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Published in final edited form as: Healthc (Amst). 2022 Jul 2;10(3):100641. doi: 10.1016/j.hjdsi.2022.100641

Integrating peer support services into primary care-based OUD treatment: Lessons from the Penn integrated model

Rebecca Arden Harris a,b,*, Kristen Campbell c, Tara Calderbank c, Patrick Dooley c, Heather Aspero c, Jessica Maginnis c, Nicole O’Donnell d, Donna Coviello c, Rachel French b,e,f, Yuhua Bao g, David S Mandell b,c, Hillary R Bogner a, Margaret Lowenstein b,h
PMCID: PMC9933784  NIHMSID: NIHMS1846798  PMID: 35785613

Abstract

Opioid use disorder (OUD) is a major public health emergency in the United States. In 2020, 2.7 million individuals had an OUD. Medication for opioid use disorder is the evidence-based, standard of care for treating OUD in outpatient settings, especially buprenorphine because it is effective and has low toxicity. Buprenorphine is increasingly prescribed in primary care, a setting that provides greater anonymity and convenience than substance use disorder treatment centers. Yet two-thirds of people who begin buprenorphine treatment discontinue within the first six months. Treatment dropout elevates the risks of return to use, infections, higher levels of medical care and related costs, justice system involvement, and death. One promising form of retention support is peer service programs. Peers combine their lived experience of substance use and recovery with formal training to help patients engage and persist in OUD treatment. They provide a range of services, including health education, encouragement and empathy, coping skills, recovery modeling, and concrete assistance in overcoming the situational barriers to retention. However, guidance is needed to define the peer role in primary care, the specific tasks peers should perform, the competencies those tasks require, training and professional development needs, and peer performance standards. Guidance also is needed to integrate peers into the care team, allocate and coordinate responsibilities among care team members, manage peer operations and workflow, and facilitate effective team communication. Here we describe a peer support program in the University of Pennsylvania Health System (UPHS or Penn Medicine) network of primary care practices. This paper details the program’s core components, values, and activities. We also report the organizational challenges, unresolved questions, and lessons for the field in administering a peer support program to meet the needs of patients served by a large, urban medical system with an extensive suburban and rural catchment area.

Clinical Trials Registration:

www.clinicaltrials.gov registration: NCT04245423.

1. Background

Opioid use disorder (OUD) is a major public health emergency in the United States (US). In 2020, 2.7 million individuals had an OUD.1 Medication for opioid use disorder (MOUD) is the evidence-based, standard of care for treating OUD in outpatient settings,2,3 especially buprenorphine because it is effective and has low toxicity.4

Buprenorphine is increasingly prescribed in primary care clinics, which provide greater anonymity and convenience than substance use disorder treatment centers.5–8 Despite the additional convenience, two-thirds of people who begin buprenorphine treatment discontinue within the first six months.4,6–16 Peer support services could improve treatment retention in primary care and thereby lower the risks of a return to opioid use, infections, justice system involvement, and overdose deaths.6,7,17–21 Peer support also may reduce the financial costs of return to drug use such as admissions into higher levels of care (e.g., acute treatment facilities, emergency department visits, inpatient stays) and law enforcement and incarceration.22

Peer support workers are a subtype of community health workers. Variously titled “Certified Recovery Specialists,” “Peer Navigators,” “Peer Mentors,” “Peer Recovery Specialists,” or “Peer Recovery Coaches,” among other titles, they combine their lived experience of substance use and recovery with formal training to provide a range of patient services. These services include health education, encouragement and empathy, coping skills, recovery modeling, crisis management, and assistance in overcoming barriers to engagement and adherence.23–26 Peers perform a variety of tasks, and different program emphasize different facets of their role. The descriptors in the job titles such as “navigator” or “coach” can signal the particular focus.

2. Problem

Integrating a new peer support services program into primary care is complex undertaking with many challenges. First, peers comprise a new addition to the primary care team, which, in the short-term, may un-settle established role definitions and inter-professional communication patterns. Second, from an operations perspective, primary care clinics are designed for short patient visits to maximize patient flow.27 A primary care provider’s (PCP) time is an expensive resource that must be allocated efficiently. A peer services program may add to the time demands, as PCPs are needed to introduce the program to new patients, to meet with patient and peer in follow-up visits, and to discuss treatment plans and progress with peers and other care team members. Further, larger primary care practices often adopt group-based models of care, where a patient may see a different PCP at each visit, which can hinder coordination among care team members. Third, rural clinics face the challenge of serving a geographically dispersed population with pronounced transportation constraints.28 Finally, strategies for financing peer programs have not been well defined.

