Perspectives on Peer Recovery Support for People Experiencing Homelessness: A Qualitative Study of Key Informants from National Health Care for the Homeless Programs

Abstract

Introduction:

People experiencing homelessness face high rates of opioid use disorder (OUD) with substantial barriers to treatment. Peer recovery support—delivered by individuals with lived experience of substance use and recovery—has emerged as a promising strategy for improving OUD care. However, little is known about peer recovery support within Health Care for the Homeless (HCH) programs.

Methods:

We conducted semi-structured qualitative interviews with 18 key informants from six stand-alone HCH programs across the United States, including program leaders (n=6), OUD clinicians (n=6), and peer recovery support specialists (PRSSs; n=6). Interviews explored perspectives on peer support roles, perceived impacts, implementation, and sustainability. We used an inductive approach for codebook development, and themes were developed iteratively, examining patterns within and across key informant groups.

Results:

Participants agreed that peer recovery support is highly valued and uniquely well-suited to the HCH context. PRSSs were viewed as critical to engaging individuals experiencing homelessness by building trust, addressing social needs, navigating fragmented systems, and providing harm-reduction-oriented, flexible support. Key implementation challenges included role ambiguity, training and supervision, workforce sustainability (risk of relapse and emotional burn out), structural constraints, and financing instability. Lack of sustainable funding was identified as a major threat to long-term program viability.

Conclusions:

Key informants perceived that peer recovery support enhances OUD care in the HCH setting through rapport building and practical supports tailored to the needs of people experiencing homelessness. Strengthening workforce infrastructure, clarifying role expectations, and developing sustainable financing mechanisms are critical to realizing the full potential of peer support within HCH programs.

1. Introduction

People experiencing homelessness face disproportionately high rates of opioid use disorder (OUD) and overdose mortality compared to the general population (Booth et al., 2023; Fine et al., 2022; Manhapra, Stefanovics, & Rosenheck, 2021; Tsai, 2018). Although medications for OUD (MOUD) substantially reduce overdose risk, treatment engagement and retention remain suboptimal—particularly among people experiencing homelessness who face stigma, trauma, unstable housing, and fragmented care (Carter, Zevin, & Lum, 2019; Fine et al., 2024; Fine et al., 2021; Sordo et al., 2017). These challenges underscore the urgent need for care models that can effectively engage and support this population throughout the continuum of OUD treatment.

Peer recovery support, or support delivered by individuals with lived experience of substance use and recovery, has emerged as a promising component of substance use disorder care (Eddie et al., 2019). Studies indicate that peer support may increase treatment linkage and engagement (Byrne et al., 2020; Deering et al., 2011; Mills Huffnagle, Brennan, Wicks, Holden, & Kawasaki, 2022; Smelson et al., 2013). Yet peer roles are highly heterogenous across programs and have rarely been tailored to the unique needs of people experiencing homelessness (Eddie et al., 2019). Guided by social support frameworks, peers can establish credibility, build trust, and provide practical and emotional support that complements clinical care (Substance Abuse and Mental Health Services Administration, 2009). These strengths may be especially important for patients experiencing homelessness, who often face mistrust of health systems and complex social barriers.

Despite the growth in peer services nationally, peer recovery support within health care programs serving people experiencing homelessness remains understudied. Questions persist regarding how peer support roles are defined and integrated, what unique contributions they may provide in the homeless health care context, and what barriers affect implementation and sustainability. To address these gaps, we conducted qualitative interviews with program leaders, OUD clinicians, and peer recovery support specialists from federally funded Health Care for the Homeless (HCH) programs across the United States to explore key informant perspectives on peer recovery support for OUD treatment in the homeless health care setting.

2. Methods

2.1. Study Design and Setting

We conducted in-depth qualitative interviews with key informants from stand-alone Health Care for the Homeless (HCH) programs across the United States to explore the benefits of and challenges with peer recovery support for opioid use disorder (OUD) treatment in the homeless health care setting. HCH programs are federally funded under Section 330(h) of the Health Resources and Services Administration (HRSA) Community Health Center Program. In 2024, 298 programs received HCH funding nationwide; 47 of these were stand-alone programs serving primarily people experiencing homelessness (Health Services and Resources Administration, 2025b). Key informants in our study included program leaders, OUD clinicians, and peer recovery support specialists (PRSSs). The study was approved by the MassGeneral Brigham Institutional Review Board and determined to be exempt under 45 CFR 46.104(d)(2).

2.2. Participant Recruitment and Sampling

In accordance with empirical estimates of sample sizes needed to achieve thematic saturation, we recruited participants from 6 HCH sites (including a program leader, OUD clinician, and PRSS from each HCH site) (Guest, Namey, & Chen, 2020). We used purposive sampling to identify HCH programs, ensuring representation across the five U.S. census regions and across tertiles of patient volume (small, medium, and large). We constructed a sampling frame using a publicly available HRSA database and then selected HCH programs to ensure inclusion of at least one program from each census region and at least one program from each patient-volume tertile (Health Resources and Services Administration, 2025a). When multiple eligible programs met these criteria, sites were randomly selected and invited to participate. If a site declined, another eligible program was randomly selected as a replacement.

Program leaders were identified through the same publicly available HRSA database (Health Resources and Services Administration, 2025a). If a contacted leader believed another leader could provide more relevant insights, we redirected outreach accordingly. To confirm eligibility, we asked leaders whether their organizations met the inclusion criteria: being a stand-alone HCH program and currently employing a PRSS. Using participant-driven recruitment, program leaders then referred us to an OUD clinician and a PRSS within their organization who could offer additional perspectives.

