On July 27, 2021, Michaela Fissel received a letter from Connecticut House Speaker Matthew Ritter informing her that she was appointed to a new legislative task force created during the legislature’s 2021 push to address the mental health of Connecticut’s citizens in the wake of the COVID-19 Pandemic.
As part of the General Assembly’s top priority bill – Senate Bill 1, a massive bipartisan bill aimed at addressing comprehensive mental health services – the legislature created the Peer Support Services Task Force to “examine available methods for delivering, certifying, and paying for” peer services.
In the mental health community, “peers” are individuals who have experienced mental illness or addiction and, after going through recovery and enrolling in a training program, use their experiences to help others facing similar issues. Peer support has been shown to be an invaluable resource in helping individuals work through mental health and addiction issues and can help ease the burden placed on clinical mental health services like hospitals.
The problem, however, is that it is nearly impossible for those peer specialists to receive reimbursement for their work through insurance or Medicaid in Connecticut. There is no uniform state standard for training, testing and certifying peer specialists in the state, and no reimbursement mechanism. Insurance companies are not required to pay for them, and the state doesn’t allow for peer services to be billed through Medicaid.
Peer specialists who do receive payment, receive income through the nonprofit organizations they work for, often with grant money those nonprofits have to raise. That also means that funding for peer services is constantly an issue.
The creation of the Peer Support Services Task Force was seen as a crowning achievement for those in the mental health nonprofit community, who had been lobbying for years to make peer services reimbursement a reality in Connecticut –- Michaela Fissel was one of those people.
As head of Advocacy Unlimited, one of the several organizations that trains peer specialists in Connecticut, Fissel saw the task force as a unique opportunity for those with lived experience in the realms of mental health and addiction. According to the legislation, at least 50 percent of the task force would be comprised of individuals with lived experience, including herself.
“The thing about the task force though is that it’s actually the first task force in the United States that appointed the majority people as having direct lived experience with mental health and addiction challenges,” Fissel said. “There has never been a task force created, to my knowledge, in the United States that has ever appointed the majority of seats to people with lived experience.”
Several other appointments were made to the 10-member task force, which was given the responsibility of authoring a report regarding a certification and reimbursement model for peer specialists. The deadline was either January 1, 2022, or whenever the task force completed its study.
But the January 1 deadline came and went without a single meeting of the task force. Although some appointments were made, the task force was never fully appointed, never convened and appears quickly forgotten about by all but those directly involved in peer services. No one seems entirely sure what happened, other than legislative leaders failed to make the necessary appointments.
“The story I heard is that there were appointments made to the task force but some people within the Connecticut legislature never followed through with the appointments they were supposed to make, so the board was never fully formed,” said Jeffrey Santo, a peer specialist who runs a group called Recovery Innovations Pursing Peer Leadership and Empowerment (RIPPLE).
Nicole Hampton, a peer specialist who recently ran for state representative, also says it came down to legislative leaders not forming the task force, despite having lists of people who met the criteria that Hampton helped put together alongside other advocates.
“I didn’t understand why the next legislative session nothing came up, no bill was introduced,” Hampton said. “I actually ran for state rep. this past year and in doing so I learned that the state reps create these task forces just to shut people up because they don’t want to pass the bill. That’s what I was told.”
Fissel, however, sees something different. She believes the task force is being blocked by the Department of Mental Health and Addiction Services (DHMAS), the state agency overseeing mental health and addiction funding and policy in Connecticut.
“In my opinion, based on the information I’m privy to, it appears the state is actually blocking the task force, DMHAS, is blocking that task force from actually getting started,” Fissel said.
Fissel points to two committees convened by DMHAS in conjunction with the Connecticut Certification Board (CCB), a nonprofit that handles certification for mental health services, including peer services, in Connecticut, and the Yale Program for Recovery and Community Health (PRCH), which conducts “research, training, evaluation and policy development in the areas of recovery from serious mental illness, substance use, citizenship, social inclusion, and health disparities and equity,” according to their website.
The committees’ job is to develop a statewide certification process for peer recovery support specialists, part of the job the legislature assigned to the Peer Support Services Task Force.
Essentially, some critics like Fissel believe the task force, which would have at least been half comprised of actual peer specialists to develop this new model, was being replaced by clinicians, academics and organizations that maintain a cozy relationship with DMHAS and bypassing the task force created in 2021 charged with developing a certification and reimbursement model.
“I have been involved in conversations related to peer reimbursement for going on six years and to work so hard to get a task force enacted through a legislative bill to then have the state come in and bypass that entire legislative process, it was a further slap in the face to people who have lived experience,” Fissel said. “It was really disheartening.”