New primary care models for OUD treatment are beginning to emerge20,21 with increased interest in peer programs, but the best practices for using peers have yet to be outlined. Guidance is needed to define the peer role in primary care, the specific tasks peers should perform, the competencies required of peers, training and professional development needs, and peer performance standards. Guidance also is needed to integrate peers into a busy care team with previously established workflows and rotating team members, allocate and coordinate responsibilities among care team members, manage peer operations and workflow, and facilitate effective team communication. Finally, new strategies are needed to fund peer services in primary care. We sought to address these gaps with a care model that would serve our patient population.

In this paper, we describe a peer support program in the Penn Medicine network of primary care practices. We detail the program’s core components, values, and activities. We also discuss the organizational challenges, unresolved questions, and lessons for the field in administering a peer support program to meet the needs of patients served by a large, urban medical system with an extensive suburban, and rural catchment area.

3. Organizational context

The Penn peer program originated as an arm of a randomized controlled trial designed to test collaborative care treatment for OUD and the psychiatric disorders that commonly accompany OUD, such as depression, generalized anxiety, and post-traumatic stress disorder.29 Patients in this program receive care from a PCP, a peer recovery specialist, a licensed clinical social worker (LCSW) who provides psychotherapy, and a psychiatrist who supervises the LCWSs and, when needed, consults with the PCP. Clinic sites currently include a Philadelphia small practice, three Philadelphia group practices, and 25 small outlying practices, comprising four regions, in Lancaster, PA, and surrounding counties. The program duration is 6-months, after which patients may continue to receive MOUD and primary care services from their PCP. Peer support beyond 6 months is available to patients through a no-cost, community-based peer support program.

The peer program was designed by a planning group of experienced peers, researchers, and primary care clinicians with expertise in addiction treatment. The planning group drew upon the literature on peer programs and operations, Substance Abuse and Mental Health Services Administration (SAMHSA) toolkits, analyses of best practices from behavioral health and community health workforce planning, and experience implementing a peer-led care model in the Penn Medicine emergency departments.30 The initial design of the peer program was iteratively critiqued and refined, and a manual of operations was prepared as a reference tool.

Currently, the program has three full-time peer recovery specialists, one peer supervisor, three LCSWs, and a part-time consulting addiction psychiatrist. The participating PCPs have Drug Addiction Treatment Act of 2000 waivers to prescribe MOUD. At each practice site, champion PCPs were identified to encourage and support colleagues in prescribing MOUD.

Patients were recruited from the UPHS and Penn-Medicine Lancaster General Health primary care clinics, the UPHS hospitals (Hospital of the University of Pennsylvania, Hospital of the University of Pennsylvania-Cedar, Penn Presbyterian Medical Center, and Pennsylvania Hospital), the University of Pennsylvania Warmline (a referral mechanism that provides same-day telehealth access to MOUD and connects patients to primary care for continued MOUD treatment), and direct outreach to the community. Patient participation was voluntary.

Approximately 90 patients have enrolled in the peer program with enrollment continuing. We have compiled demographic data for the first 59 patients. The racial/ethnic composition is 51% male, 49% non-Hispanic White, 37% non-Hispanic Black, 9% Hispanic/Latino, and 5% Other. Median age is 42 years. We also compiled self-reported drug history on 51 patients. Of this group, 88% of patients reported prescription opioid use on a regular basis (anytime in the past or presently), 53% heroin use, 51% cocaine use, 51% benzodiazepine use, 38% methamphetamine use (data missing on 4 patients), and 31% fentanyl use. Median number of years of regular drug use prior to treatment was 4 years for those who used prescription opioids, 8 years for heroin, 6 years for cocaine, 9 years for benzodiazepines, 2 years for fentanyl, and 3 year for methamphetamines. Forty-seven percent of patients reported 0 overdose events, 20% experienced 1–2 overdose events, and 33% reported more than 2 overdose events.

