................................................................... 60
Integration of Social Network and Qualitative Findings .................................................. 63
Results ..................................................................................................................................... 63
Characteristics of Participating Organizations.................................................................. 63
Characteristics of Peer Providers ...................................................................................... 63
Structure of Care Coordination Networks ........................................................................ 64
Positional Variation of Peer Providers by Care Coordination Network Type .................. 64
IMPLEMENTATION OF PEER PROVIDERS 4
Triangulation of Social Network and Qualitative Results ................................................ 65
Most-Central Peer Providers ............................................................................................. 66
Least-Central Peer Providers ............................................................................................ 68
Discussion ............................................................................................................................... 70
Limitations ........................................................................................................................ 72
Conclusion ........................................................................................................................ 73
References ............................................................................................................................... 74
Chapter 4: Study 3 ........................................................................................................................ 83
Roles and Experiences of Peer Providers in Integrated Mental Health and Primary Care
Settings .................................................................................................................................... 83
Introduction ....................................................................................................................... 83
Methods................................................................................................................................... 84
Study Setting ..................................................................................................................... 84
Data Collection ................................................................................................................. 85
Data Analysis .................................................................................................................... 85
Results ..................................................................................................................................... 86
Theme I: Encouraging Physical Health Self-Management ............................................... 87
Theme II: Using Experience with Recovery to Educate Program Staff ........................... 89
Theme III: Evoking Shared Cultural Identity to Engage Clients ...................................... 90
Discussion ............................................................................................................................... 92
Limitations ........................................................................................................................ 94
Conclusions ....................................................................................................................... 95
References ............................................................................................................................... 96
Chapter 5: Conclusions, Implications, and Future Directions .................................................... 100
Introduction ........................................................................................................................... 100
Major Findings ...................................................................................................................... 102
Limitations and Future Research .......................................................................................... 105
Implications and Recommendations ..................................................................................... 108
Program Level ................................................................................................................. 108
System Level ................................................................................................................... 109
Policy Level .................................................................................................................... 111
Conclusion ............................................................................................................................ 112
References ............................................................................................................................. 113
Appendix A: Terminology Used in Dissertation ........................................................................ 116
Appendix B: LA Innovations Social Network Survey ............................................................... 117
Appendix C: Semi structured Interview Guide ........................................................................... 121
Appendix D: Qualitative Code Book .......................................................................................... 123

IMPLEMENTATION OF PEER PROVIDERS 5
Acknowledgements
I am more than grateful to the team that has supported this effort during the last 6 years
and want take the opportunity to say thank you.
To Dr. Benjamin Henwood: For your insistent (yet passive) pushing throughout the years.
Thank you for building my confidence and reinforcing how to be smart and strategic but with
integrity and kindness.
To Dr. Lawrence Palinkas: For watching over this study from its beginning and for
sharing your years of experience as an implementation scientist.
To Dr. Lourdes Baezcondi-Garbanati: For contributing a public health perspective to my
qualifying exam and dissertation research.
To Dr. Eric Rice and Dr. Tom Valente: For giving me command of one of my favorite
statistical techniques!
To Dr. Maria Aranda, Dr. Julie Cederbaum, Dr. Erick Guererro, and all who have
mentored me through my doctoral education at USC for influencing my thinking and sharing
their expertise.
To my colleagues at the Southern California Clinical and Translational Science Institute,
especially Dr. Cecilia Patino-Sutton, Dr. Melissa Wilson, Jeanne Dzekov, and all members of
Training Cohort 5. Thank you to the National Institutes of Health’s TL1 mechanism for
predoctoral trainees.
To my colleagues and friends I’ve made through the Los Angeles County Department of
Mental Health’s Innovations study—especially the Health Services Research Center at the
University of California, San Diego for providing me with this incredibly rich learning
opportunity. Thank you to Dr. Todd Gilmer, who graciously made room for a graduate student
IMPLEMENTATION OF PEER PROVIDERS 6
on his research team. Thank you to Harder + Company Community Research for facilitating my
social network data collection, especially Joelle Greene, Nicole McGovern, and Alfonso Martin.
To the doctoral program at the USC School of Social Work.
To the Los Angeles County Department of Mental Health’s Innovations program staff
members for their good-humored participation in data collection.
A final and huge thank you to the peer providers who shared their stories with me gave
me their blessing to share their stories with others. According to one peer: “They’re gonna hear
you and you represent me, so go—I’m OK with it. Just bring it back here so we can get help.”

IMPLEMENTATION OF PEER PROVIDERS 7
List of Figures and Tables
Table 1.1. Study Aims Described through Consolidated Framework for Implementation Research
Table 2.1. Peer Provider Background according to Program Type and Service Population
Table 2.2. Key Findings Using the Consolidated Framework for Implementation Research
Table 3.1. Composition of Care Coordination Networks
Table 3.2. Sample Characteristics of Peer Providers who Completed Both Social Network
Survey and Qualitative Interview
Table 3.3. Characteristics of Multidisciplinary Provider Networks
Table 3.4. Structural Equivalence through Convergence of Correlated Iterations (CONCOR)
Figure 3.1. Care Coordination Network Subtypes
Table 4.1. Sample Characteristics of Peer Providers
Table 4.2. Qualitative Results

IMPLEMENTATION OF PEER PROVIDERS 8
Abstract
Adults with mental illness are among the most medically vulnerable groups in the United
States and experience many years of life lost compared to the general population. Peer-based
services build on the experiences of individuals who have navigated health systems, can enhance
consumer self-efficacy while promoting physical and mental health, and are playing an
increasingly prominent role in the delivery of integrated physical and mental health care under
the Patient Protection and Affordable Care Act. However, there is little evidence that peer
providers are routinely implemented in integrated health care settings, and the reasons for this
remain unclear. Further, little is known about factors that affect the implementation of the peer
role in integrated health care settings.
Taking advantage of a systemwide effort to implement integrated primary, mental, and
behavioral health care in the Los Angeles County Department of Mental Health’s Innovations
Study, this three-study dissertation examined the process of implementing peer services in
integrated health care settings. This dissertation applied the Consolidated Framework for
Implementation Research to three empirical papers with the goal of understanding the roles of
peers in multidisciplinary provider networks and the experiences of peer providers who are
delivering integrated care. The study used a mixed-method approach to examine the process of
implementing peer providers in integrated health care settings.
Chapter 1 presents the current knowledge base related to services provided by peers in
traditional mental health and integrated settings, provides an overview of the three studies, and
summarizes the Consolidated Framework for Implementation Research, which is the conceptual
framework driving the three studies. Chapter 2 (Study 1) examines how peer-based services are
implemented in newly integrated behavioral health care settings in Los Angeles County using a
IMPLEMENTATION OF PEER PROVIDERS 9
dataset drawn from full-day on-site program visits. Chapter 3 (Study 2) examines social network
positions of peer providers on integrated health care teams using social network analysis. This
study also used qualitative interviews with peer providers delivering care in these integrated
programs to achieve an in-depth understanding of the variation in network positions. Chapter 4
(Study 3) presents findings of a qualitative analysis focused on the roles and experiences of peer
providers delivering integrated care. Chapter 5 discusses conclusions garnered from the three
studies, the broader importance of the findings, and implications of the dissertation for future
research. This chapter focuses on the role of organizational leadership in implementing a service
innovation, such as peer providers in integrated mental health and primary care settings.

IMPLEMENTATION OF PEER PROVIDERS 10
Chapter One: Overview of the Three Studies
Introduction and Rationale
Peer Providers in the Delivery of Care
Peer-based services are broadly defined as a method of health promotion in which
individuals share specific messages with members of their own community (Webel, Okonsky,
Trompeta, & Holzemer, 2010). These services facilitate consumer engagement with the physical
and mental health systems of care. In mental health settings, peer providers are people who have
personal experience with recovery from a mental illness (Davidson, Chinman, Sells, & Rowe,
2006) and have received formal training to deliver and coordinate mental health care (SAMHSA-
HRSA Center for Integrated Health Solutions, 2016). Key elements of peer support in mental
health settings include empowering consumers against stigma of mental illness, provision of
counseling and education, and advocacy (Gates & Akabas, 2007). Peer providers are one of the
most rapidly growing segments of the mental health workforce in the United States (Davidson et
al., 2006).
While there are varying definitions of peer providers in physical health settings (Fisher et
al., 2015), physical health peer providers often share a health condition or set of conditions with
patients and use these experiences to promote engagement and facilitate behavior change (e.g.,
Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001). In physical health settings, peer support can be
provided by community health workers, lay health advisors, or promotores de salud, for people
with a variety of health needs. In these settings, core tasks of peer providers include: assisting
with ongoing self-management; working with the clinical team to develop plans for pursuing
health goals; providing support to encourage healthy behaviors and coping with negative
emotions; and linking clients to clinical care and community resources (Fisher et al., 2015).
IMPLEMENTATION OF PEER PROVIDERS 11
Peer Providers in Integrated Primary and Mental Health Care
Because people with serious mental illness experience many years of life lost due to
treatable and preventable medical conditions, improving the physical health and wellness of this
population has become a national priority and is being addressed by integrating primary and
mental health services under the Patient Protection and Affordable Care Act (Croft & Parish,
2013). To reduce stigma and enhance consumer engagement with physical health services, peer
providers have become a vital resource for addressing the physical and mental health needs of
people with serious mental illness (Allen, Radke, & Parks, 2010; Davidson et al., 2006;
Goldberg et al., 2013; Solomon, 2004). Settings that deliver physical health services to people
with mental illness have borrowed elements of peer support from mental health peers and others
working in traditional physical health settings. As a result, peers delivering care in integrated
settings have occupied various roles in the delivery of integrated health care. These roles have
included peer health navigation, in which a peer provider facilitates engagement with primary
care services by teaching, modeling, and eventually stepping back after the consumer has gained
a sense of self-efficacy in accessing care (Brekke et al., 2013); and wellness coaching, in which a
peer provider helps an individual identify physical wellness goals such as improvement in
physical activity and nutrition or reduction in harmful habits such as smoking (Swarbrick, 2013).
Chronic disease self-management programs

(Druss et al., 2010; Goldberg et al., 2013) are
additional peer-based models that provide linkages between the primary and mental health care
systems. In these programs, peer providers facilitate educational wellness groups and participate
in the development of chronic disease self-management plans. Peer providers also play other
vital roles on multidisciplinary health care teams (Swarbrick, 2013),

and have been implemented
in a variety of settings including assertive community treatment teams (Teague, Bond, & Drake,
IMPLEMENTATION OF PEER PROVIDERS 12
1998) and the Veterans Affairs system (Resnick & Rosenheck, 2008).
Effectiveness of Peer-Based Services
When implemented in mental health settings, studies have shown that peer-based services
are an effective way to improve engagement with mental health services and improve a variety
of patient-level outcomes. A recent systematic review on the effectiveness of peer providers in
mental health settings reported that peer-based services are equally or more effective than
nonpeer services, particularly when peer providers are added to traditional services (Chinman et
al., 2014). Mental health consumers who received services from peer providers reported
improvements with treatment engagement, reductions in psychiatric symptoms (Cook et al.,
2012; van Vugt, Kroon, Delespaul, & Mulder, 2012) improvements in social functioning (van
Vugt et al., 2012), and higher levels of participation in structured activities (Craig, Doherry,
Jamieson-Craig, Boocock, & Attafua, 2004). Individuals who received care from peer providers
also reported a reduction in use of inpatient mental health services, higher levels of
empowerment, and hopefulness for recovery.
Effectiveness of Peer-Based Integrated Health Care
Although the evidence base for peer providers delivering integrated care is less developed
(Cabassa, Camacho, & Galvis, 2016), studies have suggested that services provided by peers also
support improvements in wellness outcomes of adults with mental illness. Examples of favorable
treatment outcomes include improved health behaviors such as increased physical activity and
improved medication adherence following a series of peer-facilitated educational groups (Druss
et al., 2010)

and increased use of primary care services following a health navigator intervention
(Brekke et al., 2013). A study of a peer health navigation intervention (Kelly, Fulginity, Pahwa,
Tallen, Duan, & Brekke, 2013)

reported that between baseline and 6 months, mental health
IMPLEMENTATION OF PEER PROVIDERS 13
consumers who received care from a peer health navigator reported increased use of primary care
services rather than the emergency room; decreased bodily pain, and less interference from pain
while doing normal work.
Challenges to Implementing Peer Providers for Mental Health Consumers
Despite the successes of the consumer movement in involving peer providers in mental
health and social service settings (Gates & Akabas, 2007; Ostrow & Adams, 2012) and the
effectiveness of peer-based services, several studies have reported challenges in the
implementation of this role (Gates & Akabas, 2007). Lack of role clarity resulting from poorly
defined jobs, unequal wages and benefits, and limitations in supervision and training combined
with poor communication with human services teams are structural factors that affect the
integration of peer providers into mental health teams (Gates & Akabas, 2007). Stigma from
other health and human services professionals has also affected the involvement of peer
providers in mental health settings (Fisk, Rowe, Brooks, & Gildersleeve, 2000). Underlying this
stigma is the notion that people with mental illness are not capable of functioning as service
providers and stereotypes that classify people with mental illness as unprofessional or otherwise
deficient (Oh, 2014). Further, there is a lack of consensus on the nature of peer provider
qualifications for employment in mental health settings, particularly regarding the requirements
for having experience with a given clinical condition or diagnosis (Hamilton, Chinman, Cohen,
Oberman, & Young, 2015).
Although challenges to implementing peer providers have been documented extensively
in mental health settings, whether and how systems-level challenges to implementing peer
providers in health care teams delivering integrated primary and mental health care services has
not been studied. A first step toward enhancing the availability of peer-based services in
IMPLEMENTATION OF PEER PROVIDERS 14
integrated health care settings is to understand the scope of existing implementation strategies
and organizational environments in which peer providers currently deliver care, based on a
natural experiment being conducted in Los Angeles.
Study Goal and Structure
This three-study dissertation sought to contribute to efforts to implement peer providers
on health care teams delivering integrated physical and mental health care and to achieve a
heightened understanding of factors that affect their implementation in these settings. Despite
evidence suggesting that services provided by peers can improve a variety of physical and mental
wellness outcomes among adults with mental illness, there is little evidence that peers are
routinely implemented in integrated health care settings, and the reasons for this remain unclear.
Questions remain regarding the implementation of peer providers in integrated health care
settings, the extent to which peers are engaged in multidisciplinary provider social networks, and
the perspectives of peers on delivering integrated care.
This study examined the process of implementing peer services in integrated health care
settings, explored the roles of peer providers in multidisciplinary provider networks, and
considered their perspectives on delivering care. This study used a mixed-method approach to
examine the process of implementing peer providers in integrated health care settings. The
specific aims that guided this dissertation are as follows.
Study 1: Examine the process of implementing peer-based services in newly integrated
behavioral health care settings in Los Angeles using evaluative site visit data.
Study 2: Identify network positions of peer providers in multidisciplinary provider
networks using social network analysis. Understand variation in network positions of peer
providers in integrated health teams using qualitative interviews with peer providers on
IMPLEMENTATION OF PEER PROVIDERS 15
integrated health care teams.
Study 3: Explore the experiences of peer providers in delivering integrated care to inform
future efforts to implement peer-based services in integrated health care settings.
Study Framework
The Consolidated Framework for Implementation Research (CFIR; Damschroder, Aron,
Keith, Alexander, & Lowery, 2009) guided this study
1
(see Table 1.1). The CFIR is an
implementation framework for identifying factors associated with successful program
implementation. It includes five main constructs that can affect implementation: the general
process of implementation; characteristics of an intervention; an intervention’s outer setting, or
the organizational or policy environment; the inner setting, such as a clinic site; and the
characteristics of individuals involved in the intervention. The CFIR was applied to this study to
explore factors that influence implementation of peer providers in clinic sites providing
integrated care. Table 1.1 describes each CFIR domain as it applies to this study. Specifically,
CFIR domains 1 through 3 guided the examination of organizational factors that affect the
implementation of peer providers. This was accomplished using a site visit methodology
(Lawrenz, Keiser, & Lavoie, 2003). CFIR domain 4 guided the use of social network analysis of
provider networks based on the theory of structural holes. Finally, CFIR domain 5 guided the
completion and analysis of qualitative interviews with peer providers.
Methods
Study Setting
This dissertation was embedded in the Los Angeles County Department of Mental
Health’s (DMH) Innovations Study (LA Innovations). LA Innovations was conducted under the
auspices of DMH and the University of California, San Diego using funding from California’s

