Background SAMHSA defines a peer provider as “a person who uses his or her lived  experience of recovery from mental illness and/or addiction, plus skills  learned in formal training, to deliver services in behavioral health settings  to promote mind-body recovery and resilience.” Generally, peer providers  are known as “peer support specialists” in mental health settings. Peer  support specialists are distinguished from traditional mental health service  providers by their lived experience recovering from mental illness. People  with serious mental illness generally receive longer term and more  intensive treatment—either in a primary care or specialty setting—and  peer support specialists may play a key role in the recovery process for  these individuals. Peer support specialists work in a variety of settings, including clinical  settings such as hospital emergency rooms, independent peer-run  organizations, and on support teams in housing agencies that help  eligible low-income families and persons with disabilities find rental  housing. They can also deliver a varied set of services, including sharing  of experience, goal-setting, developing coping and problem solving  strategies to help individuals self-manage their mental illnesses, and  linking individuals to desired resources like transportation or volunteer  opportunities. Importantly, the services provided by peer support  specialists complement, but do not replace, clinical services. Peer Support Specialist  Certification Like other behavioral health specialties, the requirements for certifying  peer support specialists vary by state, and certification bodies range from  state government entities to independent non-profit organizations. The  development of state-level peer support specialist certification programs  was largely driven by another HHS agency, the Centers for Medicare &  Medicaid Services, which in 2007 recognized peer support services as an  evidence-based mental health model of care and established minimum  requirements for states seeking federal Medicaid reimbursement for peer  support services. One of these requirements is that peer support  specialists complete a training and certification program as defined by the  state. Another requirement is that peer support specialists receive  supervision from a “competent mental health professional,” which may be  provided through direct oversight or periodic care consultation. The state  defines the amount, scope, and duration of the supervision as well as  who is considered a competent mental health professional. States have used the flexibility allowed by the Centers for Medicare &  Medicaid Services to create their own programs to certify peer support  specialists. Some of these state peer support specialist programs are  assessment-based certificate programs—programs that provide training  and then evaluate whether applicants achieved the learning objectives of  that training through an examination in order to receive certification. Other  programs are professional certification programs—programs that evaluate  applicants against predetermined standards of knowledge, skills, or  competencies. In professional certification programs, the certifying body  is independent from, and is not responsible for, the training process. SAMHSA and Peer  Support Specialists SAMHSA supports the peer support specialist field through training,  technical assistance, and grant funding. For example: From 2009 to 2014, SAMHSA partnered with stakeholders, such as  the National Association for State Mental Health Program Directors, to  gather nationally-recognized experts and stakeholders from across  the United States for an annual meeting. These meetings, known as  the “Pillars of Peer Support,” aimed to identify and create consensus  around factors that facilitate the use of peer support services in state  mental health systems of care. In 2015, SAMHSA developed core competencies defining the critical  knowledge, skills, and abilities needed by anyone who provides peer  support services through a technical assistance project. According  to officials, the core competencies were developed in response to  inconsistencies in the training and certification of peer support  specialists that emerged as states began to develop their programs.  SAMHSA’s core competencies reflected the five foundational  principles of peer support identified by consumers and other  stakeholders: services should be (1) recovery oriented; (2) person- centered; (3) voluntary; (4) relationship-focused; and (5) trauma  informed. In addition to developing the core competencies, the  project provides trainings and offers technical assistance to states,  counties, providers, and other stakeholders. Funding for Peer Support  Specialist Programs Although Medicaid provides the largest share of funding for state mental  health agencies, followed by state funds, SAMHSA also provides grant  funding that states can use for both the service and administrative  components of their peer support specialist programs. For example,  SAMHSA’s Center for Mental Health Services funds peer support  programs through its administration of the Community Mental Health  Services Block Grant, which provides flexible funding to the states to  support services and related support activities for individuals with serious  mental illness. While the Community Mental Health Services Block Grant  accounted for less than 1 percent of total revenues received by state  mental health agencies in fiscal year 2015, the flexibility of the funds  allows them to be expended to pay for services that Medicaid and other  health insurance will not pay for, such as training and developing  standards. In fiscal year 2018, 40 states and the District of Columbia  reported using the funds from the Community Mental Health Services  Block Grant for peer support. SAMHSA also provides discretionary grants directly to domestic nonprofit  organizations that aim to expand the capacity of peer support providers.  