All participants provided verbal consent to participate in the study and received $50 remuneration for their time. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) in reporting study methods and findings (Tong, Sainsbury, & Craig, 2007).

2.3. Data Collection

Two trained study staff members conducted all one-on-one interviews between August 29, 2024, and February 19, 2025. One interview was conducted in person, 10 via video teleconference, and 6 by telephone, depending on participant preference and location. Interviews lasted an average of 42 minutes (range: 24 – 73 minutes).

Interviews followed a semi-structured guide designed to explore key domains related to peer recovery support in the homeless health care setting, informed by prior literature on peer-delivered interventions, commonly examined constructs in implementation science, and input from experienced clinicians and program leaders. Domains included awareness of and attitudes toward peer recovery support, perceptions of its impact, and sustainability. Additional topics – such as implementation of peer recovery support programs and experiences with hiring and working with PRSSs – were discussed exclusively with program leaders and OUD clinicians. While all participants were asked about sustainability, discussions with program leaders and OUD clinicians focused on programmatic sustainability, whereas PRSSs reflected on role sustainability. The interview guide was reviewed by 3 members of the National Health Care for the Homeless Council, who provided expert feedback prior to its use.

All in-person and telephone interviews were audio-recorded, and all video teleconference interviews were video-recorded. One recording was lost due to a technical error; for this interview, the study team relied on detailed notes taken by the interviewer. All other recordings were transcribed verbatim by a professional transcription service. Two study staff verified transcripts against the recordings, correcting inaudible or inaccurate words and phrases (McLellan, MacQueen, & Neidig, 2003). All edits were tracked and approved by the study team.

2.4. Data Coding, Analysis, and Interpretation

Our analytic approach followed the Framework Method, a systematic approach to qualitative data analysis (Gale, Heath, Cameron, Rashid, & Redwood, 2013). Three study staff members first familiarized themselves with the data by reading and re-reading a subset of 3 program leader transcripts to gain a broad understanding of the content. They inductively generated codes, organizing them by domains from the interview guide and by new concepts that emerged from the data. The study team then met to discuss initial impressions, organize the emergent codes, and draft the analytic framework. This process was repeated with subsets of 3 OUD clinician transcripts and 3 PRSS transcripts, refining the analytic framework after each round.

Two study staff then applied the draft codes to an additional subset of 3 transcripts (one each from interviews with a program leader, OUD clinician, and PRSS), documenting any newly emerging codes. We planned to repeat this process until thematic saturation was reached, defined a priori as the point when no new codes emerged (Guest et al., 2020). Thematic saturation was achieved after this round, and we considered the study cohort to be final at this point.

Using NVivo, two staff members independently coded transcripts in batches of 3. After each batch, we calculated interrater reliability by domain using Cohen’s kappa and resolved discrepancies through team discussion. For subsequent batches, we calculated kappas for any domains that had not yet reached our a priori threshold of 0.80. By the fourth batch, all domains met or exceeded this threshold, and the remaining transcripts were coded independently by one staff member (Cole, 2024).

We then generated a data matrix for each domain, sorted by participant and code. Matrix columns included key informant type, code, and a summary of the associated text, with each coded excerpt recorded as a separate row. Themes were then developed iteratively, examining patterns within and across informant groups.

3. Results

3.1. Participant Characteristics

We interviewed 18 key informants (6 program leaders, 6 OUD clinicians, and 6 PRSSs) across 6 stand-alone HCH programs. Programs represented all U.S. census regions (17% Northeast, 33% South, 33% Midwest, 17% West) and varied in patient population (33% small, 17% medium, 50% large) (Table 1). The mean participant age was 47.4 years (SD 12.5), and 56% were female (Table 2). Most participants identified as White (61%), followed by Black (22%), Asian (11%), and other (5%); 11% identified as Hispanic.

Table 1.

Health Care for the Homeless programs sampled for the study (n=6)

Program Characteristics	n (%)
Region
Northeast	1 (16.7)
South	2 (33.3)
Midwest	2 (33.3)
West	1 (16.7)
Patient population size
Small (≤ 2,681)	2 (33.3)
Medium (2,682–8,144)	1 (16.7)
Large (>8,144)	3 (50.0)

Table 2.

Characteristics of key informants (n=18)

Informant Characteristics	n (%)
Age, mean (SD)	47.4 (12.5)
Gender
Male	8 (44.4)
Female	10 (55.6)
Race
Asian	2 (11.1)
Black	4 (22.2)
White	11 (61.1)
Other (Latino)	1 (5.6)
Ethnicity
Hispanic	2 (11.1)
Non-Hispanic	16 (88.9)
Role
Program leader	6 (33.3)
OUD clinician	6 (33.3)
Peer recovery support specialist	6 (33.3)

3.2. Themes by Domain (Table 3 includes exemplar excerpts)

Table 3.

