High-touch care advocacy teams support individuals through the recovery journey

Yesenia Gutierrez is Regional Associate Director of Behavioral Health Care Coordination & Advocacy, Optum. Tracy Sanders is Senior Product Director at UnitedHealth Group.  Tiffany Woods is Director of Quality Improvement at Optum.

UnitedHealth Group’s high-touch care advocacy program provides consistent support for Medicaid members living with serious mental illnesses or moderate-to-severe substance use conditions. These individuals experience barriers that make it difficult for them to engage in consistent outpatient care, including MAT (Medication Assisted Treatment). The program is run by UnitedHealth Group’s Optum division and is available to Community & State markets in which behavioral health services are administered by Optum. The program pairs a certified peer support specialist with a behavioral health care advocate to work as a team to engage individuals who have three or more admissions to the emergency room or higher levels of care within six months.

High-touch care advocacy teams offer person-centered care to aid in the recovery journey in ways that work for an individual. The program focuses on building trust and rapport while creating compassionate care experiences that deliver evidence-based interventions reflecting each person’s unique needs and preferences. The certified peer support specialist is an individual who has been successful in the recovery process and can leverage their life journey and experiences. Through one-on-one interactions in the field, the specialist learns an individual’s story and needs. The peer support specialist collaborates with a behavioral health care advocate to identify the appropriate resources to meet these needs. The care team works together to provide encouragement and information about community services and support that can assist with engagement and treatment to improve health outcomes.

High-touch care builds trust and relationships

In 2021, nearly one in three adults and 46% of young adults 18-25, had either a substance use disorder or a mental illness.¹ People experiencing both severe mental illness and a substance use disorder often have complex health needs including multiple comorbidities, more difficulties with daily living and a higher likelihood of premature death.²

People might not receive care for serious mental illness or substance abuse because they are unsure of how to navigate the care system or they lack regular access to care. Social drivers of health — including housing, food security and transportation — can greatly impact health and the ability to receive consistent care and support.

Peer support specialists can help close these gaps and improve the reach of clinical care and social support into the everyday environment of individuals. Peer support specialists work with individuals to encourage and promote the use of appropriate outpatient services, medication adherence and offer resources to improve social drivers of health.

Candidates for peer support are identified through health record data and referrals from hospital admissions reports. Referrals can also come from behavioral health case managers or our health plan, team members and colleagues. In one recent program success story, a 50-year-old individual with a history of schizoaffective disorder, hypertension, substance use, diabetes and depression was experiencing homelessness. He was referred to peer support services due to his high use of ER services and a lack of participation in both physical health appointments and behavioral health treatment. He expressed the need for a place to shower and stable housing to sleep safely and had no family connections due to loss of contact because of his addiction. Before connecting with a peer support specialist, the individual was nonresponsive to phone calls about 30% of the time and difficult to contact.

A peer support specialist and a clinical behavioral health care advocate met weekly to discuss the individual’s strengths and challenges. Together, they discussed local housing opportunities as well as navigation services and other resources. The peer support specialist also met with him during an inpatient stay in the facility. The peer support specialist listened to the individual’s recovery story, conducted a strength assessment and documented his needs and desires for his life.

Once the relationship was established, the care team had a better success rate of reaching the individual, both by phone and face-to-face. Currently, he’s living in stable housing. He’s taking his medications, keeping medical appointments, attending a support group and working on pain management. His relationship with the peer support specialist will continue until he feels he has the support he needs and is confident in his ability to follow his care plan.

Peer support in health care shows promise

UnitedHealth Group has certified peer support specialists in 14 states. Over a 12-month period, peers engaged 1,500 high-acuity behavioral health individuals. Compared with individuals who qualified but were not enrolled in the program, data shows that outpatient visits are up among program participants, while inpatient admissions and ER visits have decreased. In addition, medication adherence and Mars-12 assessment scores have improved. Mars-12 assessment scores gauge how an individual feels about their recovery process and their confidence about getting back on track given a possible relapse.

There are many applications for peer support including for youth and adult mental health and for specialty populations – such as individuals with intellectual and developmental disabilities in recovery from addiction. We’re committed to expanding our expertise and innovation in the use of peer support through more training, expanding access to special populations and providing employment paths for this growing health care field.