Peer Recovery Employment Program

Hamilton County Public Health (HCPH) serves 45 jurisdictions in Hamilton County—a region in southwestern Ohio. HCPH offers a wide range of services via its 100+ employees, with positions ranging from: environmental health specialists, plumbers, health educators, physicians, nurses, health counselors, epidemiologists as well as positions in several other specialty areas. Hamilton County has a population of 817,473, with the county seat being the city of Cincinnati. The U.S Census Bureau indicates that Hamilton County residents are 67.6% white, 26.6% black or African American, 3.6% Hispanic or Latino and 2.9% Asian. The median household income in Hamilton County is approximately $57,212.

                As with many counties across the United States, Hamilton County has had harrowing witness to the devastating impact of the current addiction crisis. Seeing an upward trend in overdose deaths over the past 10 years, Hamilton County has only recently reached a point of stasis but has still managed to average 472 overdose deaths annually between the period 2016-2021. This crisis has impelled a nationwide effort to utilize people with lived experience—or peers—to aid addicted individuals in getting the support they need from a trusted source. Peer Support Specialists are those parties who have been successful in their own substance abuse recovery and, in turn, become trained to help others achieve the same healthy outcomes. During the period of this project's inception, records indicated that Hamilton County had a scarcity of Peer Support Specialists, coupled with a lack of job training programs to help people in recovery become certified to enter the field of recovery support.

                To address this problem, Hamilton County Public Health partnered with Easterseals Serving Greater Cincinnati to recruit and train individuals to become certified Peer Support Specialists. The program thereby created was titled The Peer Recovery Employment Program” and included the following goals:

        -Enroll 50 recovering individuals into the program.

       -Have, at minimum, 30 program participants obtain their state Peer Recovery Support certification and subsequently                obtain employment as Peer Recovery Support Specialists.

        -Focus recruitment and outreach to those areas where the poverty rate exceeds 35%.

                    -The zip codes identified in Hamilton County that fall into this category also represent overdose hotspots for the                          county. 

During the first year of the program, each of the above-named goals was exceeded without the benefits of formal marketing and/or outreach. The success of this program was attributed to the demand for Peer Support Specialists in Hamilton County, Easterseals' rich history in workforce development, and Hamilton Country Public Health's strong ties to the local recovery community. Utilizing existing relationships, HCPH and Easterseals were able to form a strong network of intern sites and build widespread awareness of the program through formal and informal meetings as well as networking groups. The fluid collaboration between both organizations allowed for a swift start up and a very successful launch.

The Peer Recovery Employment Program has had the impact of raising the number of available Peer Support Specialists in Hamilton County by 50%. This increase brought the ratio of certified peers-to-population for Hamilton County on par with other major metropolitan areas in the State of Ohio. Fostering hope for long term stability, the graduates of this program have begun to create a network of recovering individuals who will ideally assume the mantle of being the next generation of Peer Support Specialists

             Use of peer recovery support specialists is a proven model for increasing access to treatment, sustaining recovery, and making real changes in the lives of people suffering from addiction. Studies have found that when a person is engaged in a peer support program, they are more likely to enter recovery and significantly less likely to relapse while engaging with peers. In addition, for those who do relapse, they are re-engaged in treatment at a much faster rate than those not participating in a peer support program (Boisvert, Martin, Grosek, & Clarie, 2008).The use of peer recovery support specialists is continuously expanding into new areas, including emergency departments, substance abuse treatment facilities, recovery housing, outpatient health clinics, health departments, and others. Having a workforce-ready pool of peer recovery support specialists is key to maintaining and growing the valuable use of peers in the addiction and recovery fields.

                Recovering individuals often emerge from years of addictive behavior to find themselves bereft of those basic foundational skills necessary to navigate the trials of everyday living, including those necessary to successfully transition into the job market. Skills like interviewing, professional networking, finance, and benefits management, as well as general exposure to a professional work environment may be in short supply for this population. People in recovery with the desire to become peer recovery support specialists need the skills, training, and support to complete this complex and demanding work—rendered more challenging by their own recovery management practices. In the state of Ohio, people working as peers can obtain a certification as a Peer Recovery Support Specialist by completing an online curriculum, a 40-hour in person training, and a certification exam. These trainings are not always accessible throughout the state and the technology and transportation requirements prove to be a barrier for many interested parties.

             In addition to a lack of peer support job training resources, Hamilton County was facing a shortage of certified peer recovery support specialists. In 2020, Hamilton County had 72 certified peer recovery support specialists listed on the Ohio Department of Mental Health and Addiction Services website. This equates to 1 peer for every 11,347 Hamilton County residents. This ratio underscored the necessity of this undertaking, especially when comparing Hamilton County with other Ohio counties facing a similar addiction crisis: Franklin County had 188 certified peers, or 1 for every 7005 residents, and Cuyahoga County had 268, or 1 for every 4608 residents. To meet the growing demand, and to ensure that residents affected by addiction have the help and support they need, Hamilton County needed to increase the number of peer support specialists while ensuring that the people doing this work had the training and resources needed to be successful in their roles.