There are currently three Peer Recovery Support training centers in Connecticut that are endorsed by DMHAS: Advocacy Unlimited, which focuses largely on mental illness; the Connecticut Community for Addiction Recovery’s (CCAR) Recovery Coach Academy, which focuses more on addiction; and Hartford Healthcare’s Recovery Leadership Academy, which offers training for both mental illness and addiction and further extends the “peer” label to family members of those affected by such disorders.
Graduates of these programs act as a supporting hand in mental health and addiction recovery, often bridging a gap in the mental health system, being able to relate to individuals experiencing these issues on a personal level and connecting them with the services they need to help in their recovery.
Some states, like Massachusetts, even offer Peer Respite Houses, where individuals can stay for periods of time to focus on their mental health outside of clinical settings. Critics say hospital behavioral health units are locked wards which can be coercive and frightening for those experiencing mental health issues.
These same peer recovery groups and organizations have also been trying to get the legislature to approve peer-run respites in Connecticut, to no avail as of yet.
Advocacy Unlimited operates its Bridger Program in which peer specialists provide “non-clinical support” to those affected by psychiatric, trauma or addiction issues. CCAR provides peer specialists in hospital emergency rooms for those who have been hospitalized for addiction issues and through the Department of Corrections, in which recovery coaches help incarcerated individuals’ re-entry into society by providing them access to “community providers and recovery support services.”
“Alcoholics Anonymous has been proving since 1935 that people with lived experience in recovery have something to offer one another and we can be a really crucial part in a person’s treatment and recovery,” Santo said. “We can form that bond of trust through common ground and lived experience, we can empathize with them and relate to them, we don’t judge them.”
Santo says that during the pandemic lockdown, he had over 20 individuals referred him for suicidal thoughts, the area in which he specializes as a peer support. The effects of the pandemic, as evidenced by numerous reports of overflowing behavioral health emergency rooms, a lack of inpatient psychiatric beds, therapists and other providers, essentially took Connecticut’s already struggling mental health system and stretched it to its breaking point.
The goal of Senate Bill 1 was to address some of those shortcomings, with a particular focus on children and youth. And while it will take time for many of the initiatives in that bill to take effect, the failure of the Peer Support Services Task Force to even begin was not a great start.
While peer recovery specialists are at work in the state of Connecticut, reimbursement for their services through insurance and Medicaid is non-existent, making some of these services more voluntary than professional.
“My late-night peer support group, it starts at 10 at night and runs till midnight and sometimes we go till three or four o’clock in the morning and I don’t work in the mental health field, I don’t make my living as a person supporting others,” Santo said. “I work in a plastics factory and basically live below the poverty line, so all the work I do in this community is purely volunteer because, like I said, there’s no mechanism to earn a living doing what I do. But I’ve had people come up to me and tell me that if it wasn’t for the groups and the fellowship we offered and the support we gave they wouldn’t still be alive.”
“A lot of people have been able to find employment in the mental health services system, the problem is peer level services are not reimbursable through insurance,” Santo said. “So, even though there have been more than a thousand graduates just through Advocacy Unlimited alone there really was never a mechanism put in place to get those people paid for what they’re doing.”
“If I was a case worker at Norwalk hospital, I could take someone out to Panera Bread, talk to them about their situation, try to find them services — whether its employment, housing, treatment — whatever. As that case worker I would be paid because my services are reimbursable through insurance,” Santo said. “If I walked up to the same person as a recovery support specialist, went to the same café and took them to lunch and said I’m going to connect you with this program, this program and this program, I’m going to have to go through 211, do a little bit of leg work, but we can get you into these services, my work is not reimbursable.”
In the wake of the task force’s failure to launch, however, DMHAS took it upon themselves to get the ball rolling in the right direction so that peer specialists, who they call Recovery Support Specialists (RSS), can be certified through a statewide set of standards, practices and testing, hopefully enabling recovery specialists to be reimbursed for their services outside of money raised by whichever organization they are affiliated with.
Advocates for peer recovery support specialists all wanted the legislative task force. The original bill that appeared before the General Assembly’s Insurance and Real Estate Committee was supported by the nonprofit community, the Connecticut Hospital Association, the Southwest Regional Mental Health Board and members of the public. Even the Connecticut Association of Health Plans requested a seat at the table.