Themes on peer recovery support in the homeless health care setting with exemplar quotes

Peer Support Landscape
Peer support awareness is uneven but is accepted  P1 (Program Leader): “Yeah. I think for the most part, patients are pretty receptive to this…Once you explain it, I think people are very happy to have that support.”
Peer support is expanding  P10 (Program Leader): “From my understanding, at least in our local area… it’s becoming much more widely used over the past few years. Probably in just the past three years, it has grown quite a bit… becoming more of a best practice service.”
Programs are heterogenous across settings  P6 (PRSS): “Well, I think it’s going to look a little different depending on which part of the homeless healthcare umbrella the peer recovery specialist is under. Like I mentioned, we’ve got someone who’s going to be on the outreach team, and I think his day-to-day is going to look quite different from mine being in the respite program.”
HIV and mental health models legitimize integration  P15 (Program Leader): “We have all of the other types of services that use peer support staff…in the HIV Service, the Access Service…So we don’t have issues with justifying this type of professional because there are other services that uses this role.”
Peer support complements but is distinct from behavioral health counseling  P2 (PRSS): “I can say that therapy is one thing. Recovery coaching is another, right? Two different lanes. A recovery coach is going to connect with someone in a whole different way than a therapist is going to connect…”
Attitudes Toward Peer Support
Peer support is highly compatible with the HCH setting  P1 (Program Leader): “I think peer supports are particularly well-suited to the homeless healthcare setting because a lot of our patients are very vulnerable, very mistrustful of the healthcare setting and are often very difficult to engage for various different reasons, have a lot of comorbid mental health issues, history of trauma, and having somebody who is seen as from within their community is really invaluable in building trust, so.”
Patient receptiveness grows with understanding, but some variation remains  P16 (OUD Clinician): “When they [patients] kind of realize like, ‘Okay, this person has some credibility. They understand what I’m going through.’ There’s usually a pretty warm reception.”  P12 (OUD Clinician): “If they’re stable…they’re like, ‘Why do I need this? I’m doing just fine the way I am.”
Staff support grows with familiarity  P3 (Program Leader): “Once we were educated on what their particular position was going to be, I think everybody was pretty open to it. Knowing that it was a person that had gone through the program and gone through recovery, and then there was going to be a peer support for the client, we’re pretty excited about that.”
Peer support adds unique and highly valued contributions to addiction treatment  P13 (Program Leader): “We really value having a workforce that has lived experience of substance use. We really value the insights that they bring and the way that they’re able to build rapport.”
Approach to Care
Recovery should be individualized  P5 (Program Leader): “We really want the peer to be able to explore and lead by the patient, not by their own experience.”
Peers offer consistent, immediate, and flexible support  P1 (Program Leader): “They [PRSSs] will give the patient their phone number and say, “Give me a call if you’re having trouble,” and can be a sort of ongoing support who can help when there are problems.”
Peers destigmatize care through language and advocacy  P2 (PRSS): “I think we still got a long way to go, and that is breaking the stigma around it [opioid use disorder]…I prefer helping people that are struggling with opioid use disorder to help themselves break the stigma as well…It’s important to help break that stigma by changing the language.”
Meeting people where they are is central to care  P16 (OUD Clinician): “I am a huge proponent of going out into the streets and meeting people where they are, and especially with a peer support specialist and a MAT clinician. I think you can do amazing things out there and engage people that would not normally be able to be engaged.”  P8 (PRSS): “It’s just the main fact of being heard and being seen, someone willing to listen and just meet them where they are… not necessarily going and say, ‘This is what you need to change,’ but meeting them where they are and saying, ‘Okay. Well, let’s work with where you are and be able to move forward.’”
Types of Support
Liaison between patients and providers  P17 (OUD Clinician): “A peer can advocate for the patient to the provider, maybe step in and say, “Hey, well, we talked about this,” and kind of fill in the gaps. They’re very good and useful to be the go-between, a lot of times, maybe to relay information.”
Bridge to formal care  P10 (Program Leader): “And that’s another one of our goals with him [our PRSS] is to reach out to those who aren’t currently in treatment and help bring a comfortability about it, help potentially link them to the services we have, which a lot of that just starts with building a relationship and just being present and helping people feel just comfortable with him in their own environment within the shelter.”
System navigator and care coordinator  P1 (Program Leader): “…having somebody who is able to engage with patients, help them navigate the complex system is really useful.”  P14 (PRSS): “So I see all kinds of people here. And I can get you to dental. I can get you to medical. I can get you to the psych, to the therapist. I can get you on MAT services. I can outsource you because I network with all these different programs that are here, one, because I’ve utilized a lot of their services in my past, and I’ve needed them.”
Address social needs  P18 (PRSS): “They [patients] ask me a lot to getting a driver’s license, helping them sign up for disability, social security, and things like that. And driver’s license, social security, car, birth certificates, all of those have now entered my wheelhouse.”
Tangible supports  P11 (PRSS): “So transportation, I can help with. Here, we actually use Uber as a service to transport clients from home to the health center for their appointments. And it’s free of charge. They don’t have to pay for it…We also give out bus passes and things like that. If a client needs a ride and, typically, if we have something-- if we have something scheduled, I can do that. It’s no problem.”
Harm reduction  P6 (PRSS): “So right after introducing my role, I just say like, “This clinic operates on principles of harm reduction. Are you familiar with that at all?” And if they say yes, I can just kind of be like, “Okay. Great. Are there any safe-use supplies that you need?” I feel like I usually ask if people need supplies before I even talk to them about their chemical history because they’re not likely to be offended if they don’t need supplies.”
Mentorship grounded in lived experience  P8 (PRSS): “And then also just being a peer, helping set goals, doing weekly meeting on what goals are we going to move next as far as different accomplishments and where they can move forward to hopefully, in the end, they have stable housing, stable employment, just the basic day-to-day needs. And then just providing a listening ear if there’s someone just needs to vent about whatever, being able to guide and learn how to deal with things, like I said, without turning to substances to escape whatever it is that they’re going through.”
Group-based support  P6 (PRSS): “I’m going to lead various groups. Some of them would be like recovery groups. Some of them would be just entertainment, like a gardening club or an art class or things like that.”
Impact
Strengthened engagement and retention  P3 (Program Leader): “I think it helps with compliance. More likely to return and continue treatment knowing that peer support specialists here they can lean on…Once they get the first experience and it’s a positive one, then they keep coming back, and then they keep coming back for more positive experiences.”
Reduced provider burden  P5 (Program Leader): “We have so much system fatigue among staff because it’s so hard for our clients to navigate all these systems. And so it’s been, I think, a relief sometimes to have someone else who can help with that and has time set aside to do that.”