These discretionary grants, including the Statewide Consumer Network  Program grants, have helped establish recovery-oriented, consumer- driven services at the state level. SAMHSA also provides block and  discretionary grants focused on substance use through its Center for  Substance Abuse Treatment and Center for Substance Abuse  Prevention, both of which have been used for peer recovery coaches. While most states use SAMHSA grants and state general funds to  develop and sustain their peer support programs, as of 2016, 41 states  and the District of Columbia were receiving federal Medicaid  reimbursement for the services provided by peer support specialists.  Georgia was the first state to receive federal Medicaid payment for peer  support services in 1999, and additional state Medicaid programs began  to provide coverage of peer support after the Center for Medicare &  Medicaid Services issued guidance in 2007 on the requirements for  federal payment for such services. In addition to meeting the minimum  requirements for peer support services—including training and  certification, supervision, and care coordination—states that bill for peer  support services under the Medicaid program must comply with all  Medicaid regulations and policies. Selected State  Programs Generally  Use Similar  Processes for  Certifying Peer  Support Specialists,  with Some Variation  in Program  Requirements Programs in all six states that we reviewed generally use the same  process for screening, training, and ultimately certifying peer support  specialists. See figure 1 for an illustrated example of this process. Although the six states’ programs generally use the same process for  certifying peer support specialists, as of May 2018 the programs varied in  the specific requirements applicants must meet for each of the three  stages of certification: screening, training, and certifying. See appendix  II for detailed information on state program requirements. Screening Requirements To determine applicants’ eligibility for peer support specialist certification,  all six state programs we reviewed have screening requirements  applicants must meet when applying for certification. These screening  requirements include requirements related to education, lived experience  with mental illness, prior work or volunteer experience, and letters of  recommendation. The extent to which each screening requirement was  used by each state varied, and the specifics of each requirement also  varied across the six programs we reviewed (see fig. 2). Education. Five of the six states that we reviewed required a high school  diploma or equivalent. Officials from four of these states indicated that  this level of education was necessary given the skills needed by peer  support specialists, such as reading comprehension and communication  skills. In contrast, Oregon officials told us that they did not require a high  school diploma or equivalent; however, the officials noted that most of  their peer support specialists have at least a high school education. Mental health experience. While all six state programs we reviewed  required applicants to have lived experience in recovery from mental  illness, the programs implemented this requirement in different ways.  Some required a mental health diagnosis, while others required a  minimum length of recovery time or required applicants to have received  services for a mental illness. Texas officials said they did not have a  specified length of recovery requirement due to the difficulty of pinpointing  the specific time a person began his or her recovery; rather, Texas  required applicants to self-identify as having experience living in recovery. Prior work or volunteer experience. Three of the six state programs  required applicants to have prior relevant work or volunteer experience,  although the amount of experience required varies. For example, to start  the certification process, applicants in Michigan must be currently working  in a peer support specialist role and have been in that position for at least  10 hours a week for the past 3 months. In contrast, Georgia officials told  us that they found this requirement to be a barrier for some individuals  who have not been able to work; therefore, Georgia did not have this  requirement. Letters of recommendation. Three of the six states required letters of  recommendation as another way to assess applicants’ readiness to  become peer support specialists. State officials stressed that the letter  should be a personal, work, or volunteer reference, rather than a clinical  reference. Training Requirements To ensure the competence of the peer support specialist workforce, all six  state programs we reviewed required applicants to complete an initial  training, which we refer to as “core training.” The core training is the initial  training provided to applicants seeking to become certified peer support  specialists and, while the curricula may vary by state or training vendor,  its purpose is to convey the skills and competencies that peer support  specialists need to enter the workforce. Topics covered during the training  typically include ethics, recovery, sharing the recovery story, and  communication skills. (See app. III for an example of a peer support  specialist core training schedule.) While all six states require applicants to  attend core training, the length, cost, and curricula of these trainings  varied across the states, as figure 3 shows. Length of training. All six programs required at least 40 hours of in- person core training, with Georgia and Pennsylvania requiring more than  70 hours. The