Friday, 25 September 2020

Writing Notes & Peer Roles: A Conflict of Interest

There has been a relative explosion of ‘peer’ roles in the last five years in Massachusetts. StackofFiles

In many organizations, peer roles came to be developed largely because contracts began to require them (though many of these same organizations were already contemplating how to make that move of their own volition, and some had already begun to do so).

While most people see this shift as positive, it comes with many inevitable ‘bumps,’ learning curves, and tensions.

One of the most present and ongoing tensions connected to the integration of peer roles has been figuring out how to make space for a role that operates in a substantively different way, while still needing to meet the basic requirements and needs of the organization within which the position is held. Issues of this sort that have arisen include those around:

  • medication administration
  • involvement in representative payeeships
  • treatment planning 
  • note taking.

We'll be focusing on the last part, the taking of notes.

In its purest form, the ‘peer’ role is intended to be based in mutuality, partnership and the concept of ‘in but not of’ the system. But what does each of these mean? In brief:

Mutuality: Mutuality does NOT necessarily mean exactly equal or identical roles, and still leaves room for some responsibilities for each person to be different. However, it does require that no one be seen as THE expert, and it assumes that the focus is on the relationship rather than one person. 

Partnership: This principle assumes that no one is taking on the ‘doing for’ or ‘fixing’ role, and that there is a sense of shared responsibility and participation that is practiced intentionally throughout the relationship. Power balance is critical.

'In But Not of': This is the trickiest but perhaps the most important of these concepts. The peer role has been developed around the concept that the job is to work in the system, but NOT be responsible to all the system’s systems. Instead, the main priority and focus is to make sure that the individual with whom they are working is supported to develop their voice and be heard. Above all else, the person in the peer role helps to create the conditions (by the language they use, the opportunities they point out, the resources they share, the questions they ask, etc.) to make that possible.

Plainly put, note taking interferes with all of these most basic values.dominoes

  • It takes away from mutuality by requiring one person to write about another.
  • It enhances power differentials that can damage the trust that is so critical to peer-to-peer support. 
  • It moves away from partnership and shared responsibility by creating a ‘reporting back’ requirement. 
  • Even attempts to ‘share’ writing notes WITH the person about whom the note is being written have most recently been foiled by new, computerized note keeping systems that are not accessible where meetings are actually taking place.
  • Finally, it clearly interferes with the ‘in but not of’ principle. Notes are most typically attached to treatment plans, and while it is within the scope of a peer-to-peer relationship to support someone to develop their voice and vision around what they’d like their treatment plan to say, it is NOT within the scope of that relationship to have the person in a peer role be responsible for writing that plan, writing corresponding notes in that plan, to be written into that plan as responsible for some element or intervention and so on.
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Most commonly, providers say that they have no choice but to require people in peer roles to make notes on their interactions for one or more of the following reasons:

The Whole Team Needs to be Kept in the Loop: It is true that the less documentation there is, the more trust is required that something of value is happening. Traditional teaching has also suggested that when something of value happens, we all should know about it. However, more recent understandings suggests that creating space for learning about someone in relationship rather than on paper is not only okay, but positive and even preferable and even if it means we each truly hold a different part of the connection and knowledge.

It’s our only proof that we are following through with a given treatment plan: The way that the documentation system is set up, the Individual Service Plan provides a framework for the Individual Action Plan, which provides a framework for goals and interventions, which provides a framework for notes and progress reports (and so on). Based on the previously discussed values, writing someone in a peer role into this system does not work, and also violates the Massachusetts Certified Peer Specialist’s (CPS) Code of Ethics.

Specifically, the CPS Code states that:

Certified Peer Specialists will not enter into dual relationships or commitments that conflict with the interests of those they support.”

This is considered to include being written into treatment plans and taking notes because of its interference with the ‘in but not of’ component. Otherwise, the essential commitment to advocating with and supporting the individual’s voice, preferences and self-determination can be lost or diminished. Thus, as people in peer roles should not be written into a treatment plan as responsible for any particular task, presumably other team members are written in and should be the ones actually following up on any notes and progress reports that need to be made.

It’s a requirement of the funder and/or of the Rehab Option process and/or we won’t get paid without doing it!: This is the most common concern and it is a valid one. However, it is important to note the following two points:

First, there are many different providers under the exact same funding stream and regulations as one another, and between them, different ways of doing things have developed. At lease one provider organization in Massachusetts that holds both Community Based Flexible Support (CBFS) and Emergency Services contracts is NOT asking people in peer roles to write notes. This alone suggests that it is critical for organizations to talk with one another and always ask ‘why,’ rather than assuming there are no other options.

Secondly, the Rehab Option process – while important – is not the only method of funding. While it may be seen as essential to ensure that a certain percentage of documentation is made in a particular manner in order to meet Rehab Option standards, officials within the Department of Mental Health (DMH) have also acknowledged at times that sometimes provider organizations get overly focused on the Rehab or ‘R-Day’ process.

Consider this:

  • DMH pays a provider for any day in which a particular person is enrolled in CBFS services, regardless of whether or not it qualifies as a ‘R-Day.’ If someone is documented as enrolled for a full year, DMH pays for all 365 days.
  • For days that are documented as ‘R-days’ and meet all the Rehab Options standards for being a ‘rehabilitative’ service day (a rehab-oriented goal from the treatment plan was worked on and properly documented), Medicaid then reimburses 50% of the cost for that day to DMH.
  • There are no minimum or maximum expectations for how many ‘R-days’ need to be successfully billed for a given individual (though zero ‘R-days’ over time may eventually call into question a person’s enrollment with a rehabilitative service like CBFS). It’s also worth noting that there is an average rate of about 25% R-day billing across the state.
  • This means that DMH is already anticipating paying for a majority of services without reimbursement from Medicaid.

Given that peer-to-peer supports account for only a tiny fraction of services being paid for through DMH contracts, it seems fair to assert that a goal of achieving the state average of 25% R-day billing (or even substantially higher than that) should NOT necessitate people in peer roles to participate in note writing.


Ultimately, we are all in a learning process and need not approach one another with blame or accusations. However, we do need to approach one another.   Conversations need to be ongoing and recognize that peer roles are intended to be something clearly different. They lose their value if they are the same as or too similar to other roles.

We now know from looking at the details of funding stream requirements and different organizations, that peer roles CAN be incorporated without involving them in treatment plans, medication administration, representative payeeships and note taking. We simply need to open ourselves to creativity, learning from one another and the idea that things really can be different in order to support one another to get there.





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