Plant seeds for change  P6 (PRSS): “I was worried they might think that I have some magic words that can make a person want to get sober and doesn’t quite work that way. I can help plant seeds. You never know what is actually going to be effective or is actually going to resonate with people. So you don’t always get to see the fruits of your labor.”
Contribution to broader outcomes  P18 (PRSS): “And anything we can do to help them with their medications or to help them with appointments and things like that, it’s going to keep them out of the ED.”
Implementation
Hiring process is challenging  P5 (Program Leader): “And then I think another piece of that is when we hired the peer we were told we couldn’t put experience on the job posting. And so we had to ask it in kind of a roundabout way.”
Training, supervision, and support are essential  P1 (Program Leader): “And then I think figuring out how to hire and train and develop staff working in this role is a challenge as well because there’s, like we were talking about before, less credentials, less of an infrastructure around training.”  P4 (OUD Clinician): “…if you were to hire four or five recovery coaches, you’d want to have a staff member…who understood that role-- or maybe a very, very experienced recovery coach-- but somebody who really understood the boundary issues, the kind of emotional issues, a lot of things about the challenge of that job, and was able to give people support and do training and just really help people in that role and help people sort of progress in their own sort of paths within that role.”
Clear role definition and scope remain areas for growth  P17 (OUD Clinician): “What I would say, a challenge I’ve had with certain people would be defining of roles - and I know it can be a touchy subject, and people can become offended - based on education or certification or whatever type of licenses an individual might have.”
Integration into existing workflows supports success  P10 (Program Leader): “Anytime someone starts a position and it’s a brand new position to the agency, it can be a little challenging developing workflows, making sure there is structure, that he knows what he’s doing throughout his day. So just getting that set up for the very first time wasn’t challenging. But just it did require thoughtfulness and a little bit more work upfront.”  P7 (OUD Clinician): “…there isn’t really a system of, at least here, kind of knowing who has peers, what a referral process is, how do we make that connection, and then beyond that, how we’re able to collaborate and support in the care for our mutual people.”
Funding is precarious and fragmented  P13 (Program Leader): “So I mean, we get usually single-time one or two-year grant funding that will help us to expand our workforce. A lot of the grants out there are about enhancement or expansion. They’re never about funding business as usual. And so once you have an AOD counselor or peer support or outreach worker, if they’re not rendering billable services, which they’re not, then their salary and benefits costs are overhead, in essence, that you can’t offset unless you have a grant or foundation or what have you that will help to offset it.”
Structural constraints are common challenges  P15 (Program Leader): “…we have a lot of limitations on space. And so every time we’re going to add to the treatment team-- and there are all kinds of people that want to rotate with us, do all kinds of things, and we’re like, “No, because we just can’t accommodate any more bodies.” So we are jam-packed with staff as it is. I mean, there is really nothing-- there’s not another individual that we can add to our treatment team.”
Workforce supply is insufficient, requiring strategic deployment  P17 (OUD Clinician): “I would imagine they’re probably very short-staffed in regards to what the actual need would be, how many peer support specialists is enough supply and demand.”
Ethical and recovery-safety considerations remain front-of-mind  P15 (Program Leader): “We would not hire someone with two-month sobriety. They’re going to be-- I think ours are usually years out, at least a year, probably more like in the two to five-year range for the reasons, the longer the track record, the likelihood that they will be able to remain sober in this environment. And we have had individuals in the role that have relapsed during work.”
Sustainability
Funding instability threatens long-term viability  P1 (Program Leader): “I think this would be important in having a more reliable, sustainable funding for them…Apply for more grants, is basically what we do for these kind of roles. And it is that these are valuable roles. And so we try as much as we can to supplement the grants with our budget, although that’s some years it’s easier than others.”
Reimbursement infrastructure remains underdeveloped  P4 (OUD Clinician): “I would say the fact that our state Medicaid program has not figured out a good way to bill for recovery coaching services means we just have to eat the cost or get a grant for it.”
Organizational commitment can buffer uncertainty  P13 (Program Leader): “Additionally, the other thing that I’d mentioned just on a side tangent is the organization always felt so strongly about these services that they just funded them.”
Demonstrating value drives continued investment  P15 (Program Leader): “And we prove our work by prevention. So the prevention of hospitalizations, prolonged use of services…Those are the markers that help us to continue getting the funding that we need to provide with comprehensive services, which include the peer navigators.”
Workforce sustainability is critical  P18 (PRSS): “It’s mentally draining. I think when you’re helping someone else all day long, we have to remember to take care of ourselves.”
Peer Recovery Support Specialist Qualifications and Characteristics
Lived experience is foundational  P16 (OUD Clinician): “Because, right, I can tell you, clinically, textbook, what is going on in your brain, what the medication is supposed to do, what you’re supposed to feel. But I have no idea what it’s like and what those cravings are like and how hard it is to overcome those withdrawal symptoms. But when someone has that lived experience and they’ve been through it, there’s a whole different connection that’s made.”
Stable recovery and maturity underpin role readiness  P15 (Program Leader): “We tend to look for longer sobriety. We would not hire someone with two-month sobriety. They’re going to be-- I think ours are usually years out, at least a year, probably more like in the two to five-year range for the reasons, the longer the track record, the likelihood that they will be able to remain sober in this environment.”
Cultural and community alignment fosters trust  P7 (OUD Clinician): “I think if the person is from the community, like lived experience, shared experience… whether it’s racial, cultural, or the geographic community, I think.”
Baseline training is prerequisite for the role  P17 (OUD Clinician): “The street-level understanding that a peer has is great. But I think when you’re able to combine it with the education of drug trends and other things that are going on, and just some of the techniques that we practice, it can advance them to another level in regards to their usefulness and ability to help the patients that we serve.”
Knowledge of local systems enhances impact  P10 (Program Leader): “I think preferably, they would also have utilized some resources in their path to recovery so that they are then able to have a background and share that with others.”
Motivation to give back fuels resilience  P11 (PRSS): “I like doing it because it’s what has kept me-- it’s helped me to reconnect to who I really am. And I know it works. And so I want to share that with other people who are open to what that offers. But it’s very rewarding. I love it.”
Interpersonal qualities matter  P1 (Program Leader): “I think we’re really lucky to have a person in that role in our clinic who’s really personable and really engaging and does a really great job of engaging with people and keeping connected to them…I think being dynamic, engaging, I think, is really important.”