six states required at least a week of core training to allow  sufficient time to cover a core curriculum of general peer-related  information, such as the meaning and role of peer support services, and  at times including role play, in an effort to develop the interpersonal skills  needed for an effective peer leadership. Cost of training. All states but Florida charged applicants fees to attend  training. Training fees varied by state, ranging from $85 in Georgia to  $1,400 in Pennsylvania. These fees varied because what they covered  also varied. For example, state program officials from Michigan told us  that, among other things, the $600 fee covers the price of lodging for the  core training, consultant fees, materials, and college credit hours that can  be earned by attending the training and the graduation ceremony. In  contrast, state program officials from Georgia told us that the $85 they  charge covered the cost of producing the course manual and that all other  costs are covered by the state. Training curriculum. Four of the six state programs had their own  approved core training curriculum to be used for applicants, while the  remaining two programs in Oregon and Pennsylvania allowed applicants  to select from approved training vendors—each of which had its own  training curricula. Certification Requirements To complete the certification process, all state programs we reviewed  assessed applicants’ knowledge of the concepts taught in the core  training through an examination. The applicants also had to sign and  abide by a code of ethics. However, as of May 2018, the state programs  varied as to who administered the certification examination, the type of  code of ethics applicants were required to sign, the frequency with which  certifications had to be renewed, and the continuing education  requirements certified peer support specialists had to meet. (See fig. 4.) Examination. Four of the states we reviewed administered a single,  statewide exam that applicants must pass before becoming certified,  while in the remaining two states applicants had to pass an exam  administered by the approved training vendor. The exams included  multiple choice or essay questions. One training vendor responsible for  conducting training in at least two states told us that the vendor included  an oral evaluation component as part of the exam, in light of the  communication and interpersonal skills needed for the peer role.  Similarly, a state program official from Pennsylvania told us that  observational assessments are also used to determine an applicant’s  skills and knowledge. Code of ethics. Like other health professions, peer support specialists  typically must agree to abide by a code of ethics. All six states we  reviewed required peer support specialists to sign a code of ethics before  becoming certified. Of the six states, the codes of ethics in Pennsylvania,  Georgia, Michigan, and Texas were unique to peer support specialists,  while Florida and Oregon used codes of ethics that also applied to other  workforces, such as substance use disorder professionals and community  health workers. Relatedly, five of the six states also had formal processes  in place to investigate and take action in the event that a peer violated the  code of ethics by, for example, disclosing confidential information. These  actions range from reprimand to revocation of certification. Certification renewal. Three of the six states we reviewed required peer  support specialists, once certified, to renew their certifications every 1 to 3  years, while the remaining three states awarded lifetime certifications. Continuing education. Five of the six states required certified peer  support specialists to meet annual continuing education requirements,  which ranged from approximately 10 hours per year to 36 hours every 2  years. According to some state program officials, requiring continuing  education ensures continued competence in the field of peer support or  provides specialized training, such as training for working with specific  populations (such as veterans) or incorporating additional approaches or  skill sets (such as training about the Wellness Recovery Action Plan). State Officials  Generally Cited Six  Leading Practices for  Certifying Peer  Support Specialists Officials from peer support specialist programs in selected states  generally cited six leading practices for certifying peer support specialists.  The 10 stakeholders—representing the perspectives of researchers,  training or consulting organizations, associations, and advocacy  organizations—we spoke with generally agreed that the six identified  leading practices should be incorporated into programs that certify peer  support specialists because the practices can lead to stronger quality of  services for individuals with serious mental illnesses. Leading practice one: Systematic screening of applicants. Program  officials in five of the six selected states cited the importance of  systematic or detailed screening of applicants to become peer support  specialists as a leading practice. All six state programs assessed  applicants through a variety of approaches, including (1) using screening  questions about the applicants’ understanding of the peer role, (2)  conducting telephone interviews with applicants, (3) reviewing  applications with a standardized tool or scoring rubric, and (4) having  multiple people review applications for objectivity. Eight of the 10  stakeholders we interviewed confirmed that this was a leading practice,  though some cautioned that these requirements should not unnecessarily  exclude individuals with unique backgrounds or little work history. The  Defense Centers of Excellence for Psychological Health and Traumatic  Brain Injury, which in 2011 explored how to most