1
The CFIR guided the overall dissertation, but specifically Study 1.
IMPLEMENTATION OF PEER PROVIDERS 16
Mental Health Services Act to evaluate the process of implementing 24 pilot programs that
provide integrated physical and mental health services in select DMH clinics. The goal of these
programs was to improve the physical health of DMH consumers and increase the array of
effective approaches to providing integrated care. Each participating program was required to
establish partnerships between physical and mental health settings to deliver integrated care to a
variety of special populations, including formerly homeless and racial and ethnic minority
individuals. DMH required each participating pilot program to incorporate one or more peer
providers into health care teams, although programs were given considerable leeway in doing so.
The current study capitalized on existing data from these pilot programs, which are providing
integrated care to more than 8,000 consumers in Los Angeles County, and also collected
qualitative data from peer providers to achieve an understanding of their perceptions of
providing integrated care.
To this end, 24 contracted sites provided integrated care using one of three integration
approaches: (a) the integrated clinic model, a colocated model in which physical and mental
health care are provided in one location; (b) the integrated mobile health team, which provides
field-based integrated care; and (c) the integrated services management model, which is a
culturally competent care linkage model in which consumers have their physical and mental
health care systematically coordinated in a way that is culturally competent to the clinic
population.
Study Design
This dissertation followed a sequential mixed-method design (Palinkas et al., 2011) that
involved the sequential collection and analysis of qualitative site visit data (Study 1), quantitative
social network data (Study 2), and additional qualitative semistructured interview data (Study 3).
IMPLEMENTATION OF PEER PROVIDERS 17
Study 1 examined how peer-based services are implemented in newly integrated health care
settings. Study 2 complemented and expanded on findings from Study 1 by examining the roles
and network positions of peers in integrated provider networks using social network analysis
coupled with qualitative field work. This qualitative fieldwork explicated the levels of
involvement of peers on integrated teams and variation in this involvement. Study 3 triangulated
findings from Study 1 and Study 2 through the analysis of qualitative interviews with peer
providers.
Study 1 Design and Procedures
Data used in Study 1 originated from LA Innovations evaluative site visits, which
concluded in October 2013. Site visits were conducted across all 24 LA Innovations sites using
the Integrated Treatment Tool (ITT; Center for Evidence Based Practices at Case Western
University, 2010) as an evaluation protocol. This tool was developed to evaluate integration of
primary and behavioral health care services in health settings and assessed structural components
of integrated care at the organizational, clinical, and client levels through qualitative, open-ended
interviews with staff members, clinic observation, and chart reviews. The ITT included several
questions to assess the involvement peer providers on integrated teams, including the types of
support available to peers. Questions included: How many peer support members do you
currently have on staff? What are their functions? What steps are taken to train these peer
support members? How are they supervised? How do you select your peer support personnel?
Teams of three trained implementation monitors conducted site visits. Although there are
currently no validated measures for assessing integration, one study that used the ITT reported
that higher ITT scores were associated with better patient-level outcomes (Gilmer, Henwood,
Goode, Sarkin, & Innes Gomez, in press).
IMPLEMENTATION OF PEER PROVIDERS 18
Three trained project evaluators conducted full-day (9 a.m. to 4 p.m.) visits with the
exception of one site visit, which had two project evaluators. During visits, implementation
monitors conducted open-ended interviews with health providers and clinic administrators from
each pilot program. During these interviews and throughout the site visits, evaluators recorded
field notes of their observations of the implementation of integrated care and obtained additional
information by observing program activities, such as client groups and staff meetings; reviewing
program documents (policy and procedure manuals, clinical forms, and charts); and touring the
program facilities. The site visit team met with an average of 12 staff members at each program,
usually including an executive or program director, clinical director, psychiatrist, primary care
provider, nurse, case or care manager, therapist, peer provider, and administrative assistant.
Although the majority of interviews were conducted with program staff members, interviews
were conducted with one or more program participants during 17 of the site visits. Peer
involvement on integrated teams was evaluated based on four items: (a) Peer support personnel
are members of the multidisciplinary health care team; (b) Peers receive adequate training in the
conditions, approaches, treatments, side effects, and interactions among mental health and other
health conditions; (c) Peers receive regular supervision; and (d) Peers are employed by the
organization commensurate with their skills, abilities, and education. To determine whether sites
met these criteria, implementation monitors asked several questions during visits regarding the
presence of peers, their roles, and the types of professional supports available to them. Due to
limitations in evaluation team capacity and the requests of participating organizations, these
interviews were not audio recorded.
After each site visit, project evaluators coded their field notes and observations according
to the ITT’s 30-item scheme. The level of integration at each LA Innovations site was then
IMPLEMENTATION OF PEER PROVIDERS 19
determined by aggregating ITT item scores, which range from 1 to 5 and are based on detailed
scoring criteria. Next, each monitor’s independently scored items were reviewed at group
meetings, during which a final score was assigned to each item based on a thorough rationale
achieved through consensus. Following consensus meetings, one implementation monitor used a
standardized template to write a report for each site that included detailed tables of facilitators of
and barriers to integration. Final reports were analyzed to glean information on organizational
characteristics of programs with varying levels of peer involvement and the barriers to and
facilitators of implementing peers in various settings; findings are described using the CFIR.
Study 2 Design and Procedures
Study 2 followed an exploratory mixed-method design. This expansive process of
building on the social network dataset with qualitative key informant interviews resulted in three
types of integration: (a) sampling, using quantitative data to identify peer provider informants;
(b) convergence, using both data sources to answer the same questions through triangulation; and
(c) expansion, using a qualitative dataset to explain the results of quantitative data (Palinkas et
al., 2011). Mixed-method data used in Study 2 were derived from two sources: the LA
Innovations social network survey and primary collection of qualitative data from peer providers
who participated in the social network survey. The network survey was designed to examine
communication within the LA Innovations multidisciplinary provider networks and followed the
approach used by Burt (2004) and Meltzer et al. (2010). Using an online survey platform,
respondents were asked, “With whom do you have regular contact about client care?” (see social
network survey in Appendix B). Respondents received a roster that listed providers from their
integrated teams, and nominated colleagues with whom they frequently communicate. Surveys
took approximately 12 minutes to complete. Social network data were collected during mid-
IMPLEMENTATION OF PEER PROVIDERS 20
2014, the program’s second year of operations.
Social network data were triangulated with qualitative interviews with peer providers
who completed the social network survey. These interviews focused on perceptions of the roles
of peer providers in the delivery of integrated care. Participants were also probed to describe
their experiences working with an integrated health care team and challenges they experienced
working in their team’s environment (see interview guide in Appendix C). Triangulating these
data sources explicated variation in the network positions of peer providers. To accomplish this,
peer providers who were most central and least central in their teams were identified by
calculating their indegree centrality scores and through a block-modeling procedure known as
the convergence of iterated correlations (CONCOR). Qualitative interviews from the most
central and least central peer providers were then analyzed to explore factors that explain the
variation in their network positions.
Study 3 Design and Procedures
Study 3 expanded on findings from Study 1 and Study 2 by exploring the perspectives of
peers through semistructured qualitative interviews. Using the same qualitative dataset as Study
2, analysis in Study 3 was conducted with attention to the specific roles and experiences of peer
providers delivering care in integrated programs. To this end, a procedure of coding consensus,
co-occurrence, and comparison was used (Glaser & Strauss, 1967; Willms et al., 1990). The
qualitative coding process occurred in three steps. First, the dissertation author and two trained
research assistants developed a list of codes. Second, this trio co-coded 75% of transcripts. Any
disagreement in assignment or description of codes was resolved through discussion and by
refining the definition of the codes. Third, a final list of codes was constructed through
consensus with research assistants and consisted of a numbered list of themes, issues, and
IMPLEMENTATION OF PEER PROVIDERS 21
opinions related to the roles and experiences of peer providers delivering care. Fourth, the
transcripts were assessed for agreement among study team members regarding the coding, based
on a procedure used in other qualitative studies (Boyatzis, 1998; Palinkas et al., 2011). NVivo
software (Fraser, 2000) was used to code transcripts and generate project codes that connected
segments of transcripts grouped into separate nodes (see qualitative codebook in Appendix D).
Summary
Improving the physical health of adults with serious mental illness is a public health
priority, and including peer-based services in integrated health care settings is a novel approach
to addressing this urgent public health matter. Previous studies have demonstrated that mental
health services provided by peers are an effective way to empower and engage mental health
consumers while improving other client outcomes. Similarly, studies evaluating the effectiveness
of physical health services and educational activities delivered by peer providers have also
reported favorable results for people with mental illness. However, several challenges have been
noted in the implementation of the peer role, and it is unclear whether these challenges affect
peer provider involvement in the delivery of integrated physical and mental health care. Given
the Patient Protection and Affordable Care Act’s emphasis on increasing access to care among
vulnerable populations including individuals with serious mental illness (Croft & Parish, 2013),

the current era of health care reform is a critical moment to study factors that contribute to the
successful implementation of peer providers in integrated settings. Findings from this study have
the potential to inform efforts to scale up peer-based services in integrated health settings both
locally (e.g., DMH) and nationally (e.g., SAMHSA Administration demonstration projects).
IMPLEMENTATION OF PEER PROVIDERS 22
References
Allen, J., Radke, A. Q., & Parks, J. (Eds.). (2010). Consumer involvement with state mental
health authorities. Alexandria, VA: National Association of Consumer/Survivor Mental
Health Administrators and National Association of State Mental Health Program
Directors.
Boyatzis, R. E. (1998). Transforming qualitative information: Thematic analysis and code
development. Thousand Oaks, CA: Sage.
Brekke, J. S., Siantz, E., Pahwa, R., Kelly, E., Tallen, L., & Fulginiti, A. (2013). Reducing health
disparities for people with serious mental illness. Best Practices in Mental Health, 9, 62–
82.
Burt, R. S. (2004). Structural holes and good ideas. American Journal of Sociology, 110, 349–
399. http://dx.doi.org/10.1086/421787
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IMPLEMENTATION OF PEER PROVIDERS 28
Table 1.1
Study Aims Described using the Consolidated Framework for Implementation Research
CFIR Domain Study Aims
1. Intervention characteristics
2. Process of implementation
3. Outer setting of intervention
Study 1: Examine how peer-based services are
implemented in newly integrated behavioral health care
settings in Los Angeles
4. Inner setting of intervention Study 2: Identify network positions of peer providers
within multidisciplinary provider networks using social
network analysis. Understand variation in network
positions of peer providers in integrated health teams
using qualitative interviews with peer providers on
integrated health care teams
5. Individuals involved in the
intervention
Study 3: Explore experiences of peer providers in
delivering integrated care to inform future efforts to
implement peer-based services in integrated health care
settings.