Domain: Peer Support Landscape.

Peer recovery support is expanding and increasingly viewed as an important component of addiction care, drawing legitimacy from established models in HIV and mental health, yet variation in awareness and peer support models remains across settings.

Peer support awareness is uneven but accepted.

Participants reported that peer recovery support awareness varied widely across patients and providers. Some described patients and staff members as initially unfamiliar with the role or confused by differing titles across agencies, such as “recovery coach” versus “licensed drug and alcohol counsellor,” but generally receptive once the role is explained. Despite this uneven starting point, once introduced, peer support was consistently described as well-accepted and valued.

Peer support is expanding.

Participants emphasized a steady increase in peer support in recent years, with more hiring and expansion across care settings. Program leaders and OUD clinicians described peer support as newer but increasingly seen as a “best practice” for substance use disorder treatment. However, several noted that peer support is still a small or developing component of services provided by their organization.

Programs are heterogenous across settings.

Participants highlighted wide variation in peer support models, with differences in scope, size, and integration across systems and care settings. OUD clinicians reported that the level of “professionalization” or integration of peer recovery support specialists may differ across systems. PRSSs and program leaders described how roles adapt to specific clinical settings. For example, peers in the outreach setting often emphasize harm reduction and engagement, while peers in the clinic setting often provide medication support, benefits navigation, and coordination of care.

HIV and mental health models legitimize integration.

Several participants compared addiction peer support to longstanding models in HIV and mental health care, noting that these established peer roles provide important precedents for integrating peer recovery support into the HCH addiction treatment setting.

Peer support complements but is distinct from behavioral health counselling.

Across informant types, participants emphasized that peer recovery support provides a different yet complementary function to behavioral health counselling. PRSSs meet frequently with patients to address day-to-day challenges and reinforce recovery goals, while therapists focus on structured trauma or mental health treatment. PRSSs were clear that crossing into counselling could cause harm or blur professional boundaries. Program leaders and clinicians agreed that maintaining this distinction strengthens care coordination—allowing peers to extend the reach of behavioral health services without duplicating or replacing them.

Domain: Attitudes Toward Peer Support.

Peer support was broadly viewed as a good fit for the HCH setting, with patients and staff valuing the unique relational support that PRSSs bring to addiction care for people experiencing homelessness.

Peer support is highly compatible with the HCH setting.

Peer support was described as particularly well-suited to the needs of people experiencing homelessness because it helps overcome barriers common to this population. Program leaders and OUD clinicians often highlighted system-level benefits such as reducing mistrust in health care and engaging hard-to-reach patients. PRSSs themselves emphasized how their lived experience and flexibility align with the immediate needs and realities of people experiencing homelessness.

Patient receptiveness grows with understanding, but some variation remains.

Most participants reported that patients respond positively once they understand the PRSS role. However, a few participants did note that some patients do decline participation if they feel stable and self-sufficient with regard to their recovery. PRSSs emphasized that their firsthand experience with recovery reassures patients that their guidance is authentic and relevant, making them more willing to “buy in.”

Staff support grows with familiarity.

Staff were widely described as receptive or enthusiastic once the PRSS role was explained. They valued workload relief, patient engagement, and unique insights from peers. However, one OUD clinician noted occasional tensions when individual PRSSs’ views conflicted with clinical priorities.

Peer support adds unique and highly valued contributions to addiction treatment.

Across informant roles, peer support was viewed as especially valuable due to PRSS’ relatability and their ability to build rapport in a way that traditional providers cannot.

Domain: Approach to Care.

Regarding the philosophy behind peer support, participants described an approach to care grounded in individualized, flexible, and non-stigmatizing support that prioritizes patient-defined goals and immediate needs.

Recovery should be individualized.

Participants emphasized that recovery must be individualized and defined by the patient rather than by programs, providers, or the PRSS’s own experience. PRSSs stressed the importance of respecting patients’ goals, noting that pushing certain recovery paths can be counterproductive. This patient-driven framing counters the rigidity of many treatment organizations, which often treat abstinence as the correct way, leaving patients who are not ready or able to stop their drug use feeling alienated.

Peers offer consistent, immediate, and flexible support.

Participants described availability as a hallmark of peer support, setting it apart from more traditional provider-patient relationships. PRSSs can provide frequent or even daily touchpoints, respond to crises in real time, and facilitate warm handoffs. This consistency reassures patients that support is present when challenges arise.

Peers destigmatize care through language and advocacy.

