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Person- and Family-centered Care and Peer Support

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Person-centered care enables consumers to make decisions about their care. Family and peer involvement gives them the support they need.

Person-centered care—also known as patient-centered care—means consumers have control over their services, including the amount, duration, and scope of services, as well as choice of providers. Person-centered care also is respectful and responsive to the cultural, linguistic, and other social and environmental needs of the individual.

Family-centered care recognizes the important role of family members and caregivers in the design and implementation of services.

Person- and Family-centered Treatment Planning

Person- and family-centered treatment planning is a collaborative process where care recipients participate in the development of treatment goals and services provided, to the greatest extent possible. Person- and family-centered treatment planning is care planning that is strength-based and focuses on individual capacities, preferences, and goals. Individuals and families are core participants in the development of the plans and goals of treatment.

Effective person-centered care planning strengthens the voice of the individual, builds resiliency, and fosters recovery. It is important to note that while person-centered planning is respectful and responsive to the needs of the individual, it also occurs within the professional responsibilities of providers and care teams.

Providers and systems of care should be trained on the key principles of person- and family-centered care, shared decision-making, and fostering individual self-direction in treatment planning. Training should cover awareness and sensitivity on issues of race, ethnicity, age, sexual orientation, and gender identity. Learn more about cultural competency and Certified Community Behavioral Health Clinics (CCBHCs).

Peer- and Family-support Services

Person- and family-centered care also involves peer- and family-support services. CCBHCs are responsible for providing peer specialist and recovery coaches, peer counseling, and family/caregiver supports. Peer support services are services designed and delivered by individuals who have experienced a mental or substance use disorder and are in recovery. They also include services designed and delivered by family members of those in recovery. Peer specialists foster hope and promote a belief in the possibility of recovery.

The widespread adoption of peer services has led to greater deployment across services for both physical and behavioral health. Peer-support services are provided in a variety of settings and across different models of care. They may be provided in consumer and peer-run settings, and in agency or facility-based programs. Services can be divided into three categories: crisis and respite services; level-of-care transition services; and community-based services, including outreach, engagement, and ongoing recovery supports.

Training and Certification

The peer provider has formal training to deliver services in behavioral health settings to promote recovery and resiliency. In states where peer support services are covered through state Medicaid plans, the title of “certified peer specialist” is often used. SAMHSA recognizes that states use different terminology for these providers.

Standards for certification of peer specialists are generally established and administered at the state level. Training and continuing education requirements are variable across states and certification credentials are generally not transferable across states. While most states have established criteria for peer support specialists, the guidelines are less well established for family/caregiver supports and recovery coaches. Five common competency areas are reported in training programs for peer support services: advocacy, professional responsibility, mentoring, recovery support, and cultural competency.

Payment for Peer- and Family-support Services

In 2007, the Centers for Medicare & Medicaid Services (CMS) deemed peer support services to be an evidence-based practice, and, therefore, a reimbursable service for states that choose to incorporate them into their state Medicaid plan. More than 35 states have established statewide certification programs for peer specialists, and about 40 states have built these services into their state Medicaid plans for reimbursement.

Related Resources

Requirements From the Statute and Criteria

Section 223 of the Protecting Access to Medicare Act (PL 113-93) (PAMA) requires CCBHCs to directly provide, or provide through referral or formal relationships with other providers, such as a designated collaborating organization (DCO), a broad array of services to meet the needs of the population served. Providers must offer these services in a person-centered and family-centered manner.

In addition, the Department of Health and Human Services (HHS) has developed criteria for CCBHC certification. Access the complete CCBHC certification criteria – 2016 (PDF | 755 KB).

The criteria include the following requirements related to person- and family-centered care and peer-and family-support services:

Program Requirement 1: Staffing

  • 1.b.2 The CCBHC staffing plan must include peer staff and the state should consider, along with other disciplines, requiring peer specialists/recovery coaches and staff trained to provide family support.
  • 1.c.1 Staff training must address person-centered and family-centered care. At orientation and annually thereafter, the CCBHC provides training about, among other things, the roles of families and peers.
  • 2.b.1 New consumers must receive a comprehensive person-centered and family-centered diagnostic and treatment planning evaluation to be completed within 60 calendar days of the first request for services.

Program Requirement 3: Care Coordination

  • 3.d.1 All treatment planning and care coordination activities are person-centered and family-centered and aligned with the requirements of Section 2402(a) of the Affordable Care Act.

Program Requirement 4: Scope of Services

  • 4.b.2. Person-centered and family-centered care includes care which recognizes the particular cultural and other needs of the individual.
  • 4.e.1. The CCBHC directly provides person-centered and family-centered treatment planning or similar processes, including but not limited to risk assessment and crisis planning.
  • 4.j.1 The CCBHC is responsible for peer specialist and recovery coaches, peer counseling, and family/caregiver supports. States should specify the scope of peer and family services they will require based upon the needs of the population served. Peer services that might be considered include peer-run drop-in centers, peer crisis support services, peer bridge services to assist individuals transitioning between residential or inpatient settings to the community, peer trauma support, peer support for older adults or youth, and other peer recovery services. Potential family/caregiver support services that might be considered include family/caregiver psycho-education, parent training, and family-to-family/caregiver support services.

Last Updated

Last Updated: 03/16/2023