IMPLEMENTATION OF PEER PROVIDERS 29
Chapter Two: Study 1
Implementation of Peer Providers in Integrated Mental Health and Primary Care Settings
In press at Journal for the Society for Social Work and Research
(Elizabeth Siantz, Benjamin Henwood, and Todd Gilmer)
Introduction
Peer providers have emerged as critical to efforts to facilitate engagement with both
physical and mental health services. Peer-based services are broadly defined as a method of
facilitating health promotion wherein individuals share specific health messages with members
of their own communities (Webel, Okonsky, Trompeta, & Holzemer, 2010). Although there are
varying definitions of peer providers in physical health settings (Fisher et al., 2015), these peer
providers often share a common health condition or set of conditions with patients and can
utilize these experiences to promote engagement and facilitate behavior change (e.g., Lorig,
Ritter, et al., 2001). In mental health settings, peer providers are people who have personal
experience with recovery from a mental illness (Davidson, Chinman, Sells, & Rowe, 2006) and
have received formal training to deliver and coordinate mental health care (SAMHSA-HRSA
Center for Integrated Health Solutions, 2016). Key elements of peer support in mental health
settings include empowerment against stigma of mental illness, counseling, education, and
advocacy (Gates & Akabas, 2007). According to systematic reviews, peer providers effectively
improve several patient-level outcomes in both physical health (Webel et al., 2010) and mental
health (Chinman et al., 2014) settings.
People with serious mental illness (SMI) experience many years of life lost compared to
the general population, largely due to treatable and preventable chronic care conditions (Colton
& Manderscheid, 2006). This has created urgency in the mental health community to improve
IMPLEMENTATION OF PEER PROVIDERS 30
access to and engagement with services that promote physical health and wellness in this
population. As part of this effort, peer providers have recently begun practicing in integrated
mental health and primary care service settings (Allen, Radke, & Parks, 2010; Davidson et al.,
2006; Druss et al., 2010; Goldberg et al., 2013; Solomon, 2004). In integrated settings, the roles
of peer providers have included health navigation (Brekke et al., 2013), wellness coaching
(Swarbrick, 2013), and facilitation of chronic disease self-management education groups (Druss
et al., 2010; Goldberg et al., 2013). Research has suggested that peer support in integrated
settings promotes physical health among adults with SMI. Examples of wellness outcomes
include increased physical activity (Druss et al., 2010) and improved medication adherence
(Druss et al., 2010; Goldberg et al., 2013) with or independent of provider support.
Because peer providers have been shown to effectively deliver care in a variety of
settings and improve client health outcomes, peer-based services has become one of the most
rapidly growing segments of the mental health workforce in the United States (Davidson et al.,
2006). Further, the Centers for Medicare & Medicaid Services now regard peer-based services as
an evidence-based reimbursable model of care (SAMHSA-HRSA Center for Integrated Health
Solutions, 2016), which has prompted states, counties, employers, and health plans to
increasingly cover these services.
Despite this momentum, many mental health agencies have struggled to implement peer-
support programs (Carlson, Rapp, & McDiarmid, 2001), and there is no evidence that peer
providers are being systematically incorporated into the delivery of integrated health care.
Although peer providers delivering care in physical and mental health settings share many
commonalities, their specific roles delivering care in integrated health care teams and the extent
of their implementation of integrated settings is unclear. A first step toward enhancing the
IMPLEMENTATION OF PEER PROVIDERS 31
availability of peer-based services in integrated health care settings is to understand the scope of
existing implementation strategies and organizational environments in which peer providers
currently deliver care.
The present study involved a qualitative assessment of the implementation of peer
providers in pilot programs funded to deliver integrated mental health and primary care services
under a countywide initiative, LA Innovations, overseen by the Los Angeles County Department
of Mental Health (DMH). This effort was the final initiative of California’s Mental Health
Services Act and sought to address the following question: How are peer services implemented
in newly integrated behavioral health care settings?
Methods
Study Setting
As the largest county mental health system in the nation, DMH serves more than a
quarter million county residents each year with a $1.7 billion annual operating budget. The
county is geographically large and racially diverse, with 48.3% of the population being Latino,
9.2% African American, and 1.5% American Indian or Alaska Native, constituting the largest
urban population of American Indian or Alaska Native residents in the United States. Los
Angeles County also has one of the largest homeless populations in the nation.
Study Framework
This study used the Consolidated Framework for Implementation Research (CFIR;
Damschroder et al., 2009) as a guiding framework. Because the CFIR is widely used to identify
factors that affect the implementation of new services in real-world health care settings, it is
especially appropriate for identifying factors that have affected DMH pilot programs’ decisions
to implement peer support personnel in their care teams. The CFIR features five main constructs
IMPLEMENTATION OF PEER PROVIDERS 32
that can affect implementation: the general process of implementation; characteristics of an
intervention; an intervention’s outer setting, such as an organization or policy environment; the
inner setting, such as a clinic site; and the characteristics of individuals involved in the
intervention. These domains were applied to implementation of peer services in clinic sites
providing integrated care in LA Innovations-funded programs. Of note, each of these main
constructs also includes several subdomains, which are detailed in Study 1 Appendix.
Study Sample
Using Mental Health Services Act funds, DMH issued a request for proposals from
community mental health centers to implement integrated primary care and mental health care
pilot programs. Pilot programs consisted of collaborations between public mental health settings
and federally qualified health centers, with the purpose of increasing access to primary care
services among DMH consumers and improving consumer wellness. Our study sample consisted
of the 24 integrated pilot programs that were funded in this initiative.
Data Collection
To assess variation in the process of implementing the integrated DMH pilot programs,
site visits were conducted between April and October 2013 across all 24 programs at the end of
the first year. These site visits were guided by a framework known as the Integrated Treatment
Tool (ITT), which was developed to assess the implementation of person-centered health care
homes for individuals with serious mental health conditions (Center for Evidence-Based
Practices at Case Western Reserve University, 2010). The ITT was applied using a
semistructured interview protocol that evaluated the presence of integrated care at the
organizational, treatment, and client levels through a qualitative data collection process that
included interviews and focus groups with staff members, clinic observations, and chart reviews.
IMPLEMENTATION OF PEER PROVIDERS 33
The extent to which peer providers were involved in integrated care was a specific domain in the
ITT. This information was ascertained with such questions as: How many peer support members
do you currently have on staff? What are their functions? What steps are taken to train these peer
support members? How are they supervised? How do you select your peer support personnel?
Teams of three trained evaluators conducted full-day (9 a.m. to 4 p.m.) site visits, with
the exception of one site that had only two evaluators present. During visits, implementation
monitors conducted open-ended, semistructured interviews with health providers and clinic
administrators from each pilot program. During these interviews and throughout the site visits,
evaluators recorded field notes of their observations of the implementation of integrated care and
obtained additional information by observing program activities, such as client groups and staff
meetings; reviewing program documents (policy and procedure manuals, clinical forms, and
charts); and touring the program facilities. Field notes were taken throughout the visit to capture
the content of the interviews and record observations and impressions. The site visit team met
with an average of 12 staff members at each site, usually including an executive or program
director, clinical director, psychiatrist, primary care provider, nurse, case or care manager,
therapist, peer provider, and administrative assistant. During 17 of the site visits, interviews also
included at least one program participant.
Data Analysis
Data for the present study were drawn from individual program reports developed
following each site visit. To ensure validity of these reports, the site visit team implemented a
standardized evaluation process used in previous implementation evaluations (Brunette et al.,
2008). First, evaluators coded their field notes and observations according to the ITT’s
framework for evaluating implementation of integrated behavioral health care within 1 week of
IMPLEMENTATION OF PEER PROVIDERS 34
the site visit. Evaluators separately assessed each of the 30 ITT domains. Next, each evaluator’s
independent assessment was reviewed at a group meeting, during which a final assessment of
each domain was determined based on a rationale achieved through consensus. Following group
meetings, a standardized template that reflected the ITT framework was used to write a
descriptive program report that documented successful implementation of ITT domains and areas
for improvement. Program reports were then shared with each participating program site and
DMH. For the peer provider domain, the reports described the program’s definition of peer
providers, their role, the program’s process of training and supervising peer providers, and any
challenges related to including peer providers in the integrated care team.
Using the CFIR as a guide, this study featured a case study approach to explore the
implementation of peer services in newly integrated care programs. Two study authors reviewed
each qualitative program report and developed a case summary matrix to facilitate within- and
between-case comparisons (Miles & Huberman, 1994). This matrix was presented to other
members of the evaluation team who had conducted site visits to obtain additional information
not included in the program reports. Within- and between-case comparisons were then conducted
based on each of the CFIR domains. The first author created an initial description of factors
influencing the implementation of peer services that was based on each CFIR domain. These
initial findings were then reviewed by the second author and finalized through consensus. The
use of memo writing to develop, track, and further refine the findings was employed throughout,
and confirming and countervailing evidence were considered before finalizing the results
(Charmaz, 2006). The Institutional Review Board from the University of California, San Diego,
Human Research Protection Program, and the Office of Statewide Health Planning and
IMPLEMENTATION OF PEER PROVIDERS 35
Development approved the use of these data for the purpose of this study in accordance with the
Privacy Rule of the Health Insurance Portability and Accountability Act of 1996.
Results
The following results describe peer services as implemented in newly integrated
programs using the CFIR domains, which typically describe the core components of a specific
intervention being implemented in a new context.
Outer Setting
Damschroder et al. (2009) described the outer setting of an intervention as including the
political and social context in which the intervention or organization resides. In this case, peer-
based services were implemented in integrated care programs funded by DMH.
Resulting from the racially and ethnically diverse populations that DMH serves, peer-
based services were implemented in integrated programs specially designed to meet the needs of
various ethnically diverse neighborhoods and the large homeless population. Of the 24 integrated
care pilot programs, five were colocated clinics employing an integrated clinic model (ICM).
Five other programs focused on homeless populations using a housing first approach with
primary care embedded in assertive community treatment teams, known as an integrated mobile
health team (IMHT). However, the majority of programs (n = 14) were community-designed
programs intended to target specific underserved ethnic communities, known as the integrated
services management (ISM) model.
ISM programs in particular reported that stigma of mental illness was a contextual factor
that affected the implementation of peer providers in pilot programs. Providers from ISM
programs serving Latino clients reported that the stigma of having a mental illness was so severe
among members of their community that their clients would be unlikely to engage with a peer
IMPLEMENTATION OF PEER PROVIDERS 36
provider who openly described a history of mental illness. A similar perception was expressed by
providers at one program that served Korean clients, although some individuals from this
program acknowledged that a person with lived experience of mental illness would be useful for
engaging clients and alleviating the stigma of mental illness. Other programs that did not include
peer providers reported that involving individuals in recovery from substance abuse disorders
would not be an appropriate way to engage clients with co-occurring substance abuse disorders
in care. In one instance, a provider held the belief that being served by someone in recovery
could interfere with a client’s recovery.
Policies at the state level could have contributed to this variation in definition of peer
providers in these pilot programs. As of 2015, California is one of 29 states that lack a
standardized curriculum and certification protocol for peer specialist services (California Mental
Health Planning Council, 2015). This combined with limited instructions related to the
implementation of peer providers in the pilot programs likely contributed to the substantial
variation in roles and definitions of peer providers.
Inner Setting
Damschroder et al. (2009) described the CFIR’s inner setting as the structural
characteristics of an organization, including the intervention’s social architecture, which refers to
how roles and responsibilities are organized to produce a service. In DMH, only 15 of the 24
pilot programs included peer providers on their multidisciplinary health care teams at the time of
the site visit. Each of the five IMHT programs, seven of the 14 ISM programs, and three of the
five ICM programs had implemented peer providers. For the ICM and IMHT programs, peer-
based services were familiar modes of practice; it was less clear what constituted peer-based
services for ISM programs.
IMPLEMENTATION OF PEER PROVIDERS 37
Peer providers were integral members of the IMHT teams, were heavily involved in the
planning of client care, and communicated frequently with the care team during daily team
meetings. A review of patient charts confirmed that peer providers’ responsibilities encompassed
care management and benefits coordination, and that peer providers were heavily involved in
treatment planning. Finally, peer providers in these settings also conducted ongoing outreach
through visits to client homes. In ICM settings, peer providers were less involved in care
coordination and tended to fulfill roles that required their participation in structured trainings.
These roles included facilitating support groups and the general mentoring of consumers in
developing life and social skills.
Seven of 14 ISM programs had incorporated peer providers at the time of the ITT site
visit. In ISMs, peer providers served as family advocates who attended specialty medical
appointments with clients to provide linguistic support and as mentors who specifically tried to
help clients develop social skills. Roles and responsibilities of peer providers in these programs
were also culturally specific to the communities they served, and many of these positions
emphasized linguistic support, particularly in clinics serving Latinos, Asians, and people of
Armenian and Persian cultural backgrounds. Peer providers in several ISM programs also
conducted outreach in locations that were culturally relevant to their client populations, including
Armenian grocery stores, Buddhist temples for outreach to members of the Cambodian
community, and Korean churches.
In pilot programs that did not include peer providers, some program leaders reported that
a person in this role was not a necessary addition to their team. In these cases, program leaders
reported already having the capacity to coach clients on how to navigate medical appointments
with primary care providers and specialists. In other cases, particularly in ISM programs, staff
IMPLEMENTATION OF PEER PROVIDERS 38
members articulated a sense of pride when reporting that they share similar cultural and
linguistic backgrounds as their clientele. These programs prioritized sharing ethnic background
with potential clients during outreach efforts.
Individuals Involved in the Intervention
This CFIR domain captures the role of individuals involved with the intervention or
implementation process, with the understanding that “individuals are carriers of cultural,
organizational, professional, and individual mindsets, norms, interests, and affiliations”
(Damschroder et al., 2009, results section, para. 4). There was variation in who was considered a
peer across programs. Among IMHT teams, one included a family member of a person with
mental illness as a peer provider. In other IMHT teams, some staff members self-identified as
having lived experience of mental illness. In these cases, organization leaders were able justify
having not having a staff member with the formal title of peer provider because elements of peer
support were technically available from staff members who were already fulfilling that role. At
the time of evaluation, three IMHT teams included individuals with the formal title of peer
providers who had lived experience of recovery from a mental illness. In ICM settings, two of
the peer providers openly identified as having lived recovery experience, whereas the specific
background of the third peer provider was unclear.
The definition of peer provider varied more widely among ISM programs. Instead of
having lived experience with mental illness, the majority of ISM programs defined peer
providers as individuals who shared a common cultural or linguistic identity or had a shared
experience of migration similar to the clinic’s clientele, regardless of whether that individual had
lived experience with mental illness. Providers expected a high level of stigma would cause
potential consumers to balk at outreach efforts from peer providers with lived experience with
IMPLEMENTATION OF PEER PROVIDERS 39
mental illness. In two other cases, the peer providers shared a cultural background and had lived
experience with managing a chronic disease such as diabetes. During site visits, program staff
members reported that the decision to conceptualize peer providers as such resulted from high
levels of stigma in their ethnic communities. Thus, in the majority of these settings, peer
providers with lived experience with mental illness were considered to be an inappropriate
resource for conducting outreach and increasing engagement with mental health services. Table
2.1 details peer provider backgrounds according to program type and service population.
The Process of Implementing Peer Providers
This CFIR domain includes activities of implementation process that are common across
organizational change models: “planning, engaging, executing, and reflecting and evaluating”
(Damschroder et al., 2009, process section, para. 1). In this case, DMH required integrated
programs to have peer services, but programs were not given a specific definition of peer
provider, a protocol for implementing peer providers, or guidelines regarding their roles and
responsibilities. These factors were left to the discretion of each program. Some pilot programs
aspired to hire peer support providers for their health care teams in the future, but at the time of
data collection reported that they had experienced difficulty hiring and maintaining a peer
provider. These difficulties primarily resulted from challenges finding a qualified individual to
fill the role. Ten of the 14 integrated programs that included peer providers had a formal
infrastructure for providing training for peers. These trainings included Bridge peer health
navigation (Brekke et al., 2013), Wellness Recovery Action Plan, and occasional peer advocacy
trainings through DMH. Across programs, these trainings tended to occur in settings external to
the LA Innovations program.
IMPLEMENTATION OF PEER PROVIDERS 40
Several peer providers were trained in Bridge peer health navigation (Brekke et al.,
2013), a care linkage program in which peer providers follow a manualized approach to training
and supporting consumers in coordinating and accessing primary care services. Health
navigation training had become available in DMH for peer providers during the year prior to
implementation of pilot programs. Health navigation trainings occurred in a group format and
consisted of classroom instruction, shadowing of current health navigators, and ongoing
supervision. One peer provider was trained in Wellness Recovery Action Plan (Cook et al.,
2010), a program in which peer providers help mental health consumers independently identify
resources that facilitate recovery and create their own plans for successful living. Another
provider had received training from a local peer-run organization in Los Angeles. Four programs
did not have the formal infrastructure to meet the ongoing training needs of their peer providers.
In addition to training, participants discussed supervision as another component of
implementing peer services. Ten programs provided consistent supervision of their peer
providers. Supervision styles ranged from individual clinical supervision from a program director
or other clinician on the team to group supervision with other members of the integrated team.
Because the Bridge health navigation training included a formal supervision component, several
peer providers participated in this in lieu of in-house supervision.
Discussion
This study utilized the CFIR to understand the process of implementing peer providers in
integrated health care settings. The CFIR’s outer setting revealed that stigma of mental illness in
the client community influenced program decisions to include peers who have personal
experience with mental illness; the inner setting revealed variation in the roles of peers by
program type; the domain of individuals involved in the intervention revealed variation with
IMPLEMENTATION OF PEER PROVIDERS 41
respect to the definition of peer provider; and the process domain revealed that pilot programs
had varying levels of organizational capacity for trainings of peer providers. Table 2.2 provides a
summary of key findings using the CFIR.
The CFIR’s fifth domain pertains to the characteristics of the intervention. In some
settings, peer providers had personal experience with mental illness, whereas in other cases, peer
providers had personal experience managing chronic physical health conditions. This is not
surprising given that peer services are widely included in health care models, such as the Chronic
Disease Self-Management Program (Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001), a structured,
small-group intervention designed to develop self-management skills among people with
different chronic conditions. Peer instructors with experience managing their own chronic
conditions typically facilitate this program. Variations of the program have been implemented to
improve the chronic disease self-management skills of individuals with SMI (Siantz & Aranda,
2014). Peer facilitators of chronic disease self-management programs for individuals with SMI
typically have both lived experience with mental illness and experience managing a chronic care
condition, such as diabetes (e.g., Goldberg et al., 2013; Sajatovic et al., 2011). Mental health
departments might consider using this definition of peer provider to better engage clients with
co-occurring chronic care and mental health conditions and employing this structured
intervention to improve self-management outcomes among mental health consumers.
Many programs incorporated peer providers who shared a common cultural history or
identity with the individuals being served, rather than a shared experience of mental illness. ISM
program leaders stated that elevated levels of stigma in their ethnic communities would have
made hiring a peer provider with experience managing a mental illness an ineffective way to
engage potential clients. However, there is little empirical evidence to support this perception.
IMPLEMENTATION OF PEER PROVIDERS 42
Important elements of mental health peer support and the greater self-help movement include a
peer’s capacity to share experiences, empower the individual, and reduce feelings of stigma
surrounding a particular health condition. Although a shared cultural background is a natural
extension of these factors, it remains important to ensure that mental health consumers of diverse
racial and ethnic backgrounds benefit from the lived experiences of other individuals in recovery
from mental illness. Future studies should collaborate with communities to develop peer-based
models that incorporate the multiple and intersecting aspects of client and peer identities.
The existence of varying definitions of what constitutes a peer provider in these
integrated settings raises a question of larger importance to the developing field of integrated
care: “What is a peer provider?” Although these definitional issues are more easily resolved in
the fields of mental health (where a peer provider has personal experience with mental illness) or
behavioral health (where a peer provider will have personal experience with recovery from a
substance abuse disorder), this study showed that these definitions are less clear in integrated
primary and mental health care settings in a racially and ethnically diverse public mental health
system. Prior to implementing integrated programs, public mental health departments should
engage community providers and more clearly specify their expectations regarding inclusion of
peer services.
Related to this point, there was limited discussion of the topic of culturally competent
peer support services in the IMHT and ICM pilot programs, although it was emphasized in ISM
programs. The importance of delivering culturally and linguistically appropriate services has
been discussed extensively in the literature pertaining to delivery of mental health services
(Campinha-Bacote, 2002), yet enhancing the availability of culturally competent peer-based
services has been discussed less frequently. This is an especially critical topic in the context of
IMPLEMENTATION OF PEER PROVIDERS 43
Los Angeles County, which features one of the largest and most diverse public mental health
systems in the United States. Increased dialogue in integrated care teams on the topic of
delivering culturally and linguistically appropriate services to racially and ethnically diverse
clients is essential and could be an additional strategy to engage clientele.
An additional point of discussion pertains to the optimal organizational context for
implementing peer providers. In this study, all IMHT teams included peer support. These
programs are based on the principles of assertive community treatment, which has a lengthy
history of including peer support (Teague, Bond, & Drake, 1998). Characteristics of this model
that facilitate the involvement of peer providers could include the field-based nature of IMHT
and assertive community treatment services in outreach and ongoing delivery of care. Because
IMHT teams in our study more frequently incorporated peer providers who were openly in
recovery from mental illness, perhaps this shared experience with clients is essential to client
engagement.
The final point of discussion relates to these pilot programs’ organizational capacity for
training and supervising peer providers who are delivering integrated care. Mental health
agencies’ lack of adequate support for peer providers is a frequently cited issue in the mental
health literature (Carlson et al., 2001; Gates & Akabas, 2007). Specific challenges that relate to
implementing peer providers have historically included attitudes toward recovery among nonpeer
staff members, unclearly defined jobs for peers, and a general lack of opportunities for
professional support (Gates & Akabas, 2007). The present study showed that similar factors have
the potential to affect peer providers working in integrated health care settings. Workplace
strategies are needed to build organizational capacity to promote inclusion of peer providers in
integrated settings. An example of such a strategy is one in which mental health agencies self-
IMPLEMENTATION OF PEER PROVIDERS 44
assess for specific barriers that affect the implementation of peer providers at their agencies and
then enact solutions to resolve the challenges (Gates, Mandiberg, & Akabas, 2010). This is a
promising strategy to improve perceptions of peer providers among other providers on a given
team and the professional support available to peer providers in agency settings.
Limitations
All organizations participated in the parent evaluation voluntarily, potentially biasing the
results of the parent study toward more positive results than if the integrated programs were
implemented across all mental health programs in Los Angeles County or elsewhere. Programs
that are open to providing integrated care might be more open to implementing other services
innovations, such as peer providers. An additional study limitation is that limitations of the ITT
framework precluded systematic exploration of several of the CFIR subdomains. The Study 1
Appendix details each subdomain and whether data presented here precluded analysis in this
paper. Many CFIR subdomains were excluded from this study because the implementation of
peer providers was not the primary focus of the LA Innovations initiative. The small number of
interviews conducted with consumers further limited ITT data. Although program participants
were interviewed at 17 of the participating pilot programs, additional interviews with clients
would have allowed further exploration of client perceptions of peer services in integrated
settings. Finally, due to the full-day nature of each site visit, interviews were not audio recorded.
Conclusion
Peer providers working in integrated settings share in the important task of improving
access to and empowering mental health consumers to become engaged with physical health
care. Although stigma of mental illness in the client community precluded many pilot programs
from including peer providers on their integrated care teams, DMH pilot programs that included
IMPLEMENTATION OF PEER PROVIDERS 45
peer support made efforts to accommodate their clients’ multiple and intersecting identities and
address needs related to linguistic access, mental health services, and access to primary care.
With the right support, these mental health programs could improve how they include peer
providers in their integrated teams. Enhanced training of peer providers and other agency staff
members in the intersecting areas of physical and mental health from a cultural perspective is
needed to enhance their effectiveness and community acceptance of their services. Future
research should continue to examine workplace strategies that build organizational capacity to
promote inclusion of peer providers. Finally, promoting awareness of the critical nature of peer
support services among other members of the integrated care workforce is also needed. Ongoing
efforts to address these factors are necessary to engage individuals with SMI with health services
toward the achievement of improved wellness and recovery.