PRSSs and OUD clinicians emphasized that PRSSs reduce stigma by modelling respectful, non-stigmatizing language. PRSSs were also described as important advocates for patients facing stigma within health care settings and society more broadly.

Meeting people where they are is central to care.

Across informant types, PRSSs were valued for their ability to meet patients where they are, both physically (encampments, shelters, mobile units) and in terms of recovery readiness. This approach was seen as critical to reaching individuals who are often disconnected from and mistrustful of traditional health care.

Domain: Types of Support.

Participants described PRSSs as providing a wide range of support services that help patients engage in care by serving as a liaison and navigator, building trust through practical and harm-reduction assistance, and motivating recovery through mentorship grounded in lived experience.

Liaison between patients and providers.

PRSSs were described as essential intermediaries who bridge communication and trust between patients and clinical teams. They help patients articulate needs they might not voice to clinicians and help providers understand the contextual realities shaping behavior. OUD clinicians credited peers with improving therapeutic alliance, recognition of when patients fall out of touch, and follow-up.

Bridge to formal care.

By meeting people in shelters, encampments, and community spaces, PRSSs engage individuals often disconnected from the health care system and facilitate entry into more traditional care settings. PRSSs often accompany individuals directly to clinics—making the first step feel safe and familiar.

System navigator and care coordinator.

Participants consistently described PRSSs as critical guides through fragmented care systems—across detox, MOUD programs, and specialty services. They often accompany patients to appointments and the pharmacy to pick up medications, and they help problem-solve around barriers to care.

Address social needs.

PRSSs address the social determinants of health that commonly impede treatment engagement: helping patients take the necessary steps to securing identification, benefits, housing, employment, and education. PRSSs describe these tasks as essential entry points for building trust and rapport, often beginning their meetings with these types of tangible needs before turning to recovery discussions.

Tangible supports.

PRSSs also assist with transportation and provide food, hygiene kits, phones, and other essentials. OUD clinicians and program leaders viewed these efforts as foundational, describing how addressing these basic needs created the stability required for patients to participate meaningfully in treatment.

Harm reduction.

PRSSs distribute harm-reduction supplies and provide safer-use education, using these interactions to build rapport with people not yet ready for treatment. A few clinicians noted more limited harm-reduction involvement in their settings.

Mentorship grounded in lived experience.

PRSSs provide one-on-one mentoring that blends goal setting, encouragement, role modeling, and practical coaching rooted in shared lived experience.

Group-based support.

Peer-led groups were viewed as valuable for fostering connection and shared accountability, though participation challenges among highly mobile populations led many programs to rely more heavily on one-to-one interactions. Informal activities, such as community outings or art groups, were also described as helpful for promoting recovery-oriented engagement.

Domain: Impact.

Participants described peer support as having meaningful effects on patient engagement, provider capacity, and broader health outcomes.

Strengthened engagement and retention.

Program leaders and OUD clinicians highlighted that patients often credited PRSSs as the reason they entered treatment and the reason they stayed. A key mechanism discussed was stress and anxiety reduction. PRSSs helped patients manage frustration and feel more comfortable which in turn supported both initial engagement and long-term retention.

Reduced provider burden.

Participants reported that PRSSs take on tasks that reduce strain on clinicians, from outreach and follow-up to spending extra time with patients and even helping with administrative needs. This redistribution of responsibilities freed up providers while ensuring patients received consistent support.

Plant seeds for change.

Many PRSSs described their work as incremental — “planting seeds” that may take time to grow. Even when results were not immediately visible, small, consistent actions were seen as building trust and instilling hope, which laid the groundwork for future progress in recovery. One program leader echoed this view, framing peers as “instilling hope” that sustains patients over time.

Contribution to broader outcomes.

Participants credited peer recovery support with a range of additional impacts, including improved mental health (e.g., reduced suicidal ideation), better prenatal care engagement, reduced overdose risk, and lower ED use and health care costs. PRSSs were also described as supporting abstinence and helping shorten relapses when patients did return to use.

Domain: Implementation.

Participants described several key components needed for successful peer support implementation in the HCH setting, including thoughtful hiring, training, and support, clear role structure, integration into clinical workflows, adequate resources, and attention to ethical considerations.

Hiring process is challenging.

Program leaders and OUD clinicians described the tension in hiring candidates with lived experience of substance use while navigating human resources policies that prohibit explicitly asking about substance use history. Screening for recovery stability and position “fit” was often difficult, and the process could be slow and resource-intensive due to high applicant no-show rates. Some programs relied on word-of-mouth referrals or prioritized candidates with more years in recovery to mitigate these challenges.

Training, supervision, and support are essential.

Participants described the need for baseline training in core skills (e.g., motivational interviewing, trauma-informed care), consistent supervision to prevent burnout or relapse, and continued professional development as foundational to successful implementation. PRSSs stressed the importance of supervisors with lived experience, alongside access to therapy and structured self-care supports. Program leaders described building structures such as weekly supervision, team case discussions, and professional development.

Clear role definition and scope remain areas for growth.

Participants described a wide variation in caseloads, tasks, and responsibilities across organizations. Within organizations, participants highlighted that without clear boundaries, PRSS duties can drift into case management or overlap with counseling and social work. Program leaders and OUD clinicians noted that standardized role descriptions, workflows, and onboarding toolkits would maximize PRSS functionality and reduce confusion among care teams.

Integration into existing workflows supports success.

Participants described embedding PRSSs into existing clinical workflows as being essential for success. Integration into existing workflows allowed PRSSs to engage patients at critical touchpoints and build continuity across care. In less developed models, unclear referral pathways led to underutilization and coordination challenges.