effectively apply peer  support in the military environment as part of its ongoing mission, has  similarly identified systematic screening with defined selection criteria as  a best practice for peer support programs. While work or volunteer experience can be used as a screening  requirement for applicants and was required by three of the states we  reviewed, four of the stakeholders we interviewed commented that  meeting these requirements can be challenging for individuals with a  history of mental illness who may have been previously unable to enter  the workforce. Research has shown that the stigma associated with  mental illness is a significant barrier to work for individuals with mental  illness and has shaped employer decisions about hiring or keeping a  person with mental illness in the workplace. These workplace barriers,  along with others, such as access to mental health treatment, contribute  to the relatively low workforce participation of adults with serious mental  illnesses. One stakeholder commented that peer support programs have  a responsibility not to contribute to barriers in the workplace for  individuals with mental illnesses. Our review shows that some of the peer support specialist programs in  the six selected states are taking steps to address these barriers. For  example, Florida recently changed its requirements and now provisionally  certifies peer support specialists who meet all the certification  requirements except for the requirement to have 500 hours of work or  volunteer experience. After receiving the provisional certification, peer  support specialists have 1 year to complete the work or volunteer hours  necessary to upgrade to the full certification. Leading practice two: Conducting core training in-person. Program  officials from five of the six selected states cited core training that is  conducted in-person, as opposed to online, as a leading practice. Three  program officials told us that core training should be done in-person to  foster relationship building and experiential learning to develop the  interpersonal skills a certified peer support specialist needs. All six state  programs had in-person core training, regardless of whether the training  was run by the state program itself or through approved vendors. For  example, Michigan hosts its core trainings at a retreat center where  participants are encouraged to stay for the week. Michigan program  officials told us that this creates a place for training participants from  across the state to network, discuss how their agencies work and the  types of issues they face as peer support specialists, and share best  practices. SAMHSA’s core competencies identify the importance of using  active listening skills, understanding when to share experiences and  when to listen, and using their own recovery story to inspire hope. All 10 stakeholders we interviewed confirmed that providing in-person  training was a leading practice, though 3 commented that some of the  knowledge segments could be done online. Five stakeholders we  interviewed told us that observing the skills of peer support specialists  during training or incorporating observation as part of the certification  exam is important. One stakeholder explained that while written tests are  a good measure of basic knowledge, the tests cannot fully assess the  skills and competencies needed for certification. While 2 stakeholders  cited the increased costs of delivering and grading exams with an  observational component as the reasons many states use written exams  only, 1 stakeholder noted that including an observational component is a  more accurate assessment of whether or not people have developed  needed skills. Another stakeholder commented that using a written test  alone may allow individuals who are good test takers to become certified,  even if they lack the interpersonal skills needed to be a peer support  specialist. Leading practice three: Incorporating physical health and wellness  into training or continuing education. Program officials from five of the  six selected states cited the importance of emphasizing to peer support  specialists that they should help others manage their physical health—in  addition to their mental health—during core training or continuing  education as a leading practice. All six of the selected states incorporated  managing physical health conditions into their core training or continuing  education. (See text box.) In these trainings, peer support specialists  learn how to help others with access to needed care and prevention  services, set personal health goals to promote recovery and a wellness  lifestyle, and adopt healthy habits to prevent disease or lessen the impact  of existing chronic health conditions. The need for physical health- related training was identified after a 2006 report found that individuals  with serious mental illnesses were dying 25 years earlier than the general  population, largely due to treatable medical conditions caused by  modifiable risk factors, such as smoking and poor nutrition or obesity.  