IMPLEMENTATION OF PEER PROVIDERS 46
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Table 2.1
Peer Provider Background According to Program Type and Service Population
Program Type Service Population
a
Peer Provider Background
ISM 1 African American Shared cultural background; familiarity with neighborhood surrounding clinic
ISM 2 American Indian Shared cultural background; personal experience with behavioral health
recovery
ISM 3 Chinese Shared cultural background, personal experience with chronic disease and
mental illness
ISM 4 Cambodian Shared cultural background; understanding of intergenerational trauma in
Cambodian community
ISM 5 Persian or Iranian Shared cultural and linguistic background
ISM 6 Armenian Shared cultural and linguistic background, shared migration experience
ISM 7 Hispanic Shared cultural and linguistic background
IMHT 1 Homeless and formally homeless Personal experience with mental illness
IMHT 2 Homeless and formally homeless Personal experience with mental illness
IMHT 3 Homeless and formally homeless Personal experience with mental illness
IMHT 4 Homeless and formally homeless Family member of a person with mental illness
IMHT 5 Homeless and formally homeless Personal experience with mental illness and substance abuse
ICM 1 SMI and physical illness Personal experience with substance abuse
ICM 2 SMI and physical illness Personal and family experience with mental illness
ICM 3 SMI and physical illness Mother of person with mental illness
a
All service populations also have a serious mental illness and co-occurring physical illness.
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Table 2.2
Key Findings using the Consolidated Framework for Implementation Research
CFIR Domain Key Findings
Outer setting  Pilot programs designed to serve a racially and ethnically diverse client base
 Stigma of mental illness influenced agency decisions to implement peer-based services
Inner setting  15 of 24 integrated pilot programs included peer-based services
 Peer providers in programs serving formerly homeless individuals functioned as care coordinators
and participated in team meetings
 Positions of peer providers in ISM programs serving racially and ethnically diverse clientele
emphasized linguistic support and shared experiences of immigration
 Peer providers in colocated ICM programs delivered structured interventions
Individuals involved in
intervention
 Variation in definition of peer provider within and across pilot program types
 Backgrounds of IMHT peer providers included personal experience and being a family member of
someone with SMI
 Backgrounds of ISM peer providers included shared cultural identity and language
 Backgrounds of ICM peer providers included a mix of personal experience and family experience
with mental illness
Implementation process  DMH did not provide pilot programs with specific guidelines for implementing peer providers
 10 of 14 integrated programs included peer providers had infrastructure for providing training for
peers
 10 of 14 programs provided consistent supervision for peer providers
Intervention characteristics  Some peer providers had lived experience with mental illness, but few had lived experience with
both mental illness and management of chronic care conditions

53
Study 1 Appendix
Consolidated Framework for Implementation Research Checklist

Code Topic or Description Included in
Analysis
Explanation
Yes No
I. Intervention or Program
A Source of idea for program X Throughout manuscript
B Strength and quality of
evidence supporting this
particular approach
X Throughout manuscript
C Relative advantage of
implementing versus an
alternative solution
X Throughout manuscript
D Ability to adapt the program to
meet own (local) needs
X
E Ability to test program on a
small scale and reverse course
in warranted
X Limitations in data
F Perceived difficulty of
implementation
X Limitations in data
G Perceived excellence in how
program is bundled, presented
and assembled
X Limitations in data
H Costs associated with
implementing the program
X Limitations in data
II. Outer Setting
A Needs and resources of
population being served
X Description of LA Innovations program
types
B Degree to which organization
is networked with other
organizations
X Limitations in data
C Pressure from other states,
tribes, communities
X Attitudes towards peer providers in
community
D External policies and
incentives
X DMH directive that peers are included
in LA Innovations programs
III. Inner Setting
A Structural characteristics (age,
maturity, size, social
architecture) of organizations
responsible for implementing
program
X Description of LA Innovations program
types that included peers
B Nature and quality of networks
and communications between
these organizations
X Limitations in data
C Norms, values, and guiding X Description of tasks of peer providers
IMPLEMENTATION OF PEER PROVIDERS

54
principles of organizations in different service settings as a
reflection of organization norms and
values
D Capacity for change and shared receptivity of involved individuals to the program
1 Degree to which current
situation is perceived as
intolerable or needing change
X Limitations in data
2 Degree of tangible fit between
meaning and values attached
to the program by involved
individuals, how they align
with values, and how they fit
with existing workflows and
systems
X Limitations in data
3 Shared perception of
importance of program within
the participating organizations
X Limitations in data
4 Organizational incentives and
rewards for implementing
program
X Limitations in data
5 Goals and feedback X Limitations in data
6 Learning climate X Limitations in data
E Readiness for implementation
1 Engagement of leaders in
implementing and sustaining
program
X Limitations in data
2 Available resources dedicated
for implementing and
sustaining program
X Limitations in data
3 Access to knowledge and
information about program
X Limitations in data
IV. Characteristics of Individuals
A Knowledge and beliefs about
intervention or program
X Agency staff described why or why not
peer providers would be appropriate
given their agency context
B Self-efficacy X Limitations in data
C Individual stage of change X Limitations in data
D Individual identification with
organization
X Limitations in data
E Other personal attributes X Limitations in data
V. Process
A Degree to which tasks for
implementing and sustaining
are developed in advance and
quality of those plans
X Per DMH directive, LA Innovations
programs included peer providers, but
with little or no further instructions
B Engaging the following in process of implementing and sustaining the program
IMPLEMENTATION OF PEER PROVIDERS

55
1 Opinion leaders in
organization or coalition or
partnership
X Limitations in data
2 Formally appointed internal
implementation leaders
X Limitations in data
3 Program champions X Limitations in data
4 External change agents X Limitations in data
C Carrying out or accomplishing
the program according to plan
X
D Reflecting and evaluating on
progress made towards
implementation and
sustainment
X Limitations in data

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56
Chapter Three: Study 2
Where Do Peer Providers Fit into Newly Integrated Behavioral Health Care Networks? A
Mixed-Method Study
In preparation for submission to Administration and Policy and Mental Health and Mental
Health Services Research
(Elizabeth Siantz, Eric Rice, Benjamin Henwood, and Lawrence Palinkas)
Introduction
Interdisciplinary, team-based approaches are an effective method for delivering
integrated care to people with multiple chronic conditions (Mechanic, 2012). To best meet needs
of people living with serious mental illness, peer providers have become a standard component
of health care teams that provide recovery-oriented services.

Peer providers are service
professionals in the mental health system who have their own experience in receiving mental
health care and possess clinical skills learned in training (Gates & Akabas, 2007). When hired as
mental health services team members, peer providers make major contributions to the recovery
of people with serious mental health conditions (Cook et al., 2009; Davidson et al., 1999; Mueser
et al., 2002).
Because peer providers have also become increasingly recognized for their roles in the
delivery of integrated primary and mental health services (Siantz, Henwood, & Gilmer, in press),
efforts are currently underway to increase and formalize their roles on multidisciplinary health
teams (Allen, Radke, & Parks, 2010). These roles can include wellness coaching (Swarbrick,
2013), and facilitation of chronic disease self-management educational groups (Goldberg et al.,
2013; Sajatovic et al., 2011). To increase use of primary care services, peer providers are also
being included as health navigators in Los Angeles County (Brekke et al., 2013).
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57
Despite the relative successes of the consumer movement in involving peer providers in
mental health and social service settings (Gates & Akabas, 2007; Ostrow & Adams, 2012),
previous work has reported on challenges health care teams can face when implementing peer
providers (Gates & Akabas, 2007). Persistent stigma from other human service professionals
(Fisk, Rowe, Brooks,,& Gildersleeve, 2000), poorly defined roles and jobs (Mowbray, 1997),
and a lack of professional support and supervision (Corrigan & Phelan, 2004) can hinder the
integration of peer providers in mental health and social services teams. Whether these systems-
level challenges to implementing peer providers occur in multidisciplinary health care teams
delivering integrated primary and mental health care services has not been studied, and the extent
to which peers are meaningfully incorporated into health care teams practicing in integrated
settings is also unclear.
Social network analysis combined with qualitative fieldwork is one approach to
understanding peer provider involvement in multidisciplinary teams. Sociometric techniques can
illustrate communication between providers (Burt, 2004; Meltzer et al., 2010) while allowing
researchers to quantitatively assess an individual’s level of involvement on a health care team
(Damschroder et al., 2009; Greenhalgh, Macfarlane, Bate, Kryuakidou, 2004). Block modeling
approaches to social network analysis can provide even more nuanced information related to the
composition of social networks (Valente, 2010) and allow researchers to compare the positions
of actors across networks of different sizes. Further, measures of structural equivalence can
provide information on the status of network actors relative to other members of their networks.
However, social network techniques alone are less useful for understanding the individual
experiences of network actors. Achieving this depth of information requires qualitative methods.
Therefore, using both social network and qualitative data, this study sought to accomplish the
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58
following goals: (a) identify the network positions of peer providers on integrated behavioral
health using social network analysis and (b) understand variation in network positions of peer
providers in behavioral health teams using qualitative interviews.
Methods
Setting
The present study analyzed data derived from the Los Angeles County Department of
Mental Health (DMH) Innovations evaluation (LA Innovations). From 2012 to 2015, LA
Innovations implemented integrated behavioral health pilot programs delivering services in 24
clinics in DMH, with the goal of improving client wellness outcomes by testing novel
approaches to integrating physical and mental health care. These pilot programs included eight
colocated primary and behavioral health care partnerships, known as the integrated clinic model;
11 partnerships that coordinated care across different sites, known as the integrated services
management model; and five community-based, mobile behavioral health teams with embedded
primary care, known as the integrated mobile health team. Sociometric data were collected from
the staffs of 24 pilot programs in 2014 at the end of the second year of operations to assess their
communication and connectivity and identify key network actors across programs.
Study Design
This study followed an exploratory mixed-method design (Palinkas et al., 2011). This
expansive process of building on social network data with qualitative key informant interviews
achieved three types of integration: (a) sampling, using network data to identify peer provider
informants; (b) convergence, using both data sources to answer the same questions through
triangulation; and (c) expansion, using a qualitative dataset to explain the results of quantitative
data (Palinkas et al., 2011). Studies that employ multiple methods to answer questions raised by
IMPLEMENTATION OF PEER PROVIDERS

59
other methods are useful for studying implementation of new practices in health settings
(Brunette et al., 2008).
Study Sample
The study sample consisted of integrated programs that included peer providers on their
behavioral health care teams and had one or more peer providers listed in the social network
survey who also participated in a qualitative interview. Whether a program included a peer
provider was determined using social network rosters. Of the 24 integrated pilot programs, the
network rosters of 16 programs included peer providers. Peer providers identified from these 16
rosters were then recruited for a qualitative key-informant interview based on their availability,
willingness to participate in an interview, and ability to speak English or Spanish. Three
networks that included peer providers were excluded from the present study because the peer
provider either declined to participate in the qualitative interview or was not available. Of the 32
peer providers identified through social network rosters, 24 were contacted by phone or email for
a semistructured interview. Up to three peer providers were interviewed per pilot program, at
which point saturation was achieved. The University of California, San Diego Institutional
Review Board approved this study’s social network component, whereas the University of
Southern California Institutional Review Board approved this study’s qualitative component.
Data Collection
The web-based social network survey was created following Burt (2004) and Meltzer et
al.’s (2010) approach. Each integrated program provided team rosters, which included the names
of psychiatrists, nurses, peer providers, nontraditional services providers (such as
acupuncturists), and primary care practitioners. Using an online survey platform, respondents
were asked, “With whom do you have regular contact about client care?” In response, providers
IMPLEMENTATION OF PEER PROVIDERS

60
selected LA Innovations team members from their team’s roster. Attribute information was also
collected, which included sociodemographic characteristics, professional background, and
number of years working in the profession. Surveys took approximately 12 minutes to complete.
The semistructured interview conducted with peer providers focused on their experiences
delivering care on their LA Innovations integrated behavioral health care teams. Respondents
were asked to describe their professional backgrounds as a peer provider, their responsibilities
related to their LA Innovations programs, and their experiences working on their program’s
integrated health care team. Participants were also probed to describe the challenges and
successes they’ve encountered working in their multidisciplinary team environment. Individual
interviews were conducted during spring 2015. A sample qualitative interview guide can be
found in Appendix B.
Data Analysis
The social network analysis proceeded in four stages: structural analyses of each
network, positional analyses of peer providers, convergence of iterated correlations (CONCOR)
analysis, and network visualization. Structural analyses of social networks were conducted using
UCINET for Windows, Version 6. Three network-level measures were network size, total
number of ties, and network density (i.e., the number of connections in a network reported as a
fraction of the total links possible). The indegree centrality of each peer provider was also
assessed. Indegree centrality captures the status of a network actor by assessing how frequently
others nominate that individual, or node, in the network. This metric reflects how important
others in the network perceive a given node to be. This study measured indegree centrality as the
percentage of possible nominations that peer providers received and the average percentage of
nominations received by the total network. This percentage is calculated by dividing the number
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61
of nominations received by one less than the network’s total. In instances in which two or more
peer providers are reported in the network, the average percentage of nominations they received
is reported.
To identify network actors structurally equivalent to each network’s peer provider, this
study involved conducting the CONCOR procedure for each network. Structural equivalence is
the degree to which individuals have similar patterns of ties in a network. Network actors are
structurally equivalent when they are linked to the same other people in the network (Valente,
2010). The CONCOR routine provides an unbiased mathematical partition of the network into
positions by correlating the columns of a matrix of network nominations, which results in a
matrix of correlations that is then used as input to correlate the columns (Valente, 2010).
CONCOR is useful for identifying network positions based on node similarity (Valente, 2010).
Once CONCOR subgroups were identified in this study, each team’s CONCOR subgroup was
ranked according to the average indegree centrality scores in each group, such that the CONCOR
groups were ranked according to groups that received the largest percentage of possible
nominations (i.e., highest status groups) to groups that received lowest percentage possible
nominations (i.e.. lowest status groups). Using a maximum variation approach (Aarons &
Palinkas, 2007), the roles and experience of peer providers were then compared across highest
status groups and lowest status groups. Because the CONCOR procedure allowed exploration of
structural equivalence between the peer provider and other members in the care coordination
network, the CONCOR analysis provided additional evidence pertaining to the peer provider’s
network position.
The network visualizations were created using NetDraw 2.090. The spring embedder
routine was used to generate the network visualizations. Spring embedding is based on the idea
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62
that two actors may be thought of as pushing or pulling each other; two points located close
together represent actors who have a pull on each other, whereas distant actors push one another
apart. The algorithm seeks a global optimum where there is the least stress on the springs
connecting actors to one another (Rice, Barman-Adhikari, Milburn, & Monro, 2012).
To analyze the semistructured interviews, a procedure of coding consensus, co-
occurrence, and comparison (Willms et al., 1990) was used. This analytic strategy is rooted in
grounded theory, which is theory derived from data and then illustrated by characteristic
examples (Glaser & Strauss, 1967). Audio-recorded interviews were professionally transcribed,
and lists of codes were developed by each investigator and then matched and integrated into a
single codebook. The qualitative coding process occurred in three steps. First, a list of codes was
constructed through a consensus of team members and trained research assistants and consisted
of a numbered list of themes, issues, and opinions that related to factors that influence the
network positions of peer providers. Second, the first study author and at least one research
assistant independently coded 75% of transcripts. Throughout this process, disagreement in
assignment or description of codes was resolved through discussion and by enhancing the
definitions of codes. Third, the transcripts were assessed for agreement between research team
members regarding the coding, based on a procedure used in other qualitative studies (Boyatzis,
1998; Palinkas et al., 2011). NVivo software ((Fraser, 2000) was used to code transcripts and
generate project codes that connected segments of transcripts grouped into separate nodes. These
nodes were used to further the process of axial and pattern coding to examine the association
between different a priori and emergent categories (Strauss & Corbin, 1998).

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Integration of Social Network and Qualitative Findings
Overarching qualitative themes related to the participants’ experiences working on an
integrated health care team and their positions in networks with the most and least central peer
providers identified through the social network analysis were triangulated to develop network
subtypes. These network subtypes were based on peer providers’ personal experiences working
on integrated health care teams. Triangulating data in this manner during the analysis and
interpretation phase is an approach commonly used in mixed-method studies for integrating
quantitative and qualitative data to enrich a study’s findings.
Results
Characteristics of Participating Organizations
The present study featured 13 programs with 224 network actors and achieved a response
rate of 76.8%. Care coordination network sizes ranged from 11 to 23, with a mean network size
of 17.3 (SD = 3.8). These networks included primary care professionals (n = 15) such as medical
doctors and nurse practitioners; nurses (registered and licensed vocational; n = 10); case
managers (n = 29); program administrators (n = 55); psychiatrists (n = 14); therapists and
clinicians (n = 45), peer providers (n = 28), and providers from other specialties (n = 28).
Characteristics of participating networks are detailed in Table 3.1. This table also details the
number of each type of provider in each participating program.
Characteristics of Peer Providers
Seventeen qualitative interviews with peer providers were conducted in the present study.
The average age of these peer providers was 46 (SD = 12). Approximately half of the sample was
female (n = 9; 52.9%) and was diverse with respect to racial and ethnic composition. The
majority of peer providers were African American (n = 8; 47%) or Asian (n = 6; 35.3%), and
IMPLEMENTATION OF PEER PROVIDERS