Funding is precarious and fragmented.

Funding emerged as a major barrier across organizations, with participants consistently describing peer support financing as precarious and piecemeal. Most programs depended on short-term grants, while others described drawing from opioid settlement dollars, safety-net hospital funds, or donor contributions. Participants emphasized that the true costs of peer support extend well beyond PRSS salaries to supervision, space, and supplies.

Structural constraints are common challenges.

Physical space was cited as a major barrier, with limited rooms and crowded clinics making it difficult for PRSSs to meet privately with patients. In addition, billing systems for PRSS work were described as non-existent or misaligned with the short, frequent encounters that define peer support.

Workforce supply is insufficient, requiring strategic deployment.

Participants highlighted that the demand for PRSSs exceeds the available workforce. Programs often aim to match PRSSs with patients based on shared experience or gender to strengthen rapport, but this is not always feasible. Additionally, because of the insufficient workforce supply, PRSSs are often deployed strategically—with high-volume or high-risk settings like MOUD clinics and street outreach teams taking priority.

Ethical and recovery-safety considerations remain front-of-mind.

Program leaders and OUD clinicians worried about relapse risk, and PRSSs acknowledged triggers in environments where substance use occurs. Boundary challenges were also raised, including PRSSs knowing patients from past circles or even using with them.

Domain: Sustainability.

Participants emphasized that in addition to stable funding streams, including reimbursement structures, sustaining peer support programs requires organizational commitment, meaningful evaluation, and support for PRSS workforce wellbeing.

Funding instability threatens long-term viability.

Even after programs become established, participants described sustainability as uncertain and reliant on short-term grants or temporary workarounds such cross-subsidizing from MOUD or behavioral health programs. Unlike during the implementation phase, where limited funding impacts program rollout, here the concern was whether programs could survive beyond the initial grant cycle. Without reliable funding streams, peer roles remain vulnerable despite broad recognition of their value.

Reimbursement structures remain underdeveloped.

Participants emphasized that insufficient billing mechanisms are a major barrier to sustainability. Relationship-based encounters—often brief, frequent, and occurring outside traditional settings—do not align well with existing reimbursement structures. Some programs are experimenting with billing for group service or leveraging emerging state policies, but most noted that reimbursement remains insufficient to support program growth or stability. Program leaders noted that when peer support work cannot be billed, it is devalued compared to other clinical roles, creating inequities in staffing priorities.

Organizational commitment can buffer uncertainty.

In some programs, strong leadership support has enabled programs to withstand funding gaps. Several program leaders described decisions to preserve peer roles despite budget pressures, reflecting a belief that peer support is integral to care. These examples illustrate how sustainability depends not only on external financing but also on internal prioritization.

Demonstrating value drives continued investment.

Participants consistently emphasized the need for evidence to sustain programs. Organizational and external funders look for metrics such as treatment retention, reduced emergency department utilization, and prevention of hospitalizations. At the same time, PRSSs cautioned that traditional metrics often overlook the incremental benefits that are core to peer support.

Workforce sustainability is critical.

Maintaining a stable PRSS workforce was viewed as essential to long-term program continuity. Program leaders and OUD clinicians noted challenges with turnover, often linked to relapse or emotional strain. PRSSs described the work as deeply meaningful but emotionally demanding, particularly when witnessing overdose deaths or supporting patients during crises. Strong supervision, supportive work environments, and protected time for self-care were identified as key to sustaining the workforce.

Domain: PRSS Qualifications and Characteristics.

Participants emphasized that effective PRSSs pair lived experience with readiness, cultural alignment, training and knowledge, and interpersonal strengths that support trust-building, credibility, and stability.

Lived experience is foundational.

Across informant groups, personal experience with substance use and recovery was viewed as essential for establishing trust and credibility. Several participants noted that having experienced homelessness—while not required—deepens understanding of patients’ social realities.

Stable recovery and maturity underpin role readiness.

Participants described recovery stability and emotional maturity as prerequisites for role success. Program leaders often referenced 1–3 years of sustained recovery as a common benchmark, though PRSSs noted that readiness varies by individual. Several leaders noted that difficult past experiences—such as staff relapse—had shaped organizational caution around hiring peers too early in recovery. Program leaders and OUD clinicians acknowledged a tension between hiring a “true peer” with very recent recovery and a “near peer” with more distance from substance use—balancing authenticity with role stability.

Cultural and community alignment fosters trust.

Matching peers to the cultural, racial, linguistic, geographic, and socioeconomic identifies of the population served was viewed as important. Cultural alignment was described as more than demographic similarity—it required a deep understanding of community norms, language, and systemic barriers that shape patients’ experiences.

Baseline training is prerequisite for the role.

Program leaders viewed training in areas such as motivational interviewing, trauma-informed care, and ethics as essential for translating lived experience into professional practice. Certification and ongoing skill development signaled preparedness and helped PRSSs navigate complex clinical environments.

Knowledge of local systems enhances impact.

Program leaders and OUD clinicians consistently noted that familiarity with local recovery, housing, and legal systems improves PRSS effectiveness. PRSSs echoed this perspective, describing that knowing how to navigate these systems strengthens their ability to advocate for patients.

Motivation to give back fuels resilience.

PRSSs described themselves as being motivated by gratitude and a desire to “give back” to their communities. Program leaders and OUD clinicians recognized this intrinsic motivation as a defining strength that fosters empathy, persistence, and emotional resilience.

Interpersonal qualities matter.

Beyond experience and training, participants emphasized interpersonal qualities, particularly being engaging, personable, and wise, as defining characteristics of highly effective peers.

