The Competencies of Telehealth Peer Support: Perceptions of Peer Support Specialists and Supervisors During the COVID-19 Pandemic.

This report assesses the competencies and technology needed for the provision of Telehealth Peer Support by Peer Support Specialists . The online survey assessed access to technology, core competencies required for the delivery of ThPS, and resources needed by the workforce to deliver ThPS. Responses from 313 PSS and 164 managers/supervisors of PSS from New York State were analyzed. Findings indicate nearly one-quarter of the PSS workforce continues to need access to technology and one-third need training in the delivery of ThPS. Perceptions of the important, critical, and most frequently used competencies for the delivery of ThPS were rated similarly by PSS and managers/supervisors. The broad implementation of effective ThPS requires additional resources and training for the PSS workforce. Further research to validate the ThPS competencies identified in the study will enhance training programs and resources. Policy makers and those who have advocated for the continued delivery of ThPS post-stay at home orders should ensure programs delivering ThPS provide access to technology and skills training in the competencies of ThPS. The use of ThPS post COVID-19 may address some persistent service barriers such as rural access and areas with fewer available services.

The COVID-19 pandemic and resulting stay at home orders greatly increased the use of virtual/digital/telephonic services delivered by Peer Support Specialists (PSS). Widely delivered by webcasting platforms or telephone, these peer-delivered services became known as Telehealth Peer Support (ThPS). There is no set of standards or competencies defined and tested in the literature specific to ThPS delivery. Additionally, there is no published literature on access to technology, required technical literacy and skills, or technology (hardware and software) needs required for the provision of ThPS. Even though many organizations are returning to traditional behavioral healthcare work settings, the need and desire for Telehealth services is very likely to remain (Calkins, 2021; Fisher, et al., 2020; Haque, 2020; North, 2021). This is especially true in rural areas where traditional face-to-face service delivery has historically posed barriers to accessing quality services. Therefore, it is essential that adequate resources and training to deliver ThPS are available to PSS.

There is scant research published on peer support interventions offered virtually/digitally/telephonically. Most of the literature is comprised of studies conducted on digital applications (e.g., text message, artificial intelligence, bot responses, apps) for people seeking peer support (Fortuna et al., 2018, 2019; Fortuna, Aschbrenner, et al., 2018; Fortuna, Naslund, et al., 2018; Fortuna, Naslund, et al., 2018). The studies included in one review describe digital peer-to-peer networks, peer-delivered interventions supported with technology, and asynchronous and synchronous technologies (Fortuna et al., 2020). Despite that review, identification of the competencies required for human-to-human, live, and effective ThPS, and how such competencies were arrived at is not available. Some research reviews on Telehealth delivered by traditional members of the behavioral healthcare workforce (e.g., psychiatrists, psychologists, licensed social workers, nurses) are available (Bonney et al., 2015; Donahue et al., 2021; Molfenter, et al., 2021). However, peer delivered services, are comprised of different tasks, principles of practice, and service goals which represent a unique and increasingly integral component of behavioral health care (N.A.P.S., 2013, 2019; SAMHSA, 2015; Mead & McNeil, 2004; Mead et al., 2001). Peer support is broadly defined as “giving and receiving help founded on key principles of respect, shared responsibility, and mutual agreement of what is helpful”, a major divergence from the medical model of traditional psychiatric treatment interventions (Mead et al., 2001). Peer support is provided by certified/credentialed Peer Support Specialists who share the lived experience of mental illnesses and use that experience to inspire hope for recovery in others. This report is not only timely considering the proliferation of Telehealth, Telesupport, and Telemedicine resulting from the pandemic, but also critically necessary to inform the ThPS training and competency development of the PSS workforce. This report will share the findings from the Telehealth Peer Support Survey for Peer Support Specialists and Managers/Supervisors of Peer Support Services.