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more than half spoke at least one language in addition to English (52.9%). There was also
diversity with respect to educational background, with two participants having completed high
school, nine having completed some college, and four having completed a master’s degree.
Characteristics of the study’s sample of peers are described in Table 3.2.
Structure of Care Coordination Networks
Table 3.3 describes the network structure and indegree centrality of peer providers. The
percentage nominations received by peer providers ranged from 14% to 81% (M = 30%). The
average number of nominations received by individuals (indegree centrality) in these networks
ranged from 23% to 78% (M = 44.6%). Peer providers in eight of the 13 care coordination
networks received a greater proportion of nominations relative to their network’s average.
Positional Variation of Peer Providers by Care Coordination Network Type
Table 3.4 details the results of the CONCOR analysis. The first row of this table can be
interpreted as follows. In network A, the peer provider is in the first of the network’s eight
possible CONCOR subgroups. Network A’s team leader is also in this group, making the peer
provider and team leader structurally equivalent. This CONCOR group received, on average,
76% of possible nominations, which is the highest proportion of nominations received by any
CONCOR group in the network. The percentage of possible nominations was determined using
the following formula: (x ÷ [n - 1]) ÷ y, in which x = the number of nominations received by all
providers in the CONCOR group; n = the number of people in the network; and y = the number
of network actors in the CONCOR group.
CONCOR analysis revealed that some peer providers were in highly central CONCOR
groups that received the highest percentage of nominations. Across networks in which peer
providers were in highly central CONCOR subgroups, peers were often structurally equivalent to
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65
the members of the health care team’s leadership, which included the program director, program
coordinator, and team leader. These peer providers worked with homeless and formally homeless
service populations. Other peer providers who were in medium-status network subgroups (i.e.,
groups 3 of 8, 4 of 8, or 4 of 7) were generally equivalent to clinicians and other peer providers.
Some peer providers were also in CONCOR network subgroups that received relatively low
percentages of nominations (i.e., groups 6 of 7 or 6 of 8). In these cases, peers were either not
structurally equivalent to anyone else on their teams (Network L) or structurally equivalent to
therapists, clinical supervisors, or directors of external organizations.
Triangulation of Social Network and Qualitative Results
Social network analyses revealed that peer providers had varying levels of indegree
centrality across health care teams and were in network subgroups that ranged from high to
medium to low status. Using a maximum variation approach (Aarons & Palinkas, 2007),
analyses further examined the network positions of the peer provider in the highest status and
lowest status network subgroups. Qualitative data suggested that this positional variation was
related to the peer provider’s responsibilities (e.g., outreach vs. ongoing engagement or case
management), population served (e.g., formerly homeless individuals vs. underserved ethnic
communities), and background (e.g., in recovery from mental illness vs. cultural and linguistic
broker for clients). Further analysis indicated that network positions also varied according to peer
providers’ perceived level of involvement in the social networks, and four network subtypes
emerged. In network type 1, peer providers had high centrality, were in a high-status CONCOR
group, and reported feeling central to the network. In network type 2, peer providers had high
centrality, were in a high-status CONCOR group, but reported not feeling central to the network.
In network type 3, peer providers had low centrality and were in a low-status CONCOR group,
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but report feeling central to the network. In network type, 4 peer providers had low centrality,
were in a low-status CONCOR group, and reported not feeling central to the network. Each
network subtype is depicted in Figure 3.1. The perceptions of central and noncentral peer
providers are explained further using illustrative quotes, as are each of the four network
subtypes.
Most-Central Peer Providers
In the networks of three pilot programs, peer providers were in CONCOR network
subgroups that received the highest percentage of nominations. In general, these highly central
peer providers described personal experiences they shared with clients as an asset for educating
other members of their mental health team about the realities of being homeless or living on the
street:
But until you really come from the street … I can be the one to say … when they go, oh
no, we’re gonna get them into treatment and we’re gonna put them into housing. And I’m
the one that says, no, you can’t do that right yet. They’re actively in their addiction.
They’re not gonna stay. (Network A peer)
This peer provider described using her experience to understand the client’s stage of readiness
and then communicate this information to the team. Highly central peer providers identified this
mediating role between the client and care team as especially critical, and also described having
the ability to engage clients (and potential clients) whom other team members might have
difficulty engaging.
I love it when the worst clients come in there. I mean … angry, selfish, bad attitude.
Everybody’s scared of them. You know what I’m saying? You know, they don’t want to
touch them. They’re the ones I run to. (Network B peer)
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Although highly central peer providers described using their personal experience with
recovery or other general talents for liaising between the health care team and an underserved
client community, they also expressed varying perceptions of their involvement with their
networks. In two cases, highly central peer providers reported feeling deeply involved in their
care coordination networks, resulting from infrastructure that supported team communication
and an environment in which “everyone works as one.” One highly central peer provider
described the process of group decision-making: “The psychiatrist might know how to give the
guy meds, or the doctor knows how to prescribe the meds, and this is how it’s supposed to
happen, but then we have us who know the client” (Network A peer).
This further illustrates the importance of having a connection and rapport with clients
among highly central peer providers. This peer provider felt central to the team and had high
indegree centrality, exemplifying network type 1. In contrast, in another network where the peer
provider had high centrality, he described feeling isolated from his team.
Interviewer: Do you have a lot of interaction with the other providers on the integrated
team?
Network B peer: Uh, no. They just turn up their nose to me and everything that I do.
‘Cause the client community is … you know, is my strength, you know what I’m saying?
As a peer advocate I don’t go to the staff meetings. They just let me do my thing, you
know what I’m saying? They let me do my thing.
This peer provider reported that he is uninvolved in team meetings, despite his own admission
that his strength lies in having a connection with the client community. This peer provider had
high centrality and was in a highly rated CONCOR group but described feeling marginalized by
his team, exemplifying network type 2.
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Least-Central Peer Providers
These noncentral peer providers generally did not rely on their personal experience with
mental illness to engage clients, and instead described using their familiarity with clients’
culture. In these networks, the peer providers were largely responsible for conducting outreach to
members of Armenian or Korean communities, and their involvement with a client ended
following program enrollment. In both cases, client outreach occurred at locations external to the
organization, such as local businesses and churches. One peer described her experience in
engaging potential clients by teaching art classes at a local church.
It’s very difficult for Koreans to tell [mental health professionals], OK, I have a mental
health problem, I need an [integrated services management] program. So what we did
was we did a nontraditional way of finding them. We tried art class and usually I taught
art classes. … We tried a lot of different kind of classes that we can engage with potential
clients. Koreans need to build up some relationship before they can speak up because of a
lot of stigma. (Network J peer)
This peer described utilizing her expertise with the Korean culture and highlighted her role as an
outreach professional. In doing so, she acknowledged her somewhat noncentral network position.
Similar to highly central peer providers, noncentral peer providers expressed varying
perceptions of their team involvement. One case contradicted the network findings, in which a
noncentral peer provider reported feeling that he was very involved in his team. In this case, the
peer provider regarded himself as equal to other professionals on his team. He was tasked with
data entry, client follow-up, and some clinical work, and reported feeling central:

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Interviewer: What’s been really helpful? What’s enabled you to do this?
Network M peer: I’d say my team that I work with. My team is very supportive. …
Everyone has been very, a good positive vibe. We all work as a team. We all make sure
that we get our things done on time. If I have a question and I go to a therapist or go to
[boss] or I go to [other team member] and ask them; they are very helpful with me.
This quote exemplifies the positive experience this peer provider has had with his integrated care
team and also demonstrates his feeling of inclusion with this team, which contradicts his network
position identified by the positional and CONCOR analyses. This peer provider had low indegree
centrality but felt central to the team, exemplifying network type 3.
In most networks in which the peer provider had low centrality, their perceptions of their
network position aligned with the findings of the network analysis. In these cases, peer providers
described their community outreach work or their secondary status as a peer provider resulting
from having a mental illness as reasons for being on the network’s periphery. One least-central
peer provider did not rely on his shared cultural background and did not view his status as a peer
as an asset:
I miss a lot of meetings, and then the peer part bothers me because unless I am talking at
you, it’s hard for me to get the floor. In other words, I have to be almost angry to jump in.
… I want peer advocate status to get into a group, but I don’t want peer advocate status
when it comes to levels of participation or accountability. (Network L Peer)
This peer provider had low centrality and also described not feeling central to the team,
exemplifying network type 4.
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Discussion
Peer-based services are a method of facilitating health promotion in which individuals
share health messages with members of their own community

to empower consumers who have
various health needs. The purpose of this mixed-method study was to understand variation in
network positions of peer providers in newly integrated behavioral health networks using social
network analysis coupled with qualitative interviews with peer providers. Analyses revealed that
peer providers have different levels of involvement with LA Innovations integrated health care
teams, which vary according to their roles, backgrounds, the populations they serve, and their
perceptions of their involvement with their teams. Using a maximum variation approach (Aarons
& Palinkas 2007), further analysis explored the networks of the most-central and least-central
peer providers.
With respect to variation in their network positions, some peers were highly central.
These peer providers generally had personal experience with mental illness and valued their
personal expertise with recovery. They also stated that other members of their integrated team
also valued this expertise, because it enhanced their ability to engage people with mental illness.
Some peer providers were highly central to their teams, contradicting much literature related to
the implementation of peer providers, which has reported role confusion and stigma from fellow
team members as barriers to their inclusion on a given team (Gates & Akabas, 2007). Perhaps
these organizations recognized the need for someone in the role of peer support to connect with
and engage people with serious mental health needs, facilitating their successful implementation.
Regardless, lessons learned in these exemplar programs should be shared in DMH and publicized
more widely so that other organizations can implement peer providers using similar approaches.
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In other networks, peer providers were less central. In the cases, peer providers gave
varying explanations for their peripheral involvement. In most integrated services management
networks, the cultural background that peer providers shared with their clientele was essential to
conducting community-level outreach. Although their work differed from traditional peer-based
services in mental health settings, these peer providers reported feeling that they delivered a
critical part of the program. In general, they did not report feeling marginalized.
However, in some of these networks, peers’ perceptions of working with integrated teams
did not align with their network positions. In one case, a highly central peer held the perception
that his contribution was not valued by his team. In another case involving a peer in the lowest-
status CONCOR network group, the peer held the perception that he was very involved with his
team’s work and enjoyed working in the team’s cohesive environment. However, the network
analysis revealed that his involvement with the team was quite limited, relative to the other
members. Both findings further indicate the need for agency-level training in settings in which
peer providers are incorporated. Providers on multidisciplinary teams, particularly primary care
professionals, might have limited experience working with peer providers and could benefit from
training to alleviate this tension.
In yet another case, a peer with low centrality did not perceive his network position as
low, although he shared neither cultural background nor mental illness experience with the
clientele. When planning mental health services and peer support programs, it is important to
acknowledge that the peer providers might be tasked with different types of roles and
responsibilities that influence their network positions. Because there are cases in which peer
providers are on the periphery of the network for reasons they feel are related to stigma, it is
important to check with peers and their agencies during implementation to ensure that the
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72
necessary organizational supports are in place to provide training to other members of
multidisciplinary care team regarding how to work with peer providers.
Finally, it is worth noting that peer providers in this study who expressed feeling
marginalized were often in recovery from mental illness, including peer providers who were both
in highly central network subgroups and network subgroups with lower centrality. This
perception among some peer providers is not surprising, given that previous research has
documented that agencies can be indifferent or even hostile to the presence of peer providers
(Carlson, Rapp, & McDiarmid, 2001) and that stigma persists with respect to the capacity of
people with mental health conditions to work in general and the importance of the peer role in
particular (Gates & Akabas, 2007). These challenges to implementing the peer provider role
could exacerbated when a mental health program is creating a new team with providers
representing a wide range of disciplines—many of whom might have little experience working
with peer providers. Mental health authorities should ensure that the right supports are available
to agencies to include peer providers (Gates, Mandiberg, & Akabas, 2010).
Limitations
Findings should be viewed in light of three main study limitations. First, organizations
participated in the parent evaluation voluntarily. Thus, the programs included in this study could
be more open to providing integrated care and therefore more open to implementing other
services innovations, such as peer providers. Second, there could be issues of generalizability.
Findings from this study might not be applicable to public mental health systems that differ from
DMH. Third, these data are cross-sectional and were collected during the second year of program
operations. Future studies might collect network data at multiple time points to explore whether
and how the network positions of peers (or other providers) change as pilot programs progress in
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their implementation. Finally, this study was limited by the nature of sociometric data, which
allowed examination of communication and network ties in one provider network at a time.
Future studies might ask participants to nominate providers from other pilot programs with
whom they communicate to understand whether being connected with other organizations that
have successfully implemented peer providers facilitates their inclusion with a given team.
Conclusion
Peer providers occupied a wide range of network positions in these integrated health care
teams and had a variety of experiences related to their involvement in these pilot programs.
Network analysis coupled with qualitative fieldwork is a useful approach for understanding the
extent of involvement of peer providers in these settings. To enhance the involvement of peer
providers in integrated settings, enhanced training at the agency level coupled with incentives to
support peer providers is needed to promote their involvement in integrated health settings.
Further evaluation is needed to understand other factors that promote a more inclusive,
consumer-oriented workplace in settings that deliver mental health services and recovery-
oriented integrated care.

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Table 3.1
Composition of Care Coordination Networks (13 Networks, 224 Actors)
Network Model
Type
Peer
Provider
Therapist or
Clinician
Case
Manager
Primary Care
Provider
Nurse Psychiatrist Admin Other
a
Total
A IMHT 2 4 3 1 1 1 3 0 15
B IMHT 1 0 3 1 0 1 4 5 15
C ICM 1 0 1 1 2 0 2 4 11
D ISM 2 3 1 2 1 1 9 2 22
E ISM 7 3 0 1 0 0 7 5 23
F ISM 2 5 3 1 0 1 2 1 15
G ICM 1 5 2 1 0 4 2 6 21
H ISM 2 2 1 2 2 2 2 0 13
I ISM 1 7 2 1 0 1 1 0 13
J ISM 3 6 2 1 1 0 8 2 22
K ISM 4 3 1 2 1 1 7 2 21
L IMHT 1 1 8 1 2 1 3 0 17
M ICM 1 6 2 0 0 1 5 1 16
Total 28 45 29 15 10 14 55 28 224
a
Medical assistants, physician assistants, trainees, and practitioners of complementary and alternative medicine.

79
Table 3.2
Sample Characteristics of Peer Providers Who
Completed Both Social Network Survey and Qualitative
Interview (n = 17)
Variable n %
Age
a
46 12
Female 9 52.9
Race and ethnicity
African American 8 47.1
Asian (Cambodian, Chinese, Korean) 6 35.3
American Indian (Lakota) 1 5.9
Armenian or Persian 2 11.8
Speaks Language(s) in addition to English 9 52.9
Educational background
High school 2 11.8
Some college 6 35.3
Associate’s 3 17.6
BA or BS 2 11.8
Master’s 3 17.6
MBA 1 5.9
a
Figures reflect mean and standard deviation.
80

Table 3.3
Characteristics of Multidisciplinary Provider Networks
Network Model
Type
Network
Size
Network
Density
a
Network’s Average
Indegree Centrality
b

Possible Nominations
Received by Peer
c

n % % %
A IMHT 15 81 65 73
B IMHT 15 79 70 78
C ICM 11 74 52 60
D ISM 22 47 31 45*
E ISM 23 47 30 22
F ISM 15 74 38 42*
G ICM 21 46 31 40
H ISM 13 71 52 50*
I ISM 13 70 56 15
J ISM 22 34 23 17*
K ISM 21 37 27 14*
L IMHT 17 90 78 81
M ICM 16 57 38 20
a
Proportion of possible ties that exist in a network.
b
Average indegree centrality of all providers in a network.
c
Indegree centrality of peer providers in each network calculated using the following formula: nominations
received by peer ÷ (network size - 1).
*Average indegree centrality reported for networks that include more than 1 peer provider.
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Table 3.4
Structural Equivalence through Convergence of Correlated Iterations
Network

Model
Type
Peer Provider
Group
Peer Provider Structural Equivalent Nominations
Received by Group
a
A IMHT Group 1 of 8 Team leader 76
B IMHT Group 1 of 7 Program director, administrative coordinator 78
C ICM Group 1 of 6 Health promoter 60
D ISM
D Peer 1 Group 2 of 7 Other peer provider, case manager 43
D Peer 2 Group 2 of 7 Other peer provider, case manager 43
E ISM
E Peer 1 Group 2 of 8 Clinician at partnering agency, peer 6 31
E Peer 2 Group 3 of 8 Peers 3&5, CSS worker 28
E Peer 5 Group 3 of 8 Peers 2&3, CSS worker 28
F ISM Group 3 of 7 Other peer provider 46
G ICM Group 4 of 8 Social worker, social worker 33
H ISM Group 4 of 7 Other peer provider 50
I ISM Group 5 of 7 Case manager 50
J ISM Group 5 of 7 All three peer providers, executive director of partnering organization 18
K ISM Group 6 of 7 Yoga instructor 5
L IMHT Group 6 of 8 -- 75
M ICM Group 6 of 8 MIS coordinator, therapist, clinical supervisor 18
a
Average percentage.