4. Solution

4.1. Peer qualification, recruitment, and hiring

The planning group set standards for recruiting, screening, and hiring peers. The first step was hiring the peer supervisor. The supervisor was involved in all phases of the peer hiring process, including recruiting, interviewing, and selecting applicants. Peer applicants had to have completed the Pennsylvania certification training, be stable in their recovery (per Pennsylvania certification requirements) and have passed the state certification exam. Peers were recruited through the Pennsylvania peer certification website, the Penn website, social media, and peer professional networks. The supervisor and planning group members, including a peer and a champion PCP, interviewed promising candidates. Interviewees were asked how they would respond to different scenarios (e.g., a patient reveals return to use), and how they would creatively problem-solve common difficulties (e.g., a patient has run out of medications and the pharmacy is about to close). The interview team sought candidates who exhibited empathy for vulnerable populations, used compassionate language, and expressed an understanding of the way of life of people who use drugs. The team also searched for candidates who were familiar with local resources, were passionate about low-threshold, patient-centered OUD care,31 and valued multiple pathways to recovery, meaning that they were not predisposed towards abstinence-only recovery. At present, the program has three peers and one supervisor (median age = 41 years; 3 females; 3 White, 1 Asian). Three of the four peers had prior work experience as peer recovery specialists, all with strong external recommendations. There has been no turnover in the peer workforce.

4.2. Peer training

Pennsylvania certification requires that peers receive at least 78 hours of standardized instruction on a basic set of competencies and a passing grade on the Board exam. We supplemented this training with 20 hours of training on the SAMHSA core competency categories32 and additional peer competencies that the planning group determined were needed to be a member of a collaborative care team in primary care. These competencies include information sharing, cooperative planning, and care coordination. Box 2 groups the collaborative care competencies with their respective training times into four performance domains: engagement in primary care and mental health treatment, navigation and care coordination within the Penn Medicine system, stigma reduction, and advocacy.

Box 2. Peer competency training for collaborative care of OUD.

Engagement in primary care and mental health treatment.

  • Learns roles of healthcare professionals on patient’s care team (1 hour)

  • Improves value of patient appointments (e.g., helps patients articulate questions or concerns prior to appointment, patient navigation) (2 hours)

  • Learns different therapeutic/clinical treatment modalities in patients’ care plan and uses this knowledge to tailor peer support service to achieve whole-health goals (1 hours)

  • Learns basic medical language and chart documentation (1.5 hours)

  • Learns risk factors and associated preventive/early intervention strategies to address risk and promote health and well-being including Motivational Enhancement training and suicide assessment and safety planning (5 hours)

  • Documents peer work in EHR clearly, concisely, and accurately (4 hours)

Navigation and care coordination within the Penn Medicine system.

  • Coordinates with collaborative care team members regularly to optimize the care plan for patient’s recovery needs and goals (2 hours)

  • Organizes patient appointments, referrals, and testing; provides appointment reminders; assists with transportation and practical problems that may interfere with patients’ abilities to follow provider instructions and advice (1.5 hours)

  • Strengthens patients’ ability to participate in making decisions about their care

Stigma Reduction.

  • With care team, promotes stigma reduction in primary care (0.5 hours), and

  • Helps patients address internalized stigma with compassion (0.5 hours)

Advocacy.

  • Learns social determinants of health and how these factors may impact a patient’s health and wellbeing, along with integrative strategies to address them (1 hours)

  • With care team, promotes harm-reduction principles in primary care (1.5 hours)

  • With planning group, co-produces and co-delivers research products, presentations, and trainings (ongoing, initially 1–2 hours)

The training was grounded in the understanding that recovery for peers and patients may differ, and that recovery is a process of change through which patients improve their health and wellness and live self-directed, self-actualizing lives.33 The program values shared decision-making between patient and peer and acceptance of patient choices and views.

Peers also received project-specific training on confidentiality of patient information (peers have access to patient medical records), and boundary issues (avoiding “occupational drift”), which can occur when peers assume a more medical treatment role. Other critically important boundary issues are specific to peer-patient interactions and relationships, e.g., prohibitions on intimate activities, business arrangements and gifts.

The orientation for new peers lasted from two to eight weeks depending on prior experience. In the first phase, new peers shadowed the supervisor to learn role expectations, the organizational structure, and workflow. Peers learned about the importance of clear and concise communication with care team members. In the second phase, the supervisor observed the peer’s progress by joining the peer and patient at their appointments and providing direction, support, and coaching as needed. The supervisor also reviewed peer documentation to ensure notes were complete and filed correctly. Peers reported that the practical training, especially how to effectively navigate the inner workings of a large, complex health care system like Penn Medicine, was particularly valuable.