This broad coalition was on board with the idea of a task force to establish certification and reimbursement for peer services. Obviously, that nearly unanimous support fell by the wayside at some point and DMHAS stepped in to establish statewide universal credentialing. DMHAS contracted with the Connecticut Certification Board to develop testing under the advisement of two separate committees, and that is where part of the criticism begins.
Fissel says it wasn’t long after the task force’s failure to be formed and convene that DMHAS announced it had contracted with CCB to become the certifying body for peer recovery support specialists.
“It has no transparency, it has very little inclusion of people with direct lived experience in terms of making that decision and it completely bypassed the legislature and the legislative process in terms of appointing a legislative task force and having the task force meet and make their recommendations,” Fissel said. “It just completely bypassed that and now DHMAS is running the show, and nobody is talking about it.”
DMHAS did contract with CCB, which received $130,500 in 2022 and another $117,000 so far in 2023, according to the state’s transparency website, although its not known if all those funds are related to the peer certification committees.
“They didn’t even put a request for proposals out, they never put this to bid, they just said, ‘here CCB we’re not only going to give you the money to do this work with PRCH, who is already part of the executive committee of the commissioner, but we’re going to also announce that you’re going to be the certifying body,’” Fissel continued. “It really further marginalized the voice of people who are in recovery from mental health and addiction challenges.”
Arthur Mongillo, a public information officer for DMHAS, says he knows little about the legislative task force or of its failure to convene, but says the agency had been in talks about developing a peer certification committee previously.
“I think it was already in the works, I’m not entirely certain. I know that we had been talking about doing this for a while,” Mongillo said, who also works for the Connecticut Certification Board as board vice-president and acting treasurer.
“The peer certification is somewhat different depending on what agency you go through, but we just want to make sure its standardized and it’s a clear pathway for folks to get certification. So, by working with the CCB to sort of work to administer that process, I think that helps not only create the clear path but sort of standardize this set of principles and competencies and code of ethics that are statewide,” Mongillo said.
DMHAS created two committees to develop the peer certification process: There is the Subject Matter Expert committee which includes CCB and will determine testing questions and core competencies, and there is the Advisory Committee, which examines how peer certification will be implemented and how it will affect peers currently working in the field.
Also added into the mix is that peer certification already exists in Connecticut through the CCB. Those who have received training through one of the peer training programs can test with CCB to become officially certified.
“In order to be certified it has to be third party, you can’t get the training and take the test from the same people. Everyone gets it confused. The only certification we have is through CCB,” Hampton said, who serves on DMHAS’s Advisory Committee. “I really don’t understand why we’re recreating the wheel, it’s very confusing. The CCB certification is legally defensible, it’s a true certification, its third party, you can get your training through CCAR, Advocacy Unlimited or Yale and then go get your certification at CCB.”
Santo is also currently serving on the Advisory Committee and believes that DMHAS “would love to see peers get reimbursed for the work they do because ultimately we take a tremendous burden off the current system,” but admits he also has reservations. “DMHAS has kind of done things that a lot of people have disagreed with in the past and they seem to sidestep procedure a lot,” Santo said.
Santo points out, as an example, the state’s Regional Mental Health Boards and the Catchment Area Councils (CACs) those boards oversaw. Originally, the CACs were supposed to meet weekly and be comprised of 51 percent consumers of mental health and addiction services. The idea was that bringing together consumers and officials would help identify systemic and provider problems more quickly to be able to address them.
However, in 2018, DMHAS reorganized the Regional Mental Health Boards with Regional Behavioral Health Action Organizations and, Santo says, the majority of the people at the table are now clinicians as opposed to consumers.
“We feel, at least in the peer community, that they’re trying to limit our voice as consumers,” Santo said, a criticism similar to that posed by Fissel regarding the peer certification committees. Essentially, there is a concern that people with lived experience and consumers of mental health and addiction services are having their voices drowned out in a process dictated from the top down.
Santo says he wasn’t originally on the Advisory Committee and said that when he reviewed the original eight members of the committee, he was concerned that a significant portion of the stakeholder population was being left out.
“I noticed something that was just kind of glaring in my mind,” Santo said. “Every single person they chose had a higher level of education, every person they chose was currently working in the field already and every single person that they chose lives above the poverty line so the advisory committee they put together failed to represent almost 80 percent of the people that the DMHAS service system cares for.”
Mongillo, however, says “the voice of lived experience is critical to everything we do, I think it has to inform every step of the process.” Mongillo also notes that they allowed individuals to apply for these committees.
“We put together these committees and we allowed folks to apply for them, the notices were on the website and also out on social media. The application process and the committee sort of did their work but I believe we encouraged people with lived experience to apply,” Mongillo said.