82

Fig. 3.1. Care coordination network subtypes.
Network Type Network Visualization Illustrative Quote
Type 1: High
centrality, felt
central to team

The psychiatrist might know how
to give the guy meds, or the
doctor knows how to prescribe
the meds, and this is how it’s
supposed to happen, but then we
have us who … know the client.
–Network A, IMHT
Type 2: High
centrality, felt
peripheral to
team

“They just turn up their nose to
me and everything that I do.
‘Cause the client community is …
you know, is my strength, you
know what I’m saying? As a peer
advocate I don’t go to the staff
meetings. They just let me do my
thing, you know what I’m saying?
They let me do my thing.”
–Network B, IMHT
Type 3: Low
centrality, felt
central to team

“My team is very supportive. …
Everyone has, a good positive
vibe. We all work as a team. We
all make sure that we get our
things done on time. If I have a
question and I go to a therapist or
go to [boss] or I go to [other team
member] and ask them, they are
very helpful with me.
–Network M, ICM
Type 4: Low
centrality, felt
peripheral to
team

I miss a lot of meetings, and then
the peer part bothers me because
unless I am talking at you, it’s
hard for me to get the floor. … I
have to be almost angry to jump
in. … I want peer advocate status
to get into a group, but I don’t
want peer advocate status when it
comes to levels of participation or
accountability.
–Network L, IMHT
Note. Orange box represents peer provider.
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Chapter 4: Study 3
Roles and Experiences of Peer Providers in Integrated Mental Health and Primary Care
Settings
To be submitted to Psychiatric Services
Elizabeth Siantz and Lourdes Baezcondi-Garbanati
Introduction
The Patient Protection and Affordable Care Act has positioned an expanding cohort of
individuals living with mental disorders to become leaders in the delivery of integrated health
care services. These individuals, known as peer providers, are part of a movement that was
initially established to promote social justice and social inclusion among persons living with a
mental illness (Swarbrick, 2013). Peer-based services are services provided to people with
mental illness by individuals who have personal experience with mental illness (Davidson,
Chinman, Sells, & Rowe, 2006) and have received formal training to deliver and coordinate
mental health care (SAMHSA-HRSA Center for Integrated Health Solutions, 2016).
Recently, the scope of peer-based services has expanded to include promotion of physical
health and wellness among persons living with mental illness (Allen, Radke, & Parks, 2010;
Center for Substance Abuse Treatment, 2009). Peer provider roles have included promotion of
physical activity (Druss et al., 2010), health navigation (Brekke et al., 2013), wellness coaching
(Swarbrick, 2013), and facilitation of chronic disease self-management groups (Goldberg et al.,
2013). These studies have reported that peer providers also create critical linkages between the
fragmented primary and mental health systems of care.
Although many studies have described potential roles of peer providers in delivering
physical health and wellness services, less is known about the implementation of the peer role in
a systemwide effort to deliver newly integrated physical and mental health services. The large-
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scale implementation of pilot programs funded to deliver integrated mental health and primary
care services in Los Angeles County’s Department of Mental Health (DMH) is an ideal setting to
study this service delivery innovation. Although the integrated pilot programs featured in the
present study were asked to include peer providers on their multidisciplinary health care teams,
programs were given leeway to tailor the involvement of peer-based services to their own agency
contexts. Whereas a previous study (Siantz, Henwood, & Gilmer, in press) documented the
process of implementing peer providers in these pilot programs at the system level using an
implementation framework, the present study used qualitative interviews with peer providers to
understand how peer providers working in integrated care settings experience their role in
delivering health care and how they focus their efforts. Specifically, this qualitative study
explored whether peer providers delivering integrated care focus their efforts on providing
physical health services, mental health services, or other aspects of service delivery.
Methods
Study Setting
Beginning in 2012, integrated pilot programs were implemented under a countywide
initiative overseen by DMH known as LA Innovations. The largest county mental health system
in the United States, DMH serves more than quarter million county residents each year with a
$1.7 billion annual operating budget. The county is geographically large and racially diverse,
with 48.3% of the population being Latino, 9.2% African American, and 1.5% American Indian
or Alaska Native.
Resulting from DMH’s racially and ethnically diverse client population, peer services
were implemented in integrated programs specially designed to meet the needs of the various
ethnically diverse neighborhoods and Los Angeles’ large homeless population. Of the 24
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integrated pilot programs, five were colocated clinics employing an integrated clinic model
(ICM). Five other programs focused on homeless populations using a housing first approach with
primary care embedded in assertive community treatment teams, known as an integrated mobile
health team (IMHT). However, the majority of programs (n = 14) were community-designed
programs intended to target specific underserved ethnic communities, known as the integrated
services management (ISM) model. This systemwide effort to integrated primary and mental
health care services was the final initiative of California’s Mental Health Services Act.
Data Collection
To identify peer provider key informants, LA Innovations program directors were
contacted via email and asked for the names of the peer providers on their teams. Peer providers
were then recruited for study participation through a combination of emails and follow-up phone
calls. Up to three peer providers were interviewed per pilot program, at which point saturation
was achieved. As such, inclusion criteria for peer providers employed by LA Innovations
included willingness to participate in an interview and ability to speak English or Spanish. In
total, 24 peer providers were contacted by phone or email for a semistructured interview.
The semistructured interview focused on peer providers’ experiences delivering care on
their LA Innovations integrated behavioral health care teams. Respondents were asked to
describe their professional backgrounds as a peer provider, their responsibilities related to the LA
Innovations program, and their experiences working on an integrated health care team.
Individual interviews were conducted during spring 2015. Participants also completed a brief
demographic survey. Audio-recorded interviews were professionally transcribed.
Data Analysis
To analyze these interviews, a procedure of coding consensus, co-occurrence, and
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comparison (Willms et al., 1990) was used. This analytic strategy is rooted in grounded theory,
which is theory derived from data and then illustrated by characteristic examples of data (Glaser
& Strauss, 1967). The first author and two trained research assistants developed a list of codes.
The qualitative coding process occurred in three steps. First, the first author and one or two
research assistants co-coded 75% of transcripts. The first author coded the remaining 25% of
transcripts. Any disagreement in assignment or description of codes was resolved through
discussion and by refining the definition of the codes. Second, a final list of codes was
constructed through a consensus of team members and research assistants and consisted of a
numbered list of themes, issues, and opinions that related to the roles and experiences of peer
providers. Third, the transcripts were then assessed for agreement between the authors regarding
the coding, based on a procedure used in other qualitative studies (Boyatzis, 1998). NVivo
(Fraser, 2000) was used to code transcripts and generate a series of project codes that connected
segments of transcripts grouped into separate project nodes. The University of Southern
California Institutional Review Board approved all study procedures.
Results
Nineteen of the 24 peer providers who were contacted participated in a semistructured
interview. Most peer providers were Black (n = 9) or Asian (n = 7). More than half of the study
sample spoke a language in addition to English (n = 11). These languages included Khmer (n =
3); Armenian, (n = 2), Korean (n = 3), Lakota (n = 1), and Mandarin and Cantonese (n = 1). The
majority of study sample had completed more than high school, with seven individuals having
completed some college and seven having completed a bachelor’s degree or more. Peer providers
also represented each of the LA Innovations program types, with 12 respondents employed by
ISMs, three employed by ICM programs, and four employed by IMHT programs (see Table 4.1).
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Qualitative analyses revealed variation in the roles and experiences of peer providers in
delivering care. Peer providers were involved in the delivery of physical and mental health care,
although not necessarily both, and discussed sharing various experiences with clients, including
their cultural backgrounds and experience with recovery from mental illness, addiction, and
chronic disease. Qualitative themes are summarized in Table 4.2.
Theme I: Encouraging Physical Health Self-Management
Peer providers who were involved in the promotion of client physical health reported
having various mental and physical health histories, and discussed two primary roles related to
promotion of physical health and wellness. These roles involved informal strategies to promote
the physical health and wellness self-management of clients and the more structured role of care
health navigation.
In terms of self-management strategies, several participants said they drew from
experience of managing their own chronic diseases to motivate their clients to improve treatment
adherence. In one ICM setting, a peer provider described using her experience managing
diabetes to increase her patients’ treatment adherence.
I’m a diabetic. I understand the issue of diabetes for clients. We talk medication. I try to
make them understand the importance and the urgency of getting some of these things
done. Sometimes myself, I wish there had been someone there for me because I put off
treatment for four or five years, so I try to make our clients aware that this is something
that you need to deal with. (Greta,
2
ICM)
This quote demonstrates the melding of insight from an individual experienced with the
consequences of delaying caring for a chronic disease and the authority of a service provider.

2
All names given with qualitative excerpts are pseudonyms.

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Similar approaches were described by other peers who delivered physical health services. Other
peer providers used their capital as service professionals to employ a scared-straight approach to
remind clients of the negative consequences of not managing diabetes. To ensure her clients
were aware of the dangers of poorly managed diabetes, one peer provider brought them to a
morgue.
So we went over to the morgue and [my client] kept looking at me. I said, this is where
you’re going to be at if you don’t take your medicine and insulin like you’re supposed to.
Do you know how many people die of diabetes every day? I said, show me a person that
died of diabetes today. [The morgue worker] said how about yesterday? He said she went
into insulin shock. He said at least three or four people die every day. (Maxine, ICM)
By applying this approach, Maxine is able to guide her clients toward understanding the
importance of good diabetes self-management. Whereas some peer providers used personal
experience with chronic disease or a scared-straight approach to improve client self-
management, others described using skills learned in formal trainings to facilitate use of primary
care through health navigation. To become health navigators, peers participated in a manualized
training during which they learned how to teach clients to access and eventually manage their
use of primary care services. One peer provider described using his health navigator training to
help clients become more proactive in asking questions of their primary care providers.
So part of the health navigating training told me to inform my client about being specific
when you get to [a nurse practitioner]. Have the members get three questions that they
want to ask—specific questions. We don’t want people to go in there and just to get
prodded and poked. We want them to ask questions while we’re in there to help ease
anxiety. (Darrel, IMHT)
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In the more structured role of health navigator, peer providers were trained to help clients
by providing practical advice, which can alleviate some of the nerves and apprehension that
individuals can experience as a patient with limited experience in accessing primary care
services.
In this study, several peer providers were uninvolved in the promotion of client physical
health, and were instead focused exclusively on the mental or behavioral health needs of clients
or were tasked with outreach for the purpose of program enrollment. Many of these peer
providers reported understanding the importance client physical health, but summarized their
limited involvement by saying, “That’s not our part.” In this vein, some described feeling
unprepared and unskilled to support clients in accessing and managing health care client health
care. “No, [health care is] really … that’s really out of my league. I feel out of my league. All I
know is if you got a Medicare card, you can … get anything” (Mike, IMHT).
This peer provider alluded to limitations in his training that made him feel unprepared to
engage with clients on the topics of physical health and health care. In programs in which peer
providers were not involved in the coordination of client physical health care, they were more
likely to be involved in outreach and engagement; one peer provider who was not involved in
physical health care was tasked with running a drop-in center and facilitated other mental health-
related groups.
Theme II: Using Experience with Recovery to Educate Program Staff
Similar to peers who were primarily involved with physical health promotion and service
delivery, those who were more focused on mental health services also described having a range
of mental and behavioral health histories, and some had family members with mental illness.
Although their specific roles in the delivery of mental health care varied, peers drew from their
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experience with mental illness and recovery to educate their fellow service providers on the
realities of having a mental illness. “You know, they look at me … I’m like the one that they
always go, OK we have a question, and then they look at me like … to see my reaction, you
know? Because I came from the streets” (Cheryl, IMHT).
In this instance, Cheryl’s team looks to her for expertise and interpretation of life in the
streets. Other peer providers used their personal experience with mental illness to alert (and
occasionally challenge) their colleagues when they appeared misinformed about the experience
of having a mental illness or expressed unrealistic expectations of a client.
I’m the only one that has a mental illness here in the office, and sometimes they’ll say
stuff and I’ll be like, until you know, you don’t know. … I’m just saying until you know
what it’s like to be homeless, you don’t know why they got there to be homeless, you
don’t know what their background is or none of that and then you’re passing judgment at
the same time because you want them to do what you want them to do but at the same
time you don’t know what’s happening. (Maxine, ICM)
By relaying her expertise on mental illness and homelessness to her colleagues, Maxine is
able to serve in the role of advocate for clients when working with other members of her team.
Theme III: Evoking Shared Cultural Identity to Engage Clients
Whereas peer providers in IMHT and ICM programs reported having shared experiences
of recovery from mental illness, addiction, and chronic physical health conditions, peer providers
employed by ISM programs were more likely to share a common cultural identity or linguistic
background with their clients. Instead of having direct involvement with mental health service
delivery or physical wellness, ISM peer providers primarily evoked their shared cultural
background to conduct outreach for the purposes of program enrollment.
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Several ISM peer providers reported that both mental and physical illness were
stigmatized in their communities and described how culturally specific perceptions of mental
illness influence an individual’s likelihood of accessing and receiving mental health care. In this
respect, cultural peer providers described understanding the cultural nuances of stigma as
essential to engaging their populations. One Cambodian peer provider described his familiarity
with negative connotations of the word mental in Cambodian culture:
We could use the word mental, but then when you think of mental in Khmer, it means
that, you know, you’re crazy, you’re losing it. So we use heart instead of mental. You
know, it’s like it’s not—it’s not your head. It’s your heart. Your heart is sad. You know,
you need to heal your heart. (Sam, ISM)
Similar to peer providers who used their expertise with recovery from mental illness and chronic
disease, this peer used his knowledge to avoid describing mental illness in a way that is off limits
in the Khmer culture. In describing how culture influences the experience of stigma, peer
providers also noted the historical context that is at the foundation of cultural stigma.
In the past, a preacher like that, even though you have a mental and emotional … if you
pray to God, God conquers everything. Everything can be handled through prayer. … A
Korean pastor in the past is like they don’t accept mental health problem [it means] the
faith is not good. (Donald, ISM)
Donald, who is an ordained pastor, used his shared Korean identity and professional status to
explain why outreach in his community can be so challenging. Similar to mental health peers in
recovery, these cultural peers share experiences and familiarity with a community’s historical
context of stigma. This allows peer providers to more effectively conduct community outreach
and engagement.
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Peer providers also engaged clients by blending their cultural identity with their own
experience of mental illness and recovery. Many peer providers had overlapping identities in this
respect. One peer provider had depression, is a cancer survivor, and is Chinese. He said he uses
this experience to support clients in accessing primary care.
I tell them my depression and my other problem [cancer]. I still recover. Now I’m fine. I
can help you. I just try to encourage them to keep all the appointments, that you might be
better later. And culture, all Chinese client sometime they believe some different thing
too, like they do Buddha, they can go to the temple to pray. They feel better, too.
(Manny, ISM)
Manny described blending these three identities and suggested that part of his role is to help
clients keep appointments with their many health care providers. Encouraging clients to take
their multiple health care needs seriously using a cultural perspective is optimized through a peer
provider who can relate with physical and mental health concerns and shares their ethnic and
linguistic background.
Discussion
The purpose of this study was to understand the roles of peer providers working in newly
integrated mental health and primary care settings as they relate to the provision of physical
health care, mental health care, and other aspects of service delivery. This qualitative study is
among the first to explore the specific roles of peer providers in a systemwide effort to deliver
integrated care, and generated three main points of discussion.
First, findings indicate that peer providers had varying levels of involvement in the
promotion of physical health of LA Innovations consumers. Peer providers who were involved in
consumer physical health used their personal experience and training from a highly structured
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health navigation program to encourage and support physical health self-management. Although
peer providers indicated the value of this work to their team members and clients, their roles did
not encompass the range of potential functions peer providers can have in delivering physical
health care. Organizations participating in LA Innovations might not be familiar with this range
of potential roles, which can include facilitation of chronic disease self-management groups,
recovery support and case management, and wellness coaching, or might have lacked the
capacity to train and support these positions.
Second, this study revealed that many peer providers employed by ISM programs
reported using their cultural identity (rather than personal experience with mental illness) to
build rapport with clients for the purpose of program enrolment, and functioned as a critical part
of outreach and engagement for the purpose of program enrollment. This follows a different
paradigm than typical mental health peer providers, and instead resembles the community health
worker, or promotor, model. The American Public Health Association (2016) defined a
community health worker as “a frontline public health worker who is a trusted member of and/or
has an unusually close understanding of the community served … [that] enables the worker to
serve as a liaison/link/intermediary between health/social services and the community to
facilitate access to services and improve the quality and cultural competence of service delivery.”
Given the outreach challenges noted by peer providers in their outreach efforts, this approach
was especially useful for engaging hard-to-reach clinic populations served by LA Innovations
programs. Even though this approach does not follow the definition of peer provider traditionally
used in mental health settings, this model of care is increasingly used in integrated primary care
and mental health settings in California (California Association of Social Rehabilitation
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Agencies, 2014). Limitations of this approach include its inability to offer an opportunity to
normalize experiences of mental illness and recovery.
Third, some ISM cultural peer providers discussed being in recovery from mental,
behavioral, and physical health conditions. This suggests that having cultural peers who are also
in recovery is a feasible way to incorporate this perspective on services into integrated teams that
serve racially and ethnically diverse clients. Community mental health settings should receive
ongoing support from mental health authorities to ensure that resources are available to support
such culturally competent peer-based services.
Several public mental health systems in California are in the process of formally
integrating peer providers into the physical health care of their clients (California Association of
Social Rehabilitation Agencies, 2014). However, limited resources are available to support
public mental health systems in expanding the roles of peer providers to include tasks related to
client physical health. Increased communication to facilitate learning among health systems is
one possible to improve implementation outcomes at the state level. This could be accomplished
through statewide learning collaboratives, in which mental health systems can share best
practices for expanding the peer role to include physical health care.
Limitations
Findings from the present study should be viewed in light of several limitations. First, LA
Innovations programs could differ from other integrated programs, and peer provider experiences
might not be generalizable to other settings in which peer providers are employed. Further, this
study was limited to the perspectives of peer providers. Future research should investigate the
perspectives of other mental health services providers and consumers of integrated care to
understand how these services affect their motivation for self-management of chronic diseases,
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engagement with physical health services, or other experiences accessing and utilizing integrated
health services.
Conclusions
This study showed that it is feasible to involve peer providers in the delivery of physical
health care and integrated care using a cultural perspective. Additional efforts are needed to
support DMH in incorporating the range of potential peer roles in integrated care settings.
Organizational supports, including the formal training of peer providers on matters related to
physical health and wellness from a cultural perspective, are needed so that public mental health
authorities can continue improving the physical health and wellness of people living with mental
illness using peer-based services.

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disparities for people with serious mental illness. Best Practices in Mental Health, 9(1),
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intervention to improve medical self-management for persons with serious mental illness.
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Table 4.1
Sample Characteristics of Peer Providers
(N = 19)
Variable n %
Program type
ISM 12 63.0
ICM 3 15.8
IMHT 4 21.1
Male 10 52.2
Age
a
46 12
Language spoken
b

English only 9 47.4
Armenian 2 10.5
Khmer 3 15.8
Lakota 1 5.3
Mandarin and Cantonese 1 5.3
Korean 3 15.8
Race and ethnicity
Armenian 1 5.3
Persian 1 5.3
Black 9 47.4
Cambodian 3 15.8
Chinese 1 5.3
Korean 3 15.8
American Indian (Lakota) 1 5.3
Education
High school diploma 2 10.5
Some college 7 36.8
Associate’s 3 15.8
Bachelor’s 2 10.5
Master’s 3 15.8
MBA 1 5.3
Doctorate 1 5.3
a
Figures reflect mean and standard deviation.
b
All interviews conducted in English.