Leadership encouraged peers to engage in professional development activities to improve care quality, increase job satisfaction, and advance career trajectories. Peers obtained additional certifications and skills training (e.g., motivational interviewing, public speaking), and attended conferences, webinars, and professional meetings on addiction, harm-reduction, and recovery.

4.3. Delivery of peer services

Half of patient attrition from OUD treatment occurs in the first 30 days, a period of heightened responses to opioid-related cues.2,13,34–36 Our peers act quickly to help patients build trust with care team members. Together, patient and peer take stock of patient needs and recovery capital (the patient’s internal and external resources to help sustain recovery)37 and develop a plan to meet adherence goals using assessment and recovery planning tools (Brief Assessment of Recovery Capital-10, Quality of Life assessment, and the Strength-Based Assessment). Recovery planning is flexible, however. For many patients, the initial focus is on short-term problem solving and tackling immediate material needs, such as housing, phone access, or benefits enrollment.

Over time the peers help shape new routines and strategies to cope with anxiety, craving, pain, and distress. They don’t try to persuade patients to embrace treatment or change behavior (a tenet of our training program). Instead, they apply the principles of harm-reduction and trauma-informed care. They listen reflectively to their patients’ feelings about clinicians’ recommendations and provide support. By bolstering the patient’s sense of agency and self-determination, peers improve patients’ feelings of safety with providers and the clinic so that patients don’t associate primary care with judgment, alienation, or possibly fear of arrest.38,39 Peers reassure patients that abstinence is not the expectation, and they will be treated with compassion. Addressing the damaging effects of stigma is central to the Penn program.

Peers often work at the clinic, although work patterns vary according to each PCP’s preference, meeting space availability, and scheduling demands. Some collaborative care teams formalize these procedures. Formalized procedures include team huddles before the clinic session to “run the list” (i.e., identify the tasks that need to be done that day for each patient) and share information. The peers use this time to contextualize patient experience or discuss patient needs. Teams were most likely to adopt the structured model when a PCP had a weekly MOUD clinic. Other teams check in only as needed. This approach was more common among teams with residents and attendings who rotated in the clinic less often.

With both approaches, the peers introduce themselves to new patients, communicate with patients during their PCP appointments (a “reachable moment”), meet with patients for scheduled peer appointments, text and call patients, and update care team members on new developments. At present, peers have a caseload range of 10–20 patients. The small caseload allows peers to give their patients significant social support at an especially fragile time. Successful MOUD treatment outcomes are associated with a shift in patients’ social networks to healthier relationships,40 which peers exemplify through their daily interactions with patients. Peers reported that if their advancing health care professional status created a little bit of distance with patients, it also tended to induce modeling behavior (patients have said “I want to do what you do”). As one peer described:

“Six months goes by very quickly and then we’re letting them go. But I think that there’s probably a large percentage that are able to effectively connect with us. And remember that we do get it, and that we’ve been there, and we have to remind ourselves of that, too. It’s one thing to model good recovery for someone and be able to instill hope, but I don’t want them to put me on some pedestal that appears to be unattainable because they can absolutely do this.”

When not at the clinic, peers connect with patients virtually by phone or text, or in the community, sometimes meeting at a homeless shelter, food truck, or coffee shop. They visit hospitalized patients to facilitate safe discharge. They also engage in community outreach by tabling at recovery-related events. The peers set up a physical table at these events to display program resource materials and free promotional materials advertising the program (e.g., brochures, lanyards, t-shirts). When people approach to peruse the table or ask questions about the program, the peers supply information, initiate relationships, and help interested people link to the primary care practices.

Work flexibility, independence, and autonomy are necessary elements of the peer work environment, which allows peers to adjust the mode, location, and intensity of services to patient needs. Peers divide their time between direct patient interactions (~60%) and administrative or related tasks (~40%), including case discussion and care coordination with the peer supervisor, PCPs, and team members; documentation; and community resourcing. We examined early data on the in-person, telephone, and video conference contacts between patients (n = 50) and peers. We found that most patients had contacts with peers (operationalized as in-person, telephone, or video conferencing) during the “initial engagement” stage (month 1), with the percentage of patients having peer contacts declining gradually through the “early treatment” stage (months 2 and 3), and the “stabilization” stage (months 4–6). The monthly percentages were 82% (41 of 50 patients), 76% (34 of 45), 71% (30 of 42), 57% (17 of 30), 54% (14 of 26), and 42% (8 of 19). Peers said that emotional bonding was often the main goal of patient-peer contact in the engagement stage as this can be a period of acute uncertainty for the patient, who may have difficulty adjusting. In the early treatment and stabilization stages, peers tended to shift the focus toward counter-conditioning (the process of replacing an unwanted response to drug-related stimuli with a new, wanted response) and psychosocial reinforcement.