4. Discussion

In this qualitative study of key informants from HCH programs across the United States, we found broad consensus that peer recovery support is highly valued and crucial to engaging people experiencing homelessness in OUD treatment. Participants described peer support as uniquely aligned with the needs and realities of this population—helping individuals overcome mistrust in health care, navigate fragmented systems, and remain engaged in treatment. Yet despite the clear perceived benefits, programs face persistent barriers to implementation and long-term sustainability. These findings highlight both the promise of peer recovery support in the HCH setting and the systems-level changes needed to support widespread and sustained implementation.

Consistent with prior research in mental health and HIV care, where peer support has been established as an effective adjunct to clinical services (Berg, Page, & Ogard-Repal, 2021; Smit et al., 2023), participants emphasized that peer support enhances OUD care in HCH programs by filling relational and practical gaps that traditional clinical roles cannot. PRSSs lived experience, ability to build trust, and flexibility to meet patients “where they are”—physically and emotionally—were viewed as critical for engaging individuals who often face stigma, trauma, unstable housing, and fragmented care. Our findings extend the broader peer support literature by demonstrating that peer support may be particularly well suited to HCH settings, where flexible engagement, harm-reduction grounding, and intensive system navigation are central to delivering effective addiction care.

At the same time, participants identified several implementation challenges that must be addressed to support effective peer integration. Workforce challenges included recruiting peers with sufficient recovery stability and role readiness and ensuring that training includes core competencies such as motivational interviewing, trauma-informed care, and professional ethics. Ongoing supervision—ideally from a supervisor with lived experience—was viewed as essential to support PRSSs’ emotional well-being. Role clarity was also a key need. Programs with defined workflows and strong team integration reported smoother implementation, whereas less structured environments experienced confusion or overlap with case management and behavioral health roles. In addition, patient-level barriers (e.g., unstable housing, phone loss, transportation challenges) and structural limitations (e.g., lack of space, high demand exceeding staffing) constrained service delivery.

Perhaps the most consequential barrier to sustained implementation was financial instability. Programs were frequently reliant on short-term grants, opioid settlement dollars, local safety-net funds, or private contributions, leaving little ability to plan or grow the workforce. Participants emphasized that sustainable financing must cover not only PRSS salaries but also supervision, training, workspace, and supplies—costs that grants rarely include. Though many states have introduced Medicaid billing options, variation in coverage, restrictive billing and documentation requirements, and low reimbursement rates make it difficult to sustain the intensive, flexible, and relationship-based work that peers provide (Substance Abuse and Mental Health Services Administration, 2024). Participants noted that when peer services cannot be billed or are reimbursed at low rates, they are devalued relative to more reimbursable roles, threatening workforce retention and the long-term sustainability of peer programs.

Our findings have clear policy implications. First, there is a need to strengthen peer workforce infrastructure, particularly in HCH programs that rely on peers to facilitate engagement in care. Standardized credentialing, access to continuing education, and development of career ladders could reduce turnover and promote professional growth. Supervisory models that include leaders with lived experience may improve PRSS well-being and role success. Second, role definitions and expectations should be well-defined, ensuring clarity in interdisciplinary HCH care teams. Clear role descriptions, core competency expectations, and structured onboarding processes could help ensure that PRSSs complement—rather than duplicate—other team members. National guidance could support alignment across programs. Finally, sustainable reimbursement and financing are needed to reflect the frequency and intensity of peer encounters required to engage people experiencing homelessness. States could expand Medicaid reimbursement using flexible structures already applied to community health workers or case management. Demonstration projects under CMS waiver authority could test models aligned with relational care delivery (e.g., monthly case rates, bundled payments, value-based arrangements tied to engagement or retention). HRSA could clarify how Section 330(h) funding could support peer workforce development, and states could support multiyear financing strategies rather than short-term pilot programs. Strengthening these structures, particularly within HCH programs, is critical to advancing equitable access to OUD treatment for people experiencing homelessness.

Our study has limitations. Although we recruited a geographically diverse sample, findings may not reflect the experiences of HCH programs without prior peer support experiences, those that previously used peer support but no longer do, or those embedded within larger community health centers. In addition, the study was designed to explore themes related to peer support in the HCH setting overall rather than to support comparisons across state policy environments. As such, we were unable to formally examine how variation in state-level funding and regulatory contexts may shape PRSS implementation. Future research with intentional policy-based sampling could more directly assess how differing state environments influence role definition, financing mechanisms, and program sustainability. Participants may also have been more supportive of peer roles than non-participants, and we did not include patient perspectives in this particular analysis. However, the convergence of views across program leaders, OUD clinicians, and PRSSs supports the credibility of our findings, and the multisite design provides insight into common challenges across varied organizational contexts.

5. Conclusions

Peer recovery support is perceived as being critical resource for improving OUD treatment engagement among people experiencing homelessness. Participants across informant groups emphasized that peers offer relational, practical, and harm-reduction-oriented support that traditional providers cannot. To fully realize this potential, HCH programs need stronger workforce supports, clearer role infrastructure, and sustainable financing and reimbursement pathways. As states invest opioid settlement funds and expand Medicaid coverage for peer services, strengthening peer support implementation within HCH programs offers a timely opportunity to advance health equity and improve OUD care for structurally marginalized populations.

Data statement

De-identified data supporting the findings of this study are deposited in the Harvard Dataverse repository. Access to the dataset will be made available upon reasonable request to ensure appropriate use and interpretation. Researchers interested in accessing the data may contact the corresponding author to discuss data-sharing arrangements. https://dataverse.harvard.edu/dataverse/drfine_interviews