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Table 4.2
Qualitative Results
Theme Subtheme Exemplary Quote
Encourage physical
health self-
management
Use personal
experiences
with chronic
disease
I wish there had been someone there for me because I
put off treatment for four or five years, so I try to
make our clients aware that this is something that you
need to deal with.
Scared straight So we went over to the morgue and [my client] kept
looking at me. I said this is where you’re going to be
at if you don’t take your medicine and insulin like
you’re supposed to.
Health
navigation
So part of the health navigating training told me to
inform my team about being specific when you get to
[a nurse practitioner]. Have the members get three
questions that they want to ask—specific questions.
We don’t want people to go in there and just to get
prodded and poked.
Apply personal
expertise to educate
mental health staff
You know, they look at me … I’m like the one that
they always go, OK, we have a question, and then
they look at me like … to see my reaction, you
know? Because I came from the streets.
Evoke shared
cultural identity to
engage clients
Using culture to
reduce stigma
When you think of a mental in Khmer, it means that
you’re crazy, you’re losing it. So we use heart instead
of mental. You know, it’s not your head. It’s your
heart. Your heart is sad. You know, you need to heal
your heart.
Understand
historic context
of stigma
In the past, a preacher like that, even though you
have a mental and emotional … [said] if you pray to
God, God conquers everything. Everything is just can
be handled through our prayer … a Korean pastor in
the past is like they don’t accept mental health
problem because it means the faith is not good.
Blend
understanding
of culture with
recovery
experience
I tell them my depression and my other problem
[cancer]. I still recover. Now I’m fine. I can help you.
I just try to encourage them to keep all the
appointments, that you might be better later. And
culture, all Chinese client sometime they believe
some different thing too, like they do Buddha, they
can go to the temple to pray. They feel better, too.
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Chapter 5: Conclusions, Implications, and Future Directions
Introduction
The goal of this dissertation research was to better understand the process of
implementing peer providers in a newly integrated public mental health system and their roles in
providing integrated care, using the Consolidated Framework for Implementation Research
(Damschroder et al., 2009) as a guiding framework. Using a sequential mixed-method design,
these studies had the following objectives: (a) examine how peer-based services are implemented
in newly integrated behavioral health care settings; (b) identify the network positions of peer
providers in integrated behavioral health teams and understand variation in their network
positions; and (c) explore the experiences of peer providers in integrated care settings and how
they focus their efforts.
This research is especially timely given that adults with serious mental illness remain
among the most medically vulnerable groups in the United States and experience many years of
life lost compared to the general population (Colton & Manderscheid, 2006). In recent years, the
physical health and health care needs of this population have increasingly received attention as a
public health crisis. Under the Patient Protection and Affordable Care Act, the U.S. Department
of Health and Human Services’s Substance Abuse and Mental Health Services Administration
(SAMHSA) has promoted the value of peer-based services to improve the physical health of
people living with mental illness (SAMHSA-HRSA Center for Integrated Health Solutions,
2016a). Many states, including California, have followed suit (California Association of Social
Rehabilitation Agencies, 2014). Despite this momentum, there is little evidence that peers are
routinely implemented in integrated health care programs. This dissertation sought to understand
process and challenges to implementing this role from multiple perspectives, including those of
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program staff members, administrators, and peer providers. To that end, this study analyzed
evaluative site visit data, probed into the social networks of integrated teams, and captured the
experiences of peer providers working in integrated programs.
This dissertation took advantage of an opportunity to explore the implementation of peer
providers in integrated settings presented by the Los Angeles County Department of Mental
Health (DMH) Innovations study. LA Innovations provided a unique environment to explore the
process of implementing peer providers through a countywide initiative to implement integrated
behavioral health pilot programs. The clientele served by DMH is among the most diverse in the
United States, and integrated programs funded by LA Innovations were created with the purpose
of engaging a variety of ethnic populations and homeless individuals in integrated care. All
consumers enrolled in these pilot programs had serious mental illness and a co-occurring chronic
care condition. This dissertation built on previous work reporting on outcomes of peer-based
integrated care (Brekke et al., 2013; Goldberg et al., 2013). Although the evidence base is still
developing (Cabassa, Camacho, & Galvis, 2016), studies have reported that services provided by
peers are effective at improving health behaviors and health service utilization and can be
implemented in a variety of settings. Previous studies documenting the challenges of
implementing peers in community mental health settings (e.g., Gates & Akabas, 2007) also
informed this research. This final chapter presents and interprets the central findings from these
three empirical papers and reports study limitations. This chapter concludes by providing
implications and specific recommendations for future efforts to implement peer providers in
health care settings that deliver integrated mental health and primary care services to persons
living with mental illness.
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Major Findings
This dissertation highlighted factors that affect implementation of peer providers in
integrated health care settings in Los Angeles County. First, all three studies indicate that LA
Innovations programs used varying definitions of peer provider. Several peer providers
employed by IMHT and ICM teams embodied the SAMHSA (SAMHSA-HRSA Center for
Integrated Health Solutions, 2016a) definition of peer provider, which involves having lived
experience of mental illness. In these settings, several members of their integrated teams were
aware that peer providers were in recovery from mental illness. However, the definition of peer
provider varied more widely among ISM programs. Instead of lived experience with mental
illness, the majority of ISM programs defined peer providers as individuals who shared a
common cultural or linguistic identity or had an experience of migration similar to the clinic’s
clientele.
To explain their decision to include peer providers who did not adhere to the traditional
peer background, some ISM staff members described a belief that high levels of stigma of mental
illness in some ethnic communities they serve would cause peer providers in recovery from
mental illness to be an unacceptable source of support for consumers and their families.
Qualitative interviews used in Study 2 and Study 3 provided more in-depth understanding of peer
backgrounds and revealed that some ISM peer providers were in recovery from a mental illness.
For example, the Chinese service model’s peer provider was a former consumer who had
received services from the clinic. He took pride in his transition from client to staff member, and
was glad to help clients access both physical and mental health care using his personal
experience with depression and cancer and his knowledge of Chinese and Vietnamese cultures.
Similarly, a peer provider from the Korean service model discussed using her experience with
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depression to relate to struggles of potential clients during outreach, even though both physical
and mental illness are highly stigmatized in the Korean community. Both are examples of peers
living with mental illness who are effective members of service teams in ethnic communities
where mental illness is highly stigmatized. These cases should be publicized across ISM
programs in DMH and other integrated programs where stigma might preclude community
mental health settings from including peer providers on an integrated team. Still, taken together
these three studies confirm that questions remain regarding exactly what it means to be a peer
provider in LA Innovations integrated settings.
A second key finding was substantial variation in the social network positions occupied
by peer providers. Peer providers were highly central in some LA Innovations provider
networks, but had much lower centrality in others. Study 2 indicated that peer providers who
were highly central to their integrated teams tended to be in recovery from mental illness or a co-
occurring behavioral health condition. Qualitative interviews revealed that highly central peer
providers generally prided themselves on their experiences with mental illness and spoke at
length about how their personal experience benefits their clients and teams. Peer providers who
were not central to their teams tended to be cultural peers who conducted outreach. Qualitative
interviews also revealed that perceptions of peer providers of their involvement did not always
align with their network position. In some cases, highly central peer providers reported feeling
uninvolved with their team. Although peer providers in recovery were most likely to have a
central role, they were also most likely to feel marginalized. This is an ongoing challenge to
implementing peer providers in traditional mental health settings, and suggests a need for
structured training among agencies and providers who are not experienced in working with peer
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providers. Such training might be especially critical in integrated settings, which might include
primary care professionals who have not previously been exposed to peer-based services.
A third finding was that peer providers contributed in varying ways to delivery of
integrated care in LA Innovations pilot programs. Peers focused on delivering mental health care
drew on their own experience with mental illness to educate their fellow service providers about
the realities of having a mental illness and to engage clients with mental health care. In doing so,
they discussed how their expertise functioned as a source of education for other members of their
teams.
Peer providers employed by ISM programs less frequently reported having shared
experience of recovery from mental illness, and instead reported using their cultural identity to
build rapport with clients for the purpose of program enrollment and functioning as a critical part
of outreach. Qualitative interviews with cultural peers revealed that these individuals are deeply
integrated into the ethnic communities that they serve, and thus should be recognized for having
such insight into cultural factors that present challenges to accessing services, many of which
related to historical cultural context. Examples of these factors included the Khmer Rouge
genocide, which contributed to a climate of stigma surrounding posttraumatic stress disorder in
the Cambodian community; how commodity food (such as wheat flour, sugar, and lard)
contributed to the obesity and diabetes epidemic in the American Indian community; and the role
of spirituality and religion in the Korean community, which has created a context of stigma
surrounding both physical and mental illness (i.e., that lack of spirituality causes illnesses like
cancer and depression). Although many LA Innovations cultural peers lacked personal
experience with recovery, their roles nonetheless remained critical to understanding their
consumer population and should not be dismissed.
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Also related to the roles of peer providers, many participants had limited involvement
with the actual delivery of physical health and wellness services. In cases in which peer
providers were involved with the physical health of LA Innovations consumers, their
responsibilities typically involved encouragement and support clients in the self-management of
their physical health, which was accomplished using their personal experience with chronic
disease. Health navigation (Brekke et al., 2013) was an additional physical health intervention
delivered by peer providers. As health navigators, peer providers received formal instruction in
training clients to access primary care services independent of provider support. Although peer
providers indicated the value of these roles to their teams and to clients, these roles do not
encompass the range of potential roles peers can have in delivering physical health care. These
roles can include facilitation of chronic disease self-management groups, recovery support and
case management, and wellness coaching, among other roles that promote health behavioral
change. DMH should consider formally expanding the roles of peer providers in delivery of
physical health services, and community mental health centers might also consider collaborating
with peer-run organizations to implement these service innovations.
Limitations and Future Research
This section discusses several limitations of this study that also reveal areas for additional
research. First, organizations participated in the parent evaluation voluntarily. Thus, the
programs included in this study might have been more open to providing integrated care, and
therefore more open to implementing other services innovations such as peer providers. Second,
findings from these three studies might not be generalizable to public mental health systems that
differ from DMH. This is especially true among mental health systems in rural settings or other
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settings where the racial and ethnic composition of the consumer population varies substantially
from that of Los Angeles County.
An additional limitation to the dissertation is the lack of perspectives from LA
Innovations clients. Study 1 reported that the backgrounds of peer providers included individuals
in recovery from mental illness, people with a similar cultural background as clients, and those
with a shared history of chronic care conditions. Study 3 reported on how peers use these varying
types of personal experience to support clients in their wellness and recovery. A client
perspective could have enhanced these studies in two main ways. First, client perspectives on the
utility of the varying types of peer support available through innovations models could help
DMH leaders understand the extent to which clients value this variety of peer support and
generate suggestions from clients for improving and enhancing current peer-based services.
Previous studies in general mental health settings have reported that consumers find services
provided by peers to be beneficial (Sells, Davidson, Jewell, Falzer, & Rowe, 2006), but that
specific factors that cause peer-based services to be effective are not well understood (Sells et al.,
2006; Stefancic, House, & Osterweil, 2016). Given that the implementation of peer providers in
integrated settings is a relatively new area of study, client perspectives are necessary to guide the
development of this role. In the true spirit of the maxim “nothing about us without us,”
researchers and public mental health authorities should engage consumer populations in settings
where peer-based services are delivered to incorporate this important perspective.
There were also limitations to the evaluation framework and site visit approach used in
Study 1. Under the parent study’s implementation evaluation, site visits were conducted at each
pilot program using the Integrated Treatment Tool (ITT) as a guiding framework. Efforts to
standardize use of this framework included three full days of training, multiple project evaluators
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attending each site visit, and achieving consensus on ratings of the ITT framework. However, the
ITT framework has not been validated by previous research. Further, data presented in Study 1
were collected through focus group-style interviews, which were not audio recorded or
transcribed due to the duration of each site visit and the multitude of individuals interviewed.
Therefore, this study did not feature exact quotations of the LA Innovations personnel who
participated. These study limitations have presented challenges in publishing findings from this
component of the evaluation study. Future studies using this approach should consider adding
rigor to evaluative site visits by audio recording and transcribing study interviews with providers.
In the case of the present evaluation, mental health providers and DMH officials expressed high
levels of discomfort with the evaluation team’s use of site visit methodology and voiced serious
concerns over the possibility of audio recording interviews, stating that it felt as though their
programs were being audited. To complete the evaluation as requested by DMH, the evaluation
team needed to respect this dynamic.
Additional limitations pertained to the social network evaluation. These data were cross-
sectional and collected during the second year off operations of the LA Innovations programs.
Future studies might collect network data at two time points to allow researchers to explore
whether and how the network positions of peers and other providers change as a pilot programs
progress in their implementation. Finally, this study was limited by the nature of sociometric
data, which allowed us to examine communication and network ties in only one provider
network at a time. Future studies might ask participants to nominate providers from other pilot
programs with whom they communicate to understand whether being connected with other
organizations that have successfully implemented peer providers facilitates their inclusion on a
given team.
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Implications and Recommendations
Findings from this dissertation yielded several recommendations to the delivery of peer-
based integrated health services. Many studies have recognized the important role of
organizational leadership when implementing service innovations (Aarons, Hurlburt, & Horwitz,
2011). A recent study described the role of organizational leadership in ensuring the successful
implementation of peer providers in general mental health settings (Gate & Akabas, 2007). Study
implications relate to the critical role of organizational leadership at the program, system, and
policy levels for creating a climate that allows all members of the integrated team to understand
and value the role of peer provider.
Program Level
This dissertation found that several programs experienced challenges implementing the
peer role and that some peers felt excluded from health care teams. Therefore, the first
recommendation is for program leaders to ensure that providers on their integrated teams
understand the importance of the peer role. Gates and Akabas (2007) suggested that integration
of peer providers is most successful when program leaders create a climate that allows other
members of the mental health team to understand the importance of the peer role as it relates to
the agency mission. Although it is important to acknowledge that peer providers might be tasked
with different types of roles and responsibilities based on program need and design, clearly
defining the roles of peers is also critical (Gates & Akabas 2007), and mental health agencies
must provide necessary training to other staff members that reinforces this commitment.
Resources provided by the SAMHSA-HRSA Center for Integrated Health Solutions (2016b)
might be useful in this regard.
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Also at the program level, organizational leaders in these programs should dispel the
belief that having a mental health consumer on the team could cause potential consumers to balk
at service receipt. This belief is not empirically supported and presents a serious barrier to the
implementation of a resource that is designed to reduce feelings of stigma and promote
empowerment among mental health consumers. Findings that some providers held negative
perceptions about peer-based services are consistent with previous research, which has
documented that mental health peers are underutilized members of the mental health workforce.
Previous research has documented that agencies can be indifferent to the presence of peer
providers (Carlson, Rapp, & McDiarmid, 2001) and that stigma of mental illness can also
diminish the importance of the peer role (Gates & Akabas, 2007). These ongoing challenges to
implementing peer providers can be exacerbated when mental health programs create new teams
with providers from a wide range of disciplines that might have limited experience working with
peers (Gates, Mandiberg, & Akabas, 2010). Previous studies have also reported that providers’
perceptions of an intervention can influence the likelihood of its implementation (Corrigan,
Steiner, McCracken, Blaser, & Barr, 2001). Provider training related to the utility of peer
providers in recovery from mental illness is one way to address this belief. Consumers of mental
health services should also have a role in the planning of mental health services, and can be
involved to provide additional insight into the community’s perception of the utility of peer-
based services or how to tailor these services to make these services most appropriate for a
specific population.
System Level
At the system level, public mental health authorities must support community mental
health providers to achieve inclusion of peer providers in the delivery of integrated care.
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Findings from this dissertation also suggest that more community mental health providers be
outfitted with resources to train peer providers in evidence-based approaches to supporting client
physical health and wellness. This would allow mental health systems to maximize the benefit of
peer-based services in the context of these integrated settings. Peer providers in this study had
shared mental health histories or a shared cultural identity with clients, and were often essential
to engaging hard-to-reach populations. Although these roles are valuable, peer providers were
often uninvolved in the physical health care of their clients. Public mental health systems should
consider formally training peer providers in techniques to support the physical health and self-
management of clients. A recent systematic review (Cabassa et al., 2016) provided an exhaustive
list of the roles of peers in delivering physical health interventions. This review noted that peers
can deliver a wide selection of physical health interventions, which can be classified as health
behavior interventions or interventions designed to improve utilization of health care services.
Formally training more LA Innovations peer providers in one of these many approaches could
maximize the peer role in integrated care and fuse the roles of cultural peer with physical health
and wellness support.
Also at the system level, DMH and other mental health authorities might consider
collaborating with peer-run mental health organizations as a resource for developing the peer
mental health workforce in integrated settings. These organizations are managed and staffed by
people who have received mental health services and have the mission of using support,
education, and advocacy to promote empowerment and recovery for people with mental
disorders (Ostrow & Leaf, 2014). Using data from the National Survey of Peer-Run
Organizations (Ostrow & Leaf, 2014), one study (Ostrow, Siantz, Leaf, & Mandersheid, 2016)
found that pee- run organizations are generally willing to collaborate with health homes via the
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Patient Protection and Affordable Care Act. In that study, several peer-run organizations had
reservations about working as part of a health home related to conforming to the medical model
and working with providers who do not understand recovery. Cultivating alliances among peer-
run organizations, mental health systems, and physical health services would help providers from
these various settings overcome mistrust of one another while also strengthening a peer
workforce that could potentially deliver integrated care.
As an additional way to facilitate the implementation of peers at the program level, DMH
could ask programs to evaluate their own implementation efforts. A recent study (Gates et al.,
2010) reported on an evaluation of a strategy designed to help agencies self-assess their specific
challenges in implementing peer providers and then engage in steps to resolve those challenges.
This study reported favorable outcomes using this approach, namely that staff training, goal
setting, and consultation can improve peer perceptions of inclusion. Alternately, DMH could also
increase the likelihood of successful inclusion of peers by providing incentives for organizations
that meaningfully include peers on their teams.
Policy Level
A final implication of this dissertation relates to the need to create a nationally recognized
definition of peer provider as it relates to the delivery of integrated care. According to a report
from the California Mental Health Planning Council (2015), there is no standardized role or state
certification in California for peer providers. Peer specialist certification is an official recognition
by a certifying body that a practitioner has met qualifications that include lived experience and
training from a standardized curriculum on mental health issues. Because there is no statewide
certification in California, programs that participated in this research were given considerable
leeway with respect to how they defined peer providers and peer-based services. Such a
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certification could help alleviate confusion related to what the background of peer providers
should be and could also create an administrative landscape wherein peers delivering care could
uniformly be reimbursed for their time and effort through MediCal, which currently does not
occur in California (California Mental Health Planning Council, 2015). It is worth noting,
however, that the mechanisms through which peer-based services effectively improve client
outcomes are not well understood (Sells et al., 2006; Stefancic et al., 2016), and standardizing
peer-based services could detract from factors that are most helpful about this approach.
Conclusion
To increase the involvement of peer providers in delivering integrated health services,
alliances must be created that transcend the mental health, physical health, and consumer-
operated systems of care. Input from all of these entities is needed to best support community
mental health providers in applying strategies to successfully implement peer providers in
integrated settings. Because traditional mental health settings have identified several challenges
and strategies for implementing peers, special care and enthusiasm must be applied when
working in integrated settings that include primary care professionals who likely have little
experience working on a team that includes peer providers. Similarly, peer provider training
should also include instruction on ways to effectively engage primary care professionals.
Exemplar cases should be shared in DMH and publicized more widely so that other
organizations can implement peer support models using similar approaches. Such joint efforts
are needed to improve the physical health of people living with serious mental illness and make
the delivery of integrated care more recovery oriented and empowering.