Method

Participants

PSS respondents self-identified primarily as women (61%), heterosexual (73%), and white (52%). Most respondents were full-time workers (56%). More than half of the 313 respondents had a peer support certification (55%) with the majority of those holding the Certified Peer Specialist (CPS) credential (40%). Other credentials reported were Certified Recovery Peer Advocate (9%), Family Advocate (10%), Youth Peer Advocate (1%), more than one peer certification (17%), and other (12.5%). Thirty one percent worked in peer run organizations, 15% worked in mental health settings, 3% worked in substance abuse treatment, 37% worked in behavioral health settings (mental health and substance use), less than 1% worked in Veterans Administration and 13% reported other. Most respondents reported providing peer support for one to five years (60%). PSS Managers/supervisors self-identified primarily as women (72%), heterosexual (81%), and white (65%). One third of the M/S had been in that role for five years or less (33%) and most worked in a behavioral healthcare (mental health and substance abuse) setting.

Procedure

An online survey was developed by the Academy of Peer Support, a grant funded project of New York State, to develop training content for Certified Peer Specialists (CPS) or those seeking certification and to ensure quality improvement processes related to the delivery of training. The surveys were designed to gather information on (1) survey respondents’ demographic data to describe the peer support workforce and managers/supervisors who responded, (2) access to technology among the peer support workforce, (3) the core competencies for the delivery of ThPS based on importance, criticality, and frequency, (4) the most frequently cited resources needed by the workforce to deliver ThPS, and (5) the technology requirements needed by PSS to provide ThPS.

The invitation to participate in the online survey and the link were disseminated via the state office of mental health and the state-level training and testing platform for PSS certification. The survey link was also posted on the state-level training and testing platform’s learning community website and disseminated in its newsletter. Additionally, several collaborating peer run organizations disseminated the survey via their listservs. All 2900 CPS received the survey via the APS listserv. The survey was open for a period of six weeks. A reminder message was sent via listservs to encourage participation one week prior to closing the online survey. A paper and pencil version of the survey as well as the opportunity to call-in survey responses were offered. Research staff captured and entered that data into SPSS.

Instrument

The ThPS Survey for Peer Support Specialists and Managers/Supervisors of Peer Support Services was developed using the Delphi method for survey construction (Hasson et al., 2000; Iqbal & Pipon-Young, 2009). The Delphi method is particularly useful in areas of limited research, since survey instruments and ideas are generated from a knowledgeable participant pool (Hasson et al., 2000; Iqbal & Pipon-Young, 2009) and it is suited to explore areas where controversy, debate or a lack of clarity exist. In round one of the Delphi process, the New York State office of mental health  convened a group of stakeholders to address the potential digital divide among members of the PSS workforce and people receiving ThPS in NY State during the winter of 2020. As a result of those preliminary discussions a list of broad topics related to the delivery of ThPS requiring further investigation was generated. Those topics were (1) minimum competencies for providing ThPS, (2) primary outcomes expected/desired for ThPS engagements, (3) resources to support peer workers in offering ThPS, (4) technology barriers experienced by the PSS workforce, and (5) additional resources needed to better offer ThPS. These topical areas were then used to develop ThPS competency statements by the research team. The stakeholder group reviewed them and made additional comments/edits.

In round two of the process, research personnel engaged members of the fifteen-member Advisory Council, comprised of PSS experts, to further explore those categories. This group of review participants are referred to as panelists in the Delphi method of survey construction (Hasson et al., 2000; Iqbal & Pipon-Young, 2009). The panelists were included for their expertise on the topic of Telehealth Peer Support. In collaboration with the panelists, the research team developed the survey items. For round three of the Delphi process, research personnel conducted two sequential rounds of item review based on the five broad categorical areas for investigation with the panelist group and another group of trainers employed by the state-wide psychiatric rehabilitation trade organization. Items were also presented for feedback from the NY State and Regional Advocacy Specialist (SAS and RAS) team members. This feedback from each review round was collated to construct and revise the items for the survey instrument. In the fourth round of review, the instrument evaluation phase, panelists were provided with the entire panel’s responses and asked to re-evaluate their original responses and suggest final edits.

This information resulted in two parallel survey instruments, ThPS Surveys for Peer Support Specialists and ThPS for Managers/Supervisors of Peer Support Services. The surveys were comprised of nine demographic items to describe the respondents completing the survey and ThPS competency statement items identified in the Delphi survey construction phases translated into 27 survey items. These items were then evaluated by respondents based on their importance, criticality, and the frequency in which the ThPS competency was used using a Likert-type scale (0 = lowest, 4 = highest). The survey described a competency as a “Critical work function or task. Competencies can be defined as the knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform in their work role”. Importance means that the competency is an important one performed by a PSS. Critical means that if the PSS does not demonstrate the competency, harm can be caused. Frequency refers to how often the PSS demonstrates the competency. The 27 ThPS competencies were organized using the following five categories: Outreach and Engagement, Communication Techniques, Providing or Linking to needed Supports/Resources, Documentation and Technology, and Wellness Promotion and Health Literacy. Section three of the survey included nine items that evaluated the most important outcome of ThPS engagement, and the quality, type and frequency of remote supervision PSS were receiving pre and post stay at home orders. Section four included five items related to the types of technology supports PSS were given to provide ThPS, technology barriers the PSS experienced when providing the service, access to technology, and additional resources needed to better offer ThPS. The online surveys were nearly identical except for the designation that M/S provide their perceptions on the PSS they supervise versus themselves.

Results

Usable responses (all items answered) from 313 New York State Peer Support Specialists (PSS), representing a little over 10% of the approximately 2900 credentialed Peer Support Specialists in the state, and 164 responses from M/S were analyzed.

Technology Barriers

Approximately 20% of PSS respondents reported low technology skills, 20% still need access to hardware (e.g., laptop, desktop, tablet, smart phone, cell phone), and 18% needed adequate smart/cell phone data and minute plans. The need to access software (e.g., zoom, web ex, video conferencing) was reported by 23%, 24% need financial support to access to the internet, and nearly 30% need access to secure servers for compliance/security. When asked where the PSS accesses the internet currently, 59% indicated at home, 38% indicated at the office, and 2% access the internet on their phone only and less than 1% reported no internet connection. When asked where the PSS accessed the internet prior to the stay-at-home orders, there were no significant differences from the percentages indicated in the previous question.

Resources Needed and Provided

Both PSS and M/S identified the resources organizations have provided and additional resources PSS still need to offer ThPS.

One third of both groups indicated that PSS need training on the skills to deliver digital/virtual support (approximately 75% of PSS and M/S respondents indicated their organization has provided such competency training).

Approximately 20% of both groups indicated the need for live technical support from a technical support line (approximately 60% of both groups indicated this was made available via the organization). Nearly 20% of PSS and 30% of M/S indicated the need for a smartphone (63% of PSS and 45% of M/S reported their agency has supplied them with a smart phone).

Approximately 20% of PSS indicated they need a laptop (70% of PSS and 80% of M/S reported that PSS have an agency laptop and approximately one third of PSS and M/S indicated that PSS received a tablet).

One third of both groups reported the need for financial support to pay for internet costs (one third of both groups indicated that PSS have received additional funding for internet costs from the agency).

Among both groups of respondents, nearly 20% would like PSS to have access to training on billing and documentation (50% PSS and 60% of M/S reported such training is offered).

Both groups reported that PSS should have access to a learning community with other peer support specialists offering ThPS (70% of PSS and 82% of M/S reported that their agency has connected PSS to such a community).

Telehealth Peer Support Competencies

The 27 ThPS competency statement items were evaluated based on their level of importance, how critical the competency was, and the frequency in which the competency was used in service provision. There was significant similarity among PSS and M/S in nearly every ThPS competency statement. The first analysis was a frequency analysis of importance. This analysis helped to confirm that the competency statements generated by the panelists and refined by the research team were in fact rated as the important competencies to deliver ThPS. The analysis of the importance of each ThPS competency statement item also served as the basis for the initial test of similarity among the two groups of respondents. The data listed in Table 1 represent the percentages of respondents who rated that competency statement item as a 4 (very important).

Table 1

Importance of competencies

	PSS (n = 313) (%)	M/S (n = 164) (%)
Outreach and engagement and communication technique
Using active listening skills	84	75.2
Demonstrating empathy	84	79.5
Outreaching people who could benefit from peer support	73.8	61.5
Asking open ended questions	68.7	69.2
Orienting people to peer support	67.4	62.4
Re-engaging with people less connected during COVID	67.1	53.0
Motivating people to remain in contact	66.5	63.2
Developing follow-up steps	65.8	66.7
Scheduling the next meeting/discussion	61.0	50.4
Planning for the next meeting/discussion	56.2	47.9
Summarizing the meeting	54.3	48.7
Giving Advice	25.9	17.1
Providing or linking to needed supports and services
Referring people to crisis response teams	55.6	48.7
Referring people to warmlines/hotlines	51.1	38.5
Connecting to virtual support groups	46.6	55.6
Referring people to health care providers	46.0	40.2
Identifying health care providers	46.0	40.2
Facilitating virtual support groups	45.7	36.8
Documentation and technology
Submitting documentation online	69.3	68.4
Completing documentation	66.8	76.1
Supporting the person to engage one-on-one digitally/virtually	66.1	62.4
Using technology to engage one-on-one	65.5	65.0
Accessing the Electronic Health Record	19.5	47.9
Using a script to facilitate an online support group	18.8	9.4
Wellness promotion and health literacy
Providing health information	51.8	42.7
Teaching others how to access health information	46.3	43.6
Teaching health promotion skills	48.6	47.9

Enhanced Performance Weights

The second analysis computed an overall impact weight for each ThPS competency statement combining importance, criticality, and frequency. These weights were computed by adding the importance and criticality values and multiplying that sum by the frequency value (I + C × F) (Sanchez & Fraser 1992; Kane et al., 1989). These overall impact means were transformed to Z scores for easier comparison between groups. The results, listed in Table 2, suggest no significant differences in the ThPS competency ratings between PSS and M/S, except for only one area, giving advice.

Table 2

Overall impact means as Z scores

Competency	PSS	Mngr/Sup
Demonstrating empathy	1.65235	1.56404
Using active listening	1.54071	1.37520
Completing documentation	1.42679	1.38116
Asking open-ended questions	0.98485	1.17044
Submitting documentation online	0.82047	1.01340
Developing follow-up steps	0.78102	1.03128
Using technology to engage one–one-one (virtually/phone)	0.68054	0.83052
Supporting the person to engage one-on-one (virtual/phone)	0.65149	0.61582
Scheduling the next meeting/discussion	0.63849	0.31367
Orienting to the value of peer support	0.51845	0.76093
Outreaching people	0.51158	0.04132
Planning for the next meeting/discussion	0.43206	0.11686
Re-engaging people	0.34184	0.19438
Summarizing the meeting/discussion	0.28373	0.24608
Connecting to virtual groups	0.07270	0.24211
Teaching health promotion skills	−0.14979	−0.07390
Providing health information	−0.17731	−0.25686
Teaching others to access health information	−0.44414	−0.31649
Referring to warmlines/hotlines	−0.47320	−0.68027
Identifying healthcare providers	−0.49768	0.50932
Providing options for artistic/creative expression	−0.66970	−1.07390
Referring to crisis support teams	−0.69952	−0.62264
Accessing the electronic health record	−0.83028	−0.47553
Facilitating virtual groups	−0.91897	−0.99438
Motivating people to stay in contact	−1.23931	−1.44363
Giving advice	−1.76995	−0.56100
Using a script to run an online group	−2.60487	−2.88486

Discussion

Based on the analyses conducted, the main findings of the Tele-health Peer Support Survey for Peer Support Specialists and Managers/Supervisors indicate (1) approximately one-quarter of the PSS workforce continues to need access to technology (hardware and software) and one-third need training in the delivery of ThPS, and (2) the perceptions of the importance, criticality, and frequency of the competencies for the delivery of ThPS are rated similarly among PSS and M/S.

Finding one, approximately one quarter of PSS still require the necessary hardware, software, and training to deliver ThPS, requires increased funding to organizations that employ peers. According to the M/S responses, many organizations provided PSS with smart phones, laptops, and data plans to deliver ThPS. However, nearly 20% of the PSS respondents in this survey report they still require access to hardware. Additionally, nearly one-quarter need reliable access to the internet and funding to pay for that access. The need for training to deliver ThPS indicated by respondents implies that even when provided with the necessary hardware/software, PSS need guidance and on-going support using it.

Finding two, the perceptions of the important, critical, and most frequently used competencies for the delivery of ThPS are rated similarly among PSS and managers/supervisors, may be surprising considering previous literature indicates less agreement (Foglesong et al., 2021; Forbes, et al., 2021; Mancini, 2018; Phillips, 2018). In almost all ThPS competency areas of this survey, both groups agreed. However, a relatively high percentage (41%) of supervisors identify as certified peer specialists, which may account for the high rate of agreement between the two groups. The groups differed in only one area, giving advice. The principles of peer support favor helping others to brainstorm possible options and identify their own paths to life goals as opposed to giving advice.

Conclusions

Unlike programs established prior to the pandemic that sought to create technological solutions to supplement or enhance peer support, this study has examined the competencies of telehealth peer support and rated their frequency of implementation, importance, and criticality. As Tele-health policies and procedures are being issued and codified, based largely on Telehealth practice as delivered by licensed clinicians, there is a significant risk that elements of peer support as a non-clinical mutual support approach, may be diminished or lost. This study has been an intentional effort to identify, through expert consensus by peer specialists and supervisors, the competencies required for the delivery of peer support services through Telehealth technology to inform the training of the peer support workforce. The ThPS competencies identified in this study can be translated into competency-based training and performance-based supervision that helps to preserve the unique nature of peer support services in the continuously developing world of Telehealth Peer Support.

Finally, more analysis to reveal how closely ThPS competencies align with most of the recognized standards for peer support practice should be conducted.

The data from this study can be viewed as empowering for the PSS workforce (N.A.P.S., 2013, 2019; SAMHSA, 2015). Once technology needs are met, PSS are in good position to deliver effective ThPS services if they have received adequate training in the values, principles, skills, and tasks of peer support. The ThPS competency that PSS ranked highest was demonstrating empathy. The competency that M/S ranked highest was using active listening and reflective responding techniques, with demonstrating empathy a close second. These ThPS competencies are at the core of all the communication techniques included as competency statements, which as a set, were rated high (except for giving advice). Other ThPS competencies that were ranked highly were completing documentation and submitting documentation online. While not assessed in this survey, those competencies require technology skills/literacy that should be part of the PSS training or re-orienting to job tasks if this is a new requirement as a result of ThPS delivery.

There are several limitations of these data. Demographic data on the total population of Certified Peer Specialists in New York State was not available for comparative analysis to the respondents in this study. It is therefore possible that the perceptions regarding ThPS of these respondents are different than peer specialists in general. Additionally, this data reflects the views and experiences of PSS in one state. Perhaps the technology access and competencies most important, frequent, and critical to the delivery of ThPS in this state differs from others. Finally, the authors cannot calculate a response rate because multiple digital methods of dissemination were utilized to reach the broadest audience as possible.