SAMHSA identified educating peers about health, wellness, recovery, and  recovery supports as a core competency. All 10 stakeholders we interviewed confirmed that emphasizing the  importance of physical health was a leading practice, though 2  stakeholders commented that incorporating physical health and wellness  into trainings should only be done as continuing education. Example of Leading Practice Three: Georgia Peer Support Whole Health and  Wellness Georgia determined it was important to incorporate physical health and wellness into  training for peer support specialists and was the first state to have related services— which it calls Peer Support Whole Health and Wellness—provided by certified peer  support specialists covered by Medicaid. These peer support specialists—who complete  additional training and are certified in Whole Health Action Management—receive  medical technical support from registered nurses and are trained to work in both primary  care and behavioral health settings. Georgia created the service using a SAMHSA- funded Transformation Transfer Initiative grant, which was designed to give states the  opportunity to increase their efforts to make their state behavioral health delivery systems  more consumer driven, among other things. The SAMHSA-Health Resources and Services Administration Center for Integrated  Health Solutions adapted Georgia’s training, along with a training developed by New  Jersey, to publish a Whole Health Action Management Peer Support Training Participant  Guide in 2015. This adapted 2-day training aims to teach peers to use a person-centered  planning process to create a whole health goal and how to engage in peer support,  including Whole Health Action Management peer support groups, to meet that goal. Leading practice four: Preparing organizations to effectively use  peers. Program officials from four of the six selected states cited efforts  to ready provider organizations—such as hospitals or drop-in centers—to  employ certified peer support specialists as a leading practice. State  program officials told us that organizational readiness includes making  sure staff understand the role of peer support specialists and can provide  appropriate supervision. (See text box.) Five of the selected states have  developed guidance or training for supervisors of peer support  specialists. Nine of the 10 stakeholders we interviewed confirmed that  this was a leading practice. SAMHSA identified using supervision  effectively and engaging in problem-solving strategies with a supervisor  as a core competency for this workforce. Example of Leading Practice Four: Michigan Peer Liaisons  In order to help provider organizations understand the role of peer support specialists,  Michigan created an informal peer liaison role at all 46 of the local Community Mental  Health Services Programs tasked with coordinating mental health services. State officials  told us that these peer liaisons have telephone calls and in-person meetings to provide  informal feedback on technical assistance needs and share information on how certified  peer support specialists are doing in their roles and responsibilities. According to state  officials, peer liaisons have helped prepare mental health agencies to work with peer  support specialists and have helped the state identify what new trainings should be  developed to better help peer support specialists succeed in the workplace. Many of the stakeholders we interviewed highlighted the importance of  having individuals in an organization who understand the peer support  role. Eight of the stakeholders we interviewed told us that supervisors  need to understand or be trained in the peer support role and skillset, with  three stakeholders commenting that supervisors need to be specifically  aware of the difference between peer support specialists and clinical  providers. For example, to achieve this the training and certifying  organization in Texas runs a twelve month program that helps provider  organizations effectively implement peer support services. The program,  which is designed as a learning community, focuses on changing  organizational culture, defining and clarifying the peer support specialist  role, and supervising these staff, among other things. Relatedly, three  stakeholders told us that there should be more than one peer support  specialist at each organization. One stakeholder noted that having  multiple peer support specialists at an agency provides built in support  and understanding of the peer role, which is important given that peer  support specialists typically have the lowest level of power in an organization. Another stakeholder noted that putting a single peer support  specialist in an organization can be isolating. Leading practice five: Continuing education requirements specific to  peer support. Program officials from five of the six selected states  considered it a leading practice to require, after certification, peer support  specialists to take continuing education that is specific to the peer support  role. This is to ensure that peers maintain their competency and are  aware of new developments in the field. Five of the six selected states  required certified peer support specialists to maintain their competence  through continuing education, and all five of these states had a  requirement that the continuing education be specific to the peer support  role. (See text box.) All 10 stakeholders we interviewed confirmed that  this was a leading practice. The Defense Centers of Excellence for  Psychological Health and Traumatic Brain Injury similarly identified as a  best practice enabling continued learning through structured training.  