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References
Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model of
evidence-based practice implementation in public service sectors.Administration and
Policy in Mental Health and Mental Health Services Research, 38(1), 4-23.
http://dx.doi.org/10.1007/s10488-010-0327-7

Brekke, J. S., Siantz, E., Pahwa, R., Kelly, E., Tallen, L., & Fulginiti, A. (2013). Reducing health
disparities for people with serious mental illness. Best Practices in Mental Health, 9(1),
62–82.
Cabassa, L .J., Camacho, D., & Galvis, E. (2016, January 15). Systematic literature review of
peer-based health interventions for people with serious mental illness. Paper presented at
the 20th Annual Conference of the Society for Social Work and Research, Washington,
DC.
California Association of Social Rehabilitation Agencies. (2014). Meaningful roles for peer
providers in integrated healthcare: A guide. Retrieved from
http://www.casra.org/docs/peer_provider_toolkit.pdf
California Mental Health Planning Council (2015). Peer certification: What are we waiting for?
Retrieved from
http://www.dhcs.ca.gov/services/MH/Documents/CMHPCPeerCertPaper2015.pdf
Carlson, L. S., Rapp, C. A., & McDiarmid, D. (2001). Hiring consumer-providers: Barriers and
alternative solutions. Community Mental Health Journal, 37, 199–213.
http://dx.doi.org/10.1023/A:1017569913118
Colton, C. W., & Manderscheid, R. W. (2006). Congruencies in increased mortality rates, years
of potential life lost, and causes of death among public mental health clients in eight
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states. Preventing Chronic Disease, 3(2), A42.
Corrigan, P. W., Steiner, L., McCracken, S. G., Blaser, B., & Barr, M. (2001). Strategies for
disseminating evidence-based practices to staff who treat people with serious mental
illness. Psychiatric Services, 52, 1598–1606.
http://dx.doi.org/10.1176/appi.ps.52.12.1598
Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C.
(2009). Fostering implementation of health services research findings into practice: A
consolidated framework for advancing implementation science. Implementation Science,
4, 50. http://dx.doi.org/10.1186/1748-5908-4-50
Gates, L. B., & Akabas, S. H. (2007). Developing strategies to integrate peer providers into the
staff of mental health agencies. Administration and Policy in Mental Health and Mental
Health Services Research, 34, 293–306. http://dx.doi.org/10.1007/s10488-006-0109-4
Gates, L. B., Mandiberg, J. M., & Akabas, S. H. (2010). Building capacity in social service
agencies to employ peer providers. Psychiatric Rehabilitation Journal, 34, 145–152.
http://dx.doi.org/10.2975/34.2.2010.145.152
Goldberg, R. W., Dickerson, F., Lucksted, A., Brown, C. H., Weber, E., Tenhula, W. N., …
Dixon, L. B. (2013). Living Well: An intervention to improve self-management of
medical illness for individuals with serious mental illness. Psychiatric Services, 64, 51–
57. http://dx.doi.org/10.1176/appi.ps.201200034
Ostrow, L., & Leaf, P. J. (2014). Improving capacity to monitor and support sustainability of
mental health peer-run organizations. Psychiatric Services, 65, 239–241.
http://dx.doi.org/10.1176/appi.ps.201300187
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Ostrow, L., Siantz, E., (2016). Attitudes of mental health peer-run organizations towards health
homes. Manuscript under review at General Hospital Psychiatry.
SAMHSA-HRSA Center for Integrated Health Solutions. (2016b). Education & training.
Retrieved from http://www.integration.samhsa.gov/workforce/education-training
Sells, D., Davidson, L., Jewell C., Falzer, P., & Rowe, M. (2006). The treatment relationship in
peer-based and regular case management for clients with severe mental illness.
Psychiatric Services, 57, 1179–1184. http://dx.doi.org/10.1176/ps.2006.57.8.1179
Stefancic, A., House, S., & Osterweil, S. (2016, January 15). “What we have in common”: The
role of shared experience in peer-delivered services. Paper presented at the 20th Annual
Conference of the Society for Social Work and Research, Washington, DC.

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Appendix A: Terminology Used in Dissertation

Term Definition
CFIR  Consolidated Framework for Implementation Research
 This framework guided these three studies
 Paper 1 results presented using CFIR
Convergent parallel mixed-
method design
 Multiple methods used in sequence to answer, or
expand on, questions raised by other methods
 Frequently used to study implementation of health
care innovations
LA Innovations  Los Angeles County Department of Mental Health
Innovations program
ICM  Integrated clinic model, which delivers colocated
services
 n = 5
ISM  Integrated services management model, a community-
designed structured care coordination
 n = 14
IMHT  Integrated mobile health team
 n = 5
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Appendix B: LA Innovations Social Network Survey
The purpose of this survey is to understand how each DMH Innovations Project team works
together to coordinate patient care. [Insert participant’s program name] has been selected to pilot
this brief survey. Thank you in advance for participating. We look forward to sharing our
findings at a future learning session.

Please select your name
 List network roster

For the following nine questions, select all responses that apply.

With whom do you have regular contact about client care?
 Show network roster with respondent ’s name removed

For how many years have you worked in your profession since you completed your highest level
of training?
 Less that one year (1)
 1 year (2)
 2 years (3)
 3 years (4)
 4 years (5)
 5 years (6)
 6 years (7)
 7 years (8)
 8 years (9)
 9 years (10)
 10 years (11)
 11 years (12)
 12 years (13)
 13 years (14)
 14 years (15)
 15 years (16)
 16 years (17)
 17 years (18)
 18 years (19)
 19 years (20)
 20 years (21)
 more than 20 years (22)

If ‘more than 20 years’ Is Selected, Then Skip To Click to write the question text

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Answer If ‘For how many years have you worked in you profession since you completed your
highest level of training?’ more than 20 years Is Selected

You said you’ve worked in your profession for more than 20 years. Please write in the number
of years you have worked in your profession.

For how many years have you worked at this clinic site?
 Less than one year (1)
 One year (2)
 2 years (3)
 3 years (4)
 4 years (5)
 5 years (6)
 6 years (7)
 7 years (8)
 8 years (9)
 9 years (10)
 10 years (11)
 11 years (12)
 12 years (13)
 13 years (14)
 14 years (15)
 15 years (16)
 more than 15 years (17)
If ‘more than 15 years’ Is Selected, Then Skip To ‘You said you’ve worked at this clinic...’

Answer If ‘For how many years have you worked at this clinic site?’ more than 15 years Is
Selected
You said you’ve worked at this clinic site for more than 15 years. Please write in the number of
years have you worked at this clinic site.

When did you begin working on the Homeless Innovations Project?
Month Year

Janu
ary
(1)
Febr
uary
(2)
Ma
rch
(3)
Ap
ril
(4)
M
ay
(5
)
Ju
ne
(6
)
Ju
ly
(7
)
Aug
ust
(8)
Septe
mber
(9)
Octo
ber
(10)
Nove
mber
(11)
Dece
mber
(12)
20
12
(1)
20
13
(2)
20
14
(3)
St
art
da
te
(1)
              

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How much do you think providing primary care along side mental health care can improve
patient outcomes?
 Significantly (1)
 Somewhat (2)
 Not at all (3)
 I think outcomes will be worse (4)

What is your age, please?

Are you Male or Female?
 Male (1)
 Female (2)
 Other (3)

Are you a native speaker of English?
 Yes (1)
 No (2)

Do you speak any languages other than English?
 Yes (1)
 No (2)
If No Is Selected, Then Skip To Are you Latino or Hispanic?

Answer If Do you speak any languages other than English? yes Is Selected
Please write in the languages other than English that you speak.

Are you Latino or Hispanic?
 Yes (1)
 No (2)
If No Is Selected, Then Skip To Which one or more of the following yo...

Answer If Are you Latino or Hispanic? Yes Is Selected
And what is your Latino or Hispanic ancestry or origin? Such as Mexican, Salvadoran, Cuban,
Honduran-- and if you have more than one, list all of them.

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Which one or more of the following you would use to describe yourself?
 White (1)
 Black or African American (2)
 Asian (3)
 American Indian or Alaska Native (4)
 Other Pacific Islander (5)
 Native Hawaiian (6)
 Other (7)
 Don’t know (8)
If White Is Selected, Then Skip To Thank you for participating in the DM...If Black or African
American Is Selected, Then Skip To Thank you for participating in the DM...If Asian Is
Selected, Then Skip To You said Asia, and what specific ethn...If Other Pacific Islander Is
Selected, Then Skip To You said you are Pacific Islander. Pl...If Other Is Selected, Then Skip To
Thank you for participating in the DM...If Don’t know Is Selected, Then Skip To Thank you for
participating in the DM...

Answer If Which one or more of the following you would use to describe yourself? Asian Is
Selected
Q8 You said Asian, and what specific ethnic group are you, such as Filipino, Chinese, or
Vietnamese- and if you have more than one, write them all in.

Answer If Which one or more of the following you would use to describe yourself? Other Pacific
Islander Is Selected
Q9 You said you are Pacific Islander. Please write in the specific ethnic group you identify with.

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Appendix C: Semi structured Interview Guide
[READ TO PARTICIPANT] Thank you for taking the time to speak with me today. I’m going to
ask you a series of questions about your background as a peer health provider and your
experience providing care at [INSERT CLINIC NAME]. As a reminder, all of your responses will
be kept completely confidential. If you feel uncomfortable answering any of the questions I ask,
feel free to say “skip” and we will move on to the next question. You are free to stop the
interview at anytime.

I’ll begin by asking about your background as a Peer

(1) How long have you worked in the field as a peer?
a. How did you become involved as a peer at [clinic name and LA Innovations
program]
b. How long have you been a peer here at [clinic]

(2) What kinds of peer training or trainings have you had?
a. Here at [clinic name]?
b. Training from before you worked here?
c. Through Los Angeles County Department of Mental Health?

Next I’m going to ask you about your work specifically with the [LA Innovations program
name] at [Clinic name]
I’m especially interested in your role in delivering integrated health care in [name program]. The
following questions will focus on how integrated care is delivered, and your role in providing
integrated care.

(3) Please tell me about the services available through the [name LA Innovations model]
a. How does [LA Innovations model] connect clients with physical health providers?
b. What types of ‘Traditional’ (depending on cultural group being served by model)
does [LA Innovations model] connect clients with?
c. What types of wellness groups are available?

(4) In your role as a peer in the [innovations model], what part do you play in the above tasks?
a. What are some other examples of the ways you support clients in achieving their
physical health goals?
b. Do you have a caseload, and if so, what is the size of your caseload?
c. What is the extent of your involvement in team meetings?

I am especially interested in hearing about the things that help you provide integrated care and to
support clients in achieving wellness.

(5) In thinking about providing integrated care available through [LA Innovations model],
what types of resources are available at your clinic that support you in doing your job?

I am equally interested in hearing about the factors that make it DIFFICULT to do your job.
IMPLEMENTATION OF PEER PROVIDERS

122

(6) In thinking about providing integrated care available through [LA Innovations Model] what
are some things that make it difficult to do your job?
a. An example of a time when this affected your work?

(7) Earlier in my study, I learned that many programs have different ideas of the definition
of peer occurs at most LA Innovations clinics that have not successfully implemented
peers. What are your thoughts on this?

I am also interested in your role on the healthcare team at [LA Innovations Model], the ways in
which Peers participate in healthcare teams, and the ways that peers can connect consumers to
different health care systems; for example, connect consumers getting care in the mental health
system to a physical health provider.

(8) In thinking about working on an interdisciplinary healthcare team, what makes it easier to
work with other providers from various professional backgrounds?
a. On this team at [LA Innovations Model]
b. When helping consumers connect with providers at other health clinics

(9) In thinking about working on an interdisciplinary healthcare team, what are some factors
that make it more difficult to work with other providers from various professional
backgrounds?
a. On this team at [LA Innovations Model]
b. When helping consumers connect with providers at other health clinics
c. When talking with providers on either team, for example, when you want to make an
appointment for a client

(10) Is there anything else you think I should know about in terms of:
a. What makes it easier or difficult for peers to provide integrated are,
b. Working with providers from different professional backgrounds (either in [name
clinic]
c. On teams from other health care settings?
d. Final recommendations for how to improve [LA Innovations program] or
suggestions for future efforts for peers to provide integrated care?

IMPLEMENTATION OF PEER PROVIDERS

123
Appendix D: Qualitative Code Book
Peer background: when a respondent discusses what he or she did before becoming a peer
provider
 Lived experience with recovery: This can include any discussion of the peer provider’s
experience with Behavioral Health, Mental Health, or Physical Health recovery.
 Peer related trainings: The presence or absence of peer-based trainings
 Personal background: Personal background other than mental illness- examples include
losing a parent, etc.
 Professional background Peer’s professional credentials and any work that the
respondent did before becoming peer provider

Peer roles and responsibilities: Peer provider roles, responsibilities, tasks, and general job
description
 Case management
 Client engagement
 Client outreach
 Clinical work
 Collaboration with other agencies
 Group facilitation
 Motivating techniques

Involvement with physical health: this includes helping clients access physical health care
 Chronic disease management
 Weight-loss

Involvement with Innovations team: Discussion of involvement with other providers on the
LA Innovations team
 Perceptions of Innovations team
 Team functioning
o Team allies: discussion of people on their team they confide in, or confide in
them.
 Role of race in team functioning: discussion of race and racial dynamics as it relates to
team functioning.
 Relationship with program administration: Positive and negative relationship with
admin
 Conflict with team: Discussion of team conflict and resolution.

Description of innovations program
 Innovations program operations: discussion of how clients move through the program

Culture: Discussion of client culture, role of culture in delivering services
 Cultural understanding of mental illness
 Culture and healthy lifestyle
 Culture and trauma
IMPLEMENTATION OF PEER PROVIDERS

124
 Culture and treatment

Language:
 Language as it relates to client care
 Language as it relates to work with team
Becoming a peer provider: defined as becoming a peer provider at this particular location

Benefits of being a peer provider
 Benefits to self
 Benefits to team
 Benefits to client

Challenges in being a peer provider

Definition of peer provider
 Cultural peer: discussion of experience in relating with clients based on a shared ethnic
or cultural background- this could include discussion of having a shared racial
background
 Shared identity with clients: when a peer provider describes any part of a clients
identity or experiences that they relate with- for example, when UAII peer describes
relating with client in a DV situation.

Spirituality and religion: the role of religion or spirituality in recovery in general or in the daily
life of the respondent. Note that this includes all religions that are discussed during interviews (ie
discussion of Native American religious beliefs)

Stigma of mental illness: a peer provider’s experience with stigma, or their client’s experience
with stigma; or a peer provider’s experience of stigma.

Homelessness: A peer provider’s experience with homelessness, or their client’s experience of
homelessness.

Housing: the role of housing in the peer provider’s recovery, the recovery of their clients, or a
peer provider’s experience in getting their client housing.

Discussion of psyche medications: any discussion of psyche medications

Supervision: discussion of supervision that the peer provider receives on the job.

Abstract (if available)

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Asset Metadata

Creator Siantz, Elizabeth (author)

Core Title Implementation of peer providers in integrated health care settings

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 04/22/2016

Defense Date 02/22/2016

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health services research,integrated health care,mixed methods research,OAI-PMH Harvest,peer providers

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Henwood, Benjamin (committee chair), Baezconde-Garbanati, Lourdes (committee member), Palinkas, Lawrence (committee member)

Creator Email liz.siantz@gmail.com,siantz@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-240257

Unique identifier UC11279336

Identifier etd-SiantzEliz-4349.pdf (filename),usctheses-c40-240257 (legacy record id)

Legacy Identifier etd-SiantzEliz-4349.pdf

Dmrecord 240257

Document Type Dissertation

Format application/pdf (imt)

Rights Siantz, Elizabeth

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA