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A message from Thomas Lane, NCPS, CRPS, senior director, community and recovery supports

Welcome to Magellan’s June 2020 edition of eMpowered for Wellness. This month, we are excited to re-introduce our Thought Leaders series with Dr. Karen L. Fortuna, one of the world’s leading researchers and activists focused on digital peer support and the role of technology in recovery. As a result of COVID-19, technology-enabled peer support has become the norm and vitally necessary to ensure continuity of care. We hope you enjoy our exclusive, virtual e-interview with Dr. Fortuna as she shares her unique insights about the transformation of peer support.

e4W: Dr. Fortuna, thank you so much for your time. Can you share what brought you to this field?

Dr. Fortuna: Thank you! My background is in social work. I went into this field because my dad had multiple sclerosis and he was very sick as I was growing up. People treated him like he was different just because he was in a wheelchair. I would say he was marginalized—but, to me, he was always just my dad—not different—not helpless—one of the most amazing and capable people I have ever known in my life. So here I am. Working with peer support specialists that may have at one point in their life been viewed as “different” or “helpless” and I work with peer support specialists to accomplish things they maybe never thought possible.

e4W: You are recognized as one of the world’s leading researchers into the area of digitally delivered peer support. What drove your interest in pursuing this topic?

Dr. Fortuna: My initial exposure to mental health services began in the first year of a Masters in Social Work internship at the University of Pennsylvania. During this internship, I provided group-based self-management training to adults with a lived experience of a mental health condition and chronic health conditions. During this experience, I was impressed by the severity of disabilities that continued to be present for adults with a lived experience of a mental health condition despite participation in evidence-based programs. I subsequently pursued a volunteer opportunity with Dr. Mark Salzer to learn about efforts to improve the effectiveness of interventions for people with a lived experience of a mental health condition; in addition to being introduced to community-based research and peer support specialists.

As a result, I have developed an understanding of the history of the peer recovery movement, peer perspectives and theories of service delivery—and I saw recovery for the first time. I was sold! Recovery is real! This experience laid the foundation for my research career focused on digital peer support as an innovative service delivery strategy. Digital peer support is defined as live or automated peer support services delivered through technology mediums.

e4W: One of the hallmarks of your work has been using a co-design approach, working collaboratively with persons with lived experience to inform your projects. Would you share with our readers what co-design is and why you choose this approach?

Dr. Fortuna: Co-design is a partnership in research that promotes shared decision making in all aspects of the research process. Our model, the Peer and Academic Partnership, supports collaboration, engagement, shared decision-making, principles of reciprocal relationships, co-learning, partnership, trust, transparency and honesty. We use this co-design approach because peer support specialists bring new insights and energy to our research that our team believes will lead to the next discovery in the social sciences. Plus, it’s fun! I have an amazing group across the globe that I work with!

e4W: One of your projects at Dartmouth was the creation of PeerTECH, a peer-delivered and technology-supported integrated medical and psychiatric self-management smartphone intervention. Can you explain how PeerTECH is used to augment the peer support experience for the end user?

Dr. Fortuna: PeerTECH is a smartphone app that allows service users to text message peer support specialists and develop a plan to work towards optimal mental health, physical health and social health. The PeerTECH app offers support outside of a clinical environment and thus augments traditional clinical services. PeerTECH includes peer-led videos and experiential learning tasks on psychoeducation and coping skills training on the following topics: (1 & 2) Identifying Your Recovery and Wellness Goals: Setting recovery and health goals and strategies to achieve goals and orientation to the smartphone application; (3 & 4) Psychoeducation: Psychoeducation on SMI and medical illness; (5) Stress Vulnerability and Illness: Causes of mental illness and factors that influence its course; (6) Building Social Supports and Recovery and Wellness: How to build social supports; (7) Medication Adherence Strategies: Behavioral tailoring and motivational techniques for medication adherence; (8) Psychiatric and Medical Relapse Prevention: Identify warning signs and develop a relapse prevention plan; (9) Coping with Psychiatric Symptoms and Health-Related Stress and Solving Problems: Establish a method for managing symptoms; (10) Coping with Stress, Chronic Pain and Medical Symptoms: Identifying stressors that exacerbate symptoms and strategies to cope with stress; (11) Medication Misuse: Addressing medication misuse and the effects on symptoms and functioning; and (12) A Guide to Navigating the Mental Health and Medical Healthcare System: Accessing mental health and medical health services and making informed decisions.

We conducted a small pilot study and established the preliminary feasibility and acceptability of PeerTECH8. Using a pre/post design, in which n=10 adults (Mean age of 68.8 years; SD=4.9) with mental health conditions and medical comorbidity who received PeerTECH in their homes. The pilot study demonstrated that PeerTECH is feasible for both peers and service users. On average, 74% to 88% of participants engaged weekly with the smartphone application and 33% to 47% engaged daily. PeerTECH was associated with statistically significant improvements in psychiatric self-management (p <.001). Improvements were found (though not statistically significant) in self-efficacy for managing chronic health conditions, social support, hope, quality of life, medical self-management skills and empowerment.

e4W: Our lives have changed almost overnight as a result of the COVID-19 pandemic. The expansion of virtual peer support has grown exponentially over the past 8-10 weeks. What are some of the challenges and opportunities facing the field relevant to technology-enabled peer support?

Dr. Fortuna: Some of the challenges have been getting people access to technology. Thankfully, there has been a lot of support from the local United Way, to Safelink, to SAMHSA capacity building grants. Interestingly, a lot of it is about choice. Some people may choose to not engage with a video conference on a computer or a smartphone but may prefer a telephone call. The technology is just the medium to offer an authentic human connection, so the tech really doesn’t matter—whether it’s text message, a telephone call, or even virtual reality—All are mediums to offer peer support.

e4W: You and your colleague, Mr. Robert Walker, have trained over 1,600 peer supporters from around the globe over the last several weeks. Can you share with our readers key elements and highlights of this first-in-field new curriculum leading to a certification in digital peer support?

Dr. Fortuna: Most existing telemental health trainings are designed for individuals who have their professional degrees and licensures, including psychiatrists, psychologists, registered nurses and licensed clinical social workers. As digital peer support is quickly expanding across the globe in the wake of the COVID-19 pandemic, telemental health trainings developed for peer support specialists are needed now. My colleague, Mr. Rob Walker, and I decided we had to do something. So, we revamped our two-month long training and turned it into a four-hour certification for rapid uptake—we designed the certification so people could take it and be able to keep their “virtual” doors open. We offered 140 spots in five free trainings—but then we had thousands of people who still needed training, so we started offering the certification across the globe so as many doors as possible could stay open and offer much needed peer support services. We also started a Train-the-Trainer program, in which the states of Virginia, Maryland, New York, and New South Wales Australia are training their entire state states! Virginia alone has trained nearly 600 people as of June 1, 2020.

The Digital Peer Support Certification includes training on Digital Communication Skills; How to Engage Service Users with Technology; Technology Literacy and Usage Skills; Bonding and Connection through Technology; Available Technologies; Privacy and Confidentiality; Monitoring Digital Peer Support; and, How to Address a Digital Crisis (http://digitalpeersupport.org/certification/). The Digital Peer Support Certification was co-designed with scientists and peer support specialists and has been found to be an effective knowledge translation training that has shown to increase peer support specialists’ capacity to use digital peer support in practice.

e4W: In your April 2020 Journal of Medical Internet Research article, Digital Peer Support Mental Health Interventions for People With a Lived Experience of a Serious Mental Illness: Systematic Review, you and your fellow researchers concluded, “Digital peer support interventions appear to be feasible and acceptable, with strong potential for clinical effectiveness. However, the field is in the early stages of development and requires well-powered efficacy and clinical effectiveness trials.”

With this in mind, where do you think digital peer support will be in the next 2-5 years?

Dr. Fortuna: In the past few months, the field of peer support has changed forever. In the next five years, we will see more pre/post studies and a few large scale studies (fully-powered studies) to examine the effectiveness of digital peer support. Digital peer support technology mediums will also advance to include virtual reality and video games. We expect to see peer telehealth be a reimbursable service after the COVID-19 crisis and augment in-person peer support. It’s an exciting time!

e4W: Is there anything else you would like to share with our readers?

Dr. Fortuna: Thank you so much for the opportunity for me to share my journey and the really cool work on which our global team has embarked! Check out our website to sign up for our newsletter, digitalpeersupport.org.

e4W: Dr. Fortuna, we are so appreciative of your work and leadership in this area. Thank you for sharing your insights with our readers.

About Dr. Karen L. Fortuna: Dr. Fortuna holds a doctorate in social welfare and a master’s degree in social work. She is an Assistant Professor of Psychiatry in the Geisel School of Medicine at Dartmouth College. Her primary research interest is service delivery strategies for older adults with serious mental illnesses and chronic health conditions. Dr. Fortuna is using community-engaged research methods to develop and implement peer-supported mobile health (mHealth) intervention. Dr. Fortuna was awarded a NIMH K01 award (K01MH117496), a NARSAD Young Investigator Grant from the Brain and Behavior Foundation, the Alvin R. Tarlov & John E. Ware Jr. Award in Patient Reported Outcomes, and the Gerontological Society of America’s AGESW Faculty Achievement Award. Dr. Fortuna served on the International Standards Advisory Committee to develop the first-ever international accreditation standards for behavioral healthcare for older adults. Dr. Fortuna also serves on the American Psychiatric Association expert advisory panel on smartphone apps.

Dr. Fortuna led the development of the first digital peer support curriculum to equip older adult peer supporters with the skills and knowledge to offer digital peer support. The Digital Peer Support Certification was co-produced with Dartmouth scientists and peer support specialists and has been found to be an effective knowledge translation training that has shown to increase peer support specialists’ capacity to use digital peer support in practice (http://digitalpeersupport.org/).

We hope you enjoyed this feature article from the Magellan Healthcare eMpowered for Wellness June newsletter.

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