Mongillo also denies that DMHAS is attempting to sidestep the legislature through creating these committees after the task force failed to convene.
“I don’t think that was the intent,” Mongillo said. “I don’t think I know too much about the origins of the task force to really speak to that, but it doesn’t seem to me as sidestep. Every step of the process was well informed and open for folks to apply to these committees. I understand that people have criticisms of the process, and I think that maybe extends from concern about being shut out somehow, but really what we’re trying to do is create a pathway for more folks to enter the profession.”
But the committees being run by DMHAS are essentially taking on the work previously meted out to the Peer Support Services Task Force, and making their own determinations as to how it will all work.
“Even the committee I sit on, they’re taking the work we’re doing as suggestion,” Hampton said. “So, its not even like we’re determining stuff, they’re taking our thoughts and ideas and looking at it as a suggestion.”
Fissel, Hampton and others continue to wait for further appointments to the task force so they can determine how peer support specialists should be certified and reimbursed. But with a year now passed since the January 1, 2022, date, things don’t look to be moving at all.
Meanwhile, DMHAS’s two committees continue to meet and work out their suggestions by which peer specialists can be certified through a uniform standard. Mongillo says there’s no way to put a time estimate on when the committees will reach their conclusions and statewide certification can be put in place. It’s a complicated process.
“Obviously, there’s a need to be delivered here but a lot of that depends on the folks at the Connecticut Certification Board and their ability to get this up and running too,” Mongillo said.
If and when that uniform certification standard for peer recovery support specialists gets put in place, and if a reimbursement model can be achieved with or without the task force, the state may be able to save lives and potentially money by having a reimbursable peer program in place. Peer respite homes have been shown to decrease expensive hospitalization for mental illness in other states, and peer specialists could be utilized more often and effectively to aid in recovery.
“I’m confused why Connecticut is taking so long to make peer services billable,” Hampton said. “In thirty-nine other states, peer services are billable through Medicaid and Connecticut is supposed to be at the forefront of recovery, we’re supposed to be so far advanced of everybody but in reality we’re not because we don’t even have peer services billable in our state.”
Hampton points to Medicaid waiver 1115, to which the State of Connecticut applied and was granted the waiver in April of 2022. The State’s waiver application involves the use of peer services to support the state’s mental health services. Hampton says that waiver should enable Medicaid to be billed for peer support specialists.
“Here’s this waiver that supports peer services being billable in Connecticut but we didn’t even pass it in the legislature,” Hampton said.
The addition of certified, reimbursable peer recovery support specialists to Connecticut’s mental health system could likely not come at a more important time.
According to the Kaiser Family Foundation, the percentage of adults and youth experiencing anxiety or depressive episodes prior to the pandemic was roughly in line with the United States as a whole, 7.1 percent for adults and 14.4 percent for youth. Over the course of one week during the pandemic in 2021, however, adults reporting anxiety or depressive episodes was 28.7 percent, but actually lower than the national rate.
For substance addiction, however, Connecticut was ahead of the national average, with a significantly higher drug overdose death rate than the rest of the country and a higher rate of alcohol use disorder among adults and youth.
The need for outreach, services and help is at an all-time high and although the legislature sought to address that in Senate Bill 1, the failure to convene the peer task force for over a year means a longer delay to implementing potentially life-changing services for those in need.
“I know that in certain settings the peer recovery support specialists are critical in the emergency departments, engaging with people who have just gone through this, being there to walk alongside them with their own expertise, just gives them an expertise that is unmatched,” Mongillo said. “I definitely think that this is a benefit to the process, I think this will help get more people into recovery and that’s really the lowest common denominator, so to speak, we want to help shepherd people into recovery by whatever pathway they choose.”
Santo, however, has an even loftier goal: licensure. Licensing would give peer recovery support specialists like himself the ability to set up their own practice, getting out from under the umbrella of DMHAS, which in the past has suffered from budget cuts, and no longer requiring organizations like Advocacy Unlimited to fundraise in perpetuity to enable their programs.
“The ultimate goal should be going beyond certification, the ultimate goal should be licensure,” Santo said. “Right now, if we were to get a peer run respite tomorrow and we had all the infrastructure in place and the all the people trained to run it we would still be under the DMHAS umbrella because they would be funding us.”
“If people like me were able to get licensure rather than certification, we could bill for our own services directly to the insurance companies,” Santo continued. “We would be completely independent and self-sufficient which what ultimately we should be shooting for.”