SAMHSA identified seeking opportunities to increase knowledge and  skills of peer support as a core competency for peer support specialists. Example of Leading Practice Five: Pennsylvania Continuing Education  Requirement As an added step to ensure that the peer support specialist workforce is competent,  Pennsylvania places some of the burden on provider agencies for ensuring that certified  peer support specialists meet continuing education requirements. The state requires its  licensed provider agencies to develop a staff training plan to ensure that each certified  peer specialist receives the continuing education they need. Pennsylvania also requires  these agencies to provide opportunities for certified peer specialists to network with other  certified peer specialists both within and outside the agency. The state monitors  compliance with these requirements through annual inspections. State officials told us  that this requirement serves as a safety net and assures them that certified peer support  specialists are up to date in their training. Leading practice six: Engaging peers in the leadership and  development of certification programs. Program officials from four of  the six selected states cited having certified peer support specialists lead  or participate in the certification process of applicants as a leading  practice. State program officials told us that peers should lead in a variety  of ways, including helping screen applicants, developing curricula,  providing training, and serving as mentors or supervisors to other certified  peer support specialists. For example, Michigan concurrently runs its  continuing education courses and core training in the same location so  that experienced peer support specialists can mentor new peers. Officials  from all six selected states told us that certified peer support specialists in  their states participate in some part of the certification process. (See text  box.) The Defense Centers of Excellence for Psychological Health and  Traumatic Brain Injury similarly identified as a best practice leveraging the  unique experiences and benefits peer support specialists offer as peers  throughout a peer support specialist program, including in positions of  leadership. All 10 stakeholders we interviewed confirmed that this was a  leading practice. Example of Leading Practice Six: Oregon Traditional Health Worker Commission  Through service on a statewide commission, peer support specialists in Oregon have a  leadership role in developing the education and training requirements for certified peer  support specialists and others. The Oregon Health Authority’s Traditional Health Worker  Commission promotes the role, engagement, and utilization of traditional health  workers—health workers who are certified by the state—in Oregon’s health care delivery  system. The commission includes member representatives of each type of traditional  health worker, including peer support specialists. In addition to developing the education  and training requirements for peer support specialists and other types of traditional health  workers, the commission developed the scope of practice to be used by provider  organizations that employ peer support specialists. On an ongoing basis, the commission  advises the Oregon Health Authority about the traditional health worker program and  ensures that the program is responsive to consumer and community health needs.  Oregon state officials consider having this advisory body with representation from the  peer community to be a best practice, commenting that the commission provides the  hands-on knowledge that the state can then implement through policy and rules. Agency Comments We provided a draft of this report to HHS for review and comment. The  Department did not have any comments. We are sending copies of this report to the appropriate congressional  committees, the Secretary of the Department of Health and Human  Services, the Secretary of the Department of Defense, and other  interested parties. In addition, the report is available at no charge on the  GAO website at http://www.gao.gov. If you or your staff should have any questions about this report, please  contact me at (202) 512-7114 or DeniganMacauleyM@gao.gov. Contact  points for our Office of Congressional Relations and Public Affairs may be  found on the last page of this report. GAO staff who made key  contributions to this report are listed in appendix IV. Appendix I: List of Organizations and  Individuals Interviewed State peer support specialist  programs Stakeholders Appendix II: Summary of Peer Support  Specialist Program Screening, Training, and  Certification Requirements in Selected  States Recovery experience   Must have lived  experience with a  mental illness or  substance use disorder  and have been in  recovery for a minimum  of 2 years.  Must have been in  recovery for at least 1  year between diagnosis  of mental illness or  substance use disorder  and application for  training program. Must have been  diagnosed with a mental  illness and been in  recovery for a minimum  of 1 year. Must currently be or  formerly have been  receiving services for  mental illness or  substance use disorder. Must currently be or  formerly have been  receiving services for a  mental illness. Minimum of 12  months of work or  volunteer  experience within  the last 3 years   Not required  2 (type unspecified) Must self-identify as  being in recovery from a  mental health challenge. For the purposes of this report, we use the term “peer support specialist” to describe individuals who  use their own lived experience recovering from mental illnesses to support others in their recovery;  however, each state may have different titles in place for the certified role achieved through their peer  support specialist programs. Appendix III: Example of a Peer Support  Specialist Core Training The training schedule below, developed by the Appalachian Consulting  Group, illustrates the content areas that may be included in core training  curriculum for peer support specialists seeking certification. The  Appalachian Consulting Group’s curriculum was used in the first  Medicaid-billable peer support specialist program in Georgia in 1999, and  since then the curriculum has been used to train peer support specialists  in 25 states. This training schedule is an example of the types of content  that could be included in such training, and is not an endorsement of a  particular training curriculum. Appendix IV: GAO Contact and Staff  Acknowledgments GAO Contact Staff  Acknowledgments In addition to the contact named above, Tom Conahan (Assistant  Director), Summar Corley (