Most contacts were by telephone (73%), followed by in-person (26%), and video conferencing (3%). At the median, the duration of each contact was 25 minutes (1st quartile: 11 minutes; 3rd quartile: 45 minutes). Brief back-and-forth text messaging, which most patients and peers used, was not included in the activity records. Texting seldom included significant clinical information.

4.4. Peer and care team collaboration

At the start of the program, the planning group briefed the PCPs, the LCSWs, and clinic staff about the peer role, peer responsibilities relative to other care team members, integration of peer services with ongoing medical care, and procedures to access peer services. The Philadelphia-area peers and care team members were provided with clinic “touch-down” space to discuss patient needs. Peers were equipped with essential office resources and cell phones for patient and work-related communication, and laptops for electronic health records (EHR) updates and scheduling.

Each peer is partnered with a LCSW, and the dyad shares a panel of patients with PCPs in their designated clinic. Peers meet their partner LCSW weekly to discuss their patients and treatment plans. Peers also meet biweekly with a champion PCP and the LCSWs to consider complex cases and system-level difficulties. At team meetings, the peers share feedback on the program’s implementation, offer suggestions for quality improvement, and relay information on local substance use patterns and related topics. Peers communicate with PCPs through various channels: by staff messages and encounter notes in the EHR, by phone and text, and in face-to-face meetings.

4.5. Peer supervision

The supervisor is an experienced peer with strong mentorship skills. Along with carrying a 50% caseload of patients, she manages all facets of our decentralized peer program. The supervisor and two peers are in Philadelphia. A third peer is based in Lancaster County, about 70 miles from Penn’s main campus.

The supervisor meets weekly with each peer to review patient progress, help solve problems, foster skills development, and provide feedback on performance. The supervisor also makes a point of checking in on the peer’s recovery and self-care.

Many patients with substance use disorder have experienced a traumatic event, like witnessing an overdose death, seeing someone killed or seriously injured, intimate partner violence, or adverse childhood experiences.41 The stresses and isolation associated with the COVID-19 pandemic and the national political unrest of 2020–2021 made a supportive and trauma-informed approach even more essential. The supervisor fosters an environment that recognizes the widespread prevalence of trauma and how trauma may affect everyone in the program, including patients, providers, and peers. Service provision can mirror power dynamics experienced in past traumatizing relationships.42 To prevent re-traumatization, the supervisor cultivates an atmosphere where colleagues can examine internalized biases. She reframes unexpected outcomes as learning opportunities and urges peers to take time for self-care.

4.6. Aftercare

Little is known about when patients can safely stop OUD treatment, and individual needs vary. On average, patients who remain on MOUD longer tend to have better outcomes.43 Our program provides patients with peer and psychotherapy support for 6 months, the period of initial stabilization. Continuation of peer support beyond 6 months is available to patients through a no-cost, community-based peer support program. Remote programs also are available which can be more convenient for patients in rural counties. Our peers arrange the peer-to-peer “warm handoff” for patients who choose an aftercare option.

Patients with long-term psychotherapy needs receive referrals for mental health care outside of the Penn system where only short-term therapy is available; however, the supply of behavioral health workers is inadequate to meet demand, sometimes leaving patients struggling to find a therapist, a problem exacerbated by the dearth of mental health providers who accept the patients’ insurance. Both the care teams and the community peer programs draw on their informal networks to help patients locate therapists with experience in SUD, but this remains a weak link in the continuum of care.

4.7. Financing of peer services

Our peer program is funded through a National Institute of Mental Health grant. Insurance plans are not billed and there are no out-of-pocket costs to patients. We are discussing with the health system and insurers how to pay for the program once the grant ends. We review below several existing payment mechanisms to sustain peer programs beyond grant-funding.

