. . .a service innovation
Four years ago, Tomicia R. needed help. In addition to being overcome by grief after the death of a son during childbirth, she was blacking out. Accompanied by her mother, she went to the local hospital's emergency room in New York's Hudson River Valley. A medical evaluation could find no reason for the blackouts, and she was directed to the psych ER for further evaluation. Meanwhile her mother was sent home while she waited to see a social worker.
It turned into a six-hour wait, short by some ER standards, and all the while Tomicia, 32, remembers feeling invisible. Nurses and doctors moved briskly while her only diversion was a wall-mounted TV. Sitting alone, she kept asking herself what would come next. "Am I staying, am I going home, what will happen to me?" After meeting with a social worker, she was admitted for 17 days.
Last November, Tomicia again needed an emergency psychiatric evaluation and she returned to the same hospital, Kingston Hospital, this time by ambulance. Once inside the emergency room, her experience was entirely different. And it wasn't only that five hours are shorter than six. What really mattered, she said, was the presence of a peer counselor who stayed with her during the entire time, bringing her Ginger Ale, ready to answer questions, there to explain or offer support for however long it took.
"Even when you know what to expect it can be scary, depending on what your crisis is and what you're going through," Tomicia said, grateful for the help.
The peer counselor program in this emergency room is a decade old, and it grew from attempts to manage the chaos at Benedictine Hospital, in Ulster County, New York. Citizen protests led to angry demonstrations outside the hospital, along with sit-ins at board meetings inside. When local officials wanted help to improve services, they turned to a PEOPLe, Inc., a peer-run agency in Poughkeepsie, New York.
The timing could not have been better. Steve Miccio had recently started working at PEOPLe, and his own hospital admission through an emergency room, plus his later employment in one, left indelible marks. Miccio knew from both sides of the desk what the crisis felt like. As a consumer he wanted humane and careful understanding; as a screener in the emergency room, he saw that talking with someone who had been through a similar, wrenching moment could allay fears and dampen anxiety.
These insights have contributed to the evolving program he continues to husband as executive director of PEOPLe. When peer counselors were introduced in the Benedictine Hospital, staff was initially uncomfortable. "They thought we were watching and criticizing and there to play gotacha," Miccio said of the early days. He quickly realized training needed to address this. "It's not us versus them," but how to treat people better with dignity and respect.
Careful ground-work enabled peer counselors to reassure that they were there to engage and support people in crisis who were otherwise left to their own while fears and anxieties grew.
Key to the work of a peer counselor is learning how to listen to someone in crisis. Good listening not only shows respect, Miccio said, but it validates someone's experience, often intensified during an emergency. Some people arrive by police escort, others by ambulance or family, some by themselves. Training emphasizes how to focus on what the individual offers and is concerned about, and when to use one's personal experiences to offer support without overshadowing.
Other aspects of training include learning about the laws governing the triage system (first medical clearance, then onto the psych ER), checking insurance papers, and hospital protocol. Role playing and shadowing trained personnel, and learning not to give personal or medical advice are also part of the mix. The core, however, comes from the principles of recovery-based values, including informed choice and partnership found in
"Infusing Recovery-Based Principles into Mental Health Services."
There is a growing awareness of the value of peer counselors, separate and distinct from case managers or therapists, for many points of entry in behavioral health systems. They appear throughout agencies helping people leave jails, prisons, state hospitals and in primary care settings.
Peer advocates have been working in hospital settings, but it is relatively new for the ER. At Kingston Hospital, four people work a total of 60 hours a week providing assistance to between 300 and 600 people a year. After the death of Esmin Green, who slumped to the floor in the ER at Kings County Hospital Center in 2008 following 24 hours of neglect, PEOPLe was asked to train peers they would employ. A peer counselor now works with 6,000 to 8,000 people coming through the ER annually.
It's an example of what Miccio called "taking care of your own before taking care of the rest of the world."
Regions Hospital, St. Paul
Nearly a year ago, Dr. Michael Trangle, director of the emergency room, oversaw the introduction of peers at Regions Hospital, a trauma center that provides services for a broad array of emergencies in St. Paul, Minn. He was alarmed that wait times approached 30 hours and that psych beds were always filled to capacity. After hearing Miccio speak at a conference, Trangle was all ears, and predisposed to work with the local Consumer Survivor Network, (CSN) which had a grant from the insurance company Medica to train certified peer specialists. The grant pays for up to 30 hours a week and at Regions this is shared by two people.
"I approached the relationship with optimism and an equal number of fears," Trangle said. At first he worried about whether the professional staff would get along with peers, whether they would be made to feel defensive about the medical model that includes medication. He also worried about crossing boundaries while providing personal support and what kind of training peers would receive. To supplement training from the CSN, they provided their own training on empathy, when to disclose, and how to identify oneself in the process.
Not all patients want to talk to a peer, said Maddy Cohen who manages the emergency department's crisis program at Regions Hospital. "Some ask, 'Why would I want to talk to somebody like me?'" Others appreciate having a person to share what happened to them, where they could find community resources, or what the next steps will be. For many, a peer counselor creates hope that they, too, will recover. "Just because you're feeling this way now, that doesn't mean it's the way it's always going to be," Cohen said
On balance, Cohen believes it has been a good experience for the 1,100 patients they saw in the first nine months of the program. It has also contributed to a change in cultural attitudes. Staff are less inclined to use disparaging and judgmental language, words like "crazy" or "frequent flyer" that were routine. Patient satisfaction has grown accompanied by other changes such as the reduction in waiting time to 8 hours for people needing admission, less for those who don't.
Among the biggest obstacles to expanding programs, or even maintaining them, is funding these positions. Contracts and grants run out, and the inability to sustain funding hampered continuing programs in Buffalo and Syracuse. In St. Paul, discussions are underway to expand the program but without this, Trangle worries about what will happen at the end of the one-year.
In the meantime, someone going to the emergency room at Kingston Hospital might run into Tomicia. She's recently started training on the early morning shift. The high point of her first day came with the realization that an agitated teenager grew increasingly more calm with the aid of a peer counselor. She finds it gratifying to be helping in a manner that she was helped. "I can see it from both ends of the spectrum," she said.