                To address these needs, Hamilton County Public Health partnered with Easterseals Serving Greater Cincinnati to launch a workforce development program focusing on recruiting, training, and supporting people in recovery from addiction who wanted to work as peer recovery support specialists. The program would provide the state required trainings, along with other workforce trainings such as, resume building, career aptitude testing, and interview skills training. Once a participant was ready, they would be placed in a paid internship working alongside an experienced peer support specialist. This placement included regular supervision with an experienced peer recovery support specialist who acts as a mentor to help guide program participants through the process.

Boisvert, R., Martin, L., Grosek, M., & Clarie, A. J. (2008). Effectiveness of a peer-support community in addiction recovery: participation as intervention. Occupational Therapy International, 205-220.

The Peer Recovery Employment Program's overall goal is to result in:

           -Work and work readiness as a tool to promote, support, and make durable recovery.

            -Increase the number of skilled, trained, and certified peer supporters in Hamilton County.  

The measurable outcomes and goals of the work experience program were:

              -Enroll 50 recovering individuals into the program.

               -Have, at minumom, 30 program participants obtain their state Peer Recovery Support certification and  subsequently obtain employment as a Peer Recovery Support Specialist. 

Focus recruitment and outreach to those areas where the poverty rate exceeds 35%.

              -The zip codes identified in Hamilton County that fall into this category also represent overdose hotspots for the county. 

The stated goals were met by utilizing Easterseals' workforce development experience and Hamilton County Public Health's dense community partner network. Staff from Hamilton County Public Health helped Easterseals foster relationships with the recovery community which in turn helped shape the workforce program and build a network of work experience sites. These newfound relationships helped spread information about the Peer Recovery Employment Program via networking among professionals and individuals in recovery. Personnel from Easterseals developed a curriculum that included professional development training, resume building, relationship skills, peer support training, and other professional skills. By incorporating lessons from their preestablished, successful workforce development programs, Easterseals was able to design the coursework in efficient timing—facilitating a swift program launch.

                HCPH first held meetings with community partners in early 2020 to discuss the viability of a Peer Recovery Employment Program. Prior to issuing the request for proposal, the provisional framework and objectives for the program had already been outlined by HCPH. In June of 2020, HCPH awarded the bid to Easterseals Serving Greater Cincinnati with a goal start date of September 1^st, 2020. To stay on track within the short project development period, HCPH and Easterseals would come to lean on existing relationships from within their respective organizations to shape a list of internship sites and other supportive resources. HCPH has long standing relationships with many treatment providers, healthcare systems, and recovery support organizations in Hamilton County. While Easterseals has deep ties to several community organizations, their relationships in the field of addiction and recovery were not as strong as those of HCPH during the period of the project's inception. HCPH staff helped address this deficiency by linking Easterseals with numerous organizations that would come to offer support for the Peer Recovery Employment Program. These treatment connections—coupled with the expertise of Hamilton County Public Health's staff—helped to develop a diverse pool of internship opportunities for program participants and facilitated the prompt development of the program. With this diverse group of available intern sites, participants were able to obtain experience in a variety of work environments during the program. Easterseals' solid reputation and adroitness in professional networking has helped to strengthen these relationships, leading to even more opportunities for success.

                The year one budget for this program was $349,998.56, with an estimated cost per participant of $6.999.97. These figures represented a 15-month initial contract which included 3 months to develop and launch the program, and 12 months for the first year of programmatic activity. Per the proposal, no less than 50% of funds were allocated for direct payments or incentives to program participants. This includes the hourly wages for internship hours worked as well as incentives for reaching certain milestones in the program. The grant for year 1 was $350,000.00 with an additional $350,000.00 for an optional extension year. Year 2 costs are estimated to remain the same, with several changes to the program structure and additional personnel being hired to support the program.

               The contract between Easterseals and HCPH stipulates that the former party shall supply the latter with monthly status reports—providing updates on the progress of each participant in the program, in addition to updated worksite placement information. This data is used by HCPH and Easterseals to continually reassess the program's efficacy and to develop improvement strategies.  

               In August of 2020, one month before the program's launch, Hamilton County had a mere 72 certified peer recovery support specialists. This figure allotted Hamilton County a 1: 11,347 ratio of peer recovery support specialists to county residents. For comparison, Franklin County (in the Columbus area) had 188 peer recovery support specialists with a 1: 7,005 ratio and Cuyahoga County (in the Cleveland area) had 268 peer recovery support specialists with a 1: 4,608 ratio.

               These comparisons laid bare Hamilton County's deficiency in the arena of peer recovery support—falling significantly behind the other major metro centers in the state of Ohio. With the extant research suggesting the significant impact that peer recovery support specialists can have in linking people to addiction treatment, the need for increased support and training in Hamilton County became clear. The goals of the Peer Recovery Employment Program were to enroll 50 participants in the program, have 30 of these enrollees complete the program and obtain certification as peer recovery support specialists, and have these graduates gain employment in the field of recovery support.

                At the close of the program's 1^st year, 72 participants had been enrolled with 36 of these parties graduating and subsequently obtaining their certification as peer recovery support specialists. 34 of these graduates have been placed into high-wage, full-time employment positions within the field of recovery support.

               The close of the program's 1^st year saw a 50% increase in the number of certified peer recovery support specialists in Hamilton County, bringing the total from 72 to 108. These welcome additions to the peer recovery workforce brought the ratio of certified peers to Hamilton County residents to 1: 7,569. This ratio brings Hamilton County closer in line with other metro regions in the state of Ohio.

                   The positive word of mouth and sheer demand for the program have been other positive indicators of its success. While the goal for year 1 was to have 50 individuals enrolled, the program managers often had a wait list for openings in new cohorts and ultimately exceeded their enrollment goal by 44%. Many of the program participants were hired by the same workplaces where they completed their internships, further indicating the demand for qualified, work ready, peer recovery support specialists.

                One change that was made based on program evaluation data was the time frame for participants to complete the program. While some participants were eager and ready to enter the workforce, some required more extensive coaching and support, leading to a longer than anticipated program length. In response to this feedback, Easterseals became more flexible and responsive to the individual needs of its program participants. With some participants completing the program in less than the 6-month estimate, Easterseals was able to open additional slots in the program, which helped lead to a higher than anticipated number of first year enrollees.

                 A few lessons were learned during the first year of this program. Finding and securing work sites for the paid internships proved difficult at times. Though ostensibly an easy process, in practice, many organizations who employ Peer Recovery Support Specialists were hesitant to participate in the internship portion of the program. For new programs of a similar ilk to have a more fluid development period, more work needs to be done prior to the program's commencement to ensure that internship sites are secured and ready from the onset. Nevertheless, worksites did return to the table after witnessing the benefits from their peer organizations.

                 Another lesson was to be learned in how HCPH—the funding organization—was able to provide meaningful support to Easterseals in developing the program. In the early stages of the program, HCPH provided many contacts and helped to build some key relationships with partners throughout the region. The synergy between Easterseals—with their reputation in workforce development—and HCPH—with their reputation in the addiction and recovery field—proved a winning combination in generating early success with partnership building.  

                   For the first year of the program, Easterseals relied on a partner organization to conduct the 40- hour live trainings that are a part of the required certification process for Peer Recovery Support Specialists. While scheduling participants for this training was possible, it did create barriers insomuch as openings were not always available. For the 2^nd year, Easterseals has begun to have in-house personnel conduct these trainings, which will open more opportunities for flexible class hours and quicker completion of the training hours.

                  As the funder, HCPH learned early on that flexibility would be a necessity in the program's development and implementation. Individuals entering recovery find themselves beset with a host of newfound barriers and challenges, the Peer Recovery Employment Program's participants being no different. By design, participants can change tracts and move to one of the other workforce development programs offered by Easterseals. This option ensures that participants do not feel pigeonholed should they realize that they are no longer interested working in the field of recovery support. Flexibility is also needed in being responsive to the unique, individual needs of program participants, specifically with regards to the amount of time required to complete the program. Some participants did not require the entire 6-month training duration and were ready for employment in roughly half that time. Others have needed far more time and support to be ready for the workforce.

                    The success and continued demand for this program demonstrates the need to continue offering training and support for people in recovery. HCPH and Easterseals have seen the benefit of this program and have taken steps to secure funding for an additional 2 years of cohorts with hopes of continuing the program beyond that. Those affiliated with the program see the positive results as self-evident and demonstrative of a greater need for meaningful job training for people emerging from addiction into the recovery lifestyle.    

                   While this program is currently funded at $350,000.00 annually, it would be possible to integrate the development of peer supporters into other existing workforce development programs at a much lower cost. The largest single expense for this program were the paid internship wages. These wages help to remove barriers that could have otherwise prohibited certain participants from joining the program due to the requirements of job training classes. We believe this is an important aspect of the program and allows participants to focus on their training and development. Nonetheless, it would be possible to run this program without a paid internship, or to partner with the worksite locations to provide wages for the interns.