When the Affordable Care Act established substance use disorder and mental health services as essential benefits, Medicaid programs received new authority to cover peer services. By latest report, 38 states cover some peer support through Medicaid; however, states vary in the degree of coverage and the funding authorities used, relying variably on waivers, demonstration programs, or including it as part of rehabilitative services in their state plan.44 Regardless of the financing model, conditions for payment and documentation standards for billing Medicaid are cumbersome. Some peer programs rely instead on grant funding (e.g., Substance Abuse Prevention and Treatment Block grants, private funds) to avoid the Centers for Medicare & Medicaid Services (CMS) requirements.44,45

In Pennsylvania, the Department of Human Services established an alternative funding model for OUD treatment, the Centers of Excellence for Opioid Use Disorder program. There are 45 Centers of Excellence across the state, including the University of Pennsylvania Health System and Lancaster General Health. Centers of Excellence use an interdisciplinary care management team to coordinate patient care across physical and behavioral health, nonmedical social services, and MOUD treatment.46 Initially, these centers were supported with grant funding. In 2019, CMS approved a direct payment arrangement where Centers of Excellence can bill insurance for care management services, including peers, for each member they provide face-to-face services during a month.

Existing payment for primary care-based collaborative care, for example, the Medicare bundled payment that took effect in 2017,47 was designed to cover practice costs of staffing the care manager role (and other related costs) and is thus likely not sufficient to cover the costs of staffing both care managers and peers. Because it is a per-member-per-month payment, the amount of funding a provider organization receives for the year depends on the volume of patients seen and how long they are kept in the program.

Currently, neither the existing Medicare collaborative care payment nor the Pennsylvania Center of Excellence payment has a value-based payment component. To incentivize care quality and outcomes, Pennsylvania is exploring value-based bundled payment arrangements, with bonus payment contingent on meeting performance metrics. To date, a value-based payment schedule has not been developed.48 Our RCT study findings will have direct implications on how the design (and rate) of existing payment mechanisms needs to be adjusted to sustain a care model strengthened by both case managers and peer services.

Box 1 summarizes the main features of the Penn program.

Box 1. Main features of the Penn peer program.

Program setting:

  • 4 UPHS and 25 Penn Medicine Lancaster General Health primary care practices

OUD care team personnel:

  • Peers provide expressive, information, and instrumental supports to patients

  • PCPs prescribe MOUD in addition to providing regular primary care services

  • LCSWs provide psychotherapy

  • Consulting addiction psychiatrist provides expert prescribing guidance

Peer program structure:

  • 3 peers (2 in Philadelphia, 1 based in Lancaster County) and 1 peer supervisor

  • Each peer is assigned to one or more clinics in their region

  • Peers carry a caseload of 10–20 patients

  • Each peer is partnered with an LCSW assigned to the same clinic(s)

Schedule of peer activities:

  • Peers meet with patients at clinic appointments and as needed (in-person, phone, video)

  • Peer supervisor meets with each peer weekly to review cases and address challenges

  • Peer and LCSW meet weekly to discuss and coordinate patient treatment plans

  • Peers, champion PCPs, and LCSWs meet bi-weekly to discuss complex cases and system level difficulties

  • Peers and PCPs communicate through the EHR, by phone and text, and in-person,

Resources mobilized by peers (partial list):

  • Mutual aid societies, housing (shelters, sober living programs), childcare, elder care, transportation assistance, legal assistance, home health services, employment assistance.

Duration of program:

  • 6 months

Aftercare:

  • Interested patients are referred to community-based peer programs and/or mental health therapists for continued services

  • Patients may continue to see PCP for MOUD prescribing and primary care services

Funding:

  • The Penn peer program is funded through a grant from the National Institute of Mental Health to the University of Pennsylvania. Grant Number: UF1MH121944

5. Unresolved questions and lessons for the field

Peers can play a critical role in supporting patient-centered treatment for OUD in primary care. Below, we outline the challenges and lessons learned for integrating peers into primary care.

PCP use of group coverage.

Primary care practices often use a group coverage model where a patient may see a different provider at each visit, usually with one PCP having oversight responsibility for the patient. A group model offers more flexibility and easily adjusts to changing patient and provider schedules, but at a cost of less continuity of care in monitoring of patient progress and circumstances. Our clinics that rely on a group model faced two difficulties. First, some patients wanted to see the same PCP for all visits to develop a therapeutic relationship. For these patients, peers are instrumental in developing patient trust in the PCP group and generating a sense of continuity. Peers serve as “credible messengers” who patients can relate to and respect.49 Second, it was hard for peers to communicate with rotating clinicians. We found that champion physician-leaders could help clear obstacles to building an ongoing PCP-peer partnership by providing a visible example of team collaboration and by talking with PCP colleagues about the value of conferring with peers.

Supervising a distributed peer team.

The peer program serves multiple clinics spread across a large region. Supervising a distributed peer workforce can be challenging. A distributed team risks isolation and low morale, workflow inefficiencies, lack of team collaboration and access to support, and the buildup of unnoticed issues. The peer supervisor sets clear performance standards and conducts frequent status reviews to keep abreast of peer and patient progress and needs. Additional checkins with the supervisor, which use several communication tools (video, text, EHR message, small and large group meetings), also help reduce peer isolation and facilitate collaboration.

Patients differ in their recovery goals.

Some patients wish to abstain from all drugs while others want to reduce or stop opioid use. Each has different definitions and indicators of success and health, requiring different forms and intensity of peer support. For patients who want to stop using all drugs, milestones are clear and achievements are celebrated. Lapses are understood as part of the process. For patients who want to reduce their drug use, the markers of success are less obvious. Goals tend to be framed in terms of the treatment process, such as attending an appointment on time or taking buprenorphine most days of the week. Occasionally, peers feel dispirited by their patients’ modest progress and question whether it might reflect on their effectiveness. Supportive supervision, a team-based culture, and an emphasis on role flexibility helped peers accommodate the diversity in patient goals and person-specific strategies. In that regard, peers also report a deep satisfaction when they see patient growth along interpersonal dimensions such as renewed relationships with family members or improvements in living situations or day-to-day functioning.

Aftercare.

With the risk of return to use highest in the first few months after treatment,50 the care team works with patients to create a supportive environment and address the barriers to ongoing recovery. Plans may include continuing buprenorphine along with peer support services through community organizations. Absent a system for gathering reliable data on aftercare outcomes, we don’t know how effective these plans are. At present, peers reach out to former patients for updates, but information obtained in this way tends to be selective. Building a systematic aftercare “feedback loop” is an important continuum-of-care undertaking and a priority on our research agenda.

Funding sustainability.

The available funding mechanisms for peers are inadequate to ensure long-term program success. Notably, community health workers, of which peers are a subcategory, are similarly situated. We recommend federal authorization of standardized re-imbursements by CMS calibrated to both work volume and quality. Failing that, federal guidelines should endorse amending state plans and waiver programs to cover peer services. The current patchwork arrangement of grant funds, contracted payments, state-by-state Medicaid individualized arrangements, and the like, lacks a durable and resilient framework to address the long-term needs of patients with OUD and their communities where social inequities are prevalent.

6. Conclusions

Academic medicine offers a venue to explore and experiment to improve OUD service delivery.51 Penn has leveraged this freedom to investigate a new model of peer services. We posit that an effective peer program for OUD treatment in primary care will need to optimize programmatic components. These include articulating a clear set of program values; recruiting, screening, and hiring peers with strong qualifications; providing OUD and primary care competency training with ongoing professional development; supplying organizational resources and expert supervision; enlisting PCP champions to help formalize the status of peers in the care team; enabling peers to marshal the social service resources of the institution in support of the patient; aftercare planning; and stable financing.

In the 12-month period ending in April 2021, the number of drug overdose deaths involving an opioid surpassed 75,000 in the US,52 by far the highest yearly total on record. The most recent decline in US life expectancy was mainly due to COVID-19, but also to the sharp rise in overdose fatalities.53–55 Untreated OUD also worsens many health conditions or interferes with their treatment.56 Lowering opioid morbidity and mortality rates will require significant progress in initiating and retaining persons in treatment.17,57 This report describes the elements of a scalable, collaborative care peer program designed to increase patient retention in primary care OUD treatment.

Funding source

This study is funded through a grant from the National Institute of Mental Health to the University of Pennsylvania. Grant Number: UF1MH121944.

Abbreviations:

EHR

electronic health records

LCSW

licensed clinical social worker

OUD

opioid use disorder

MOUD

medication for opioid use disorder

PCP

primary care provider

SAMHSA

Substance Abuse and Mental Health Services Administration

UPHS

University of Pennsylvania Hospital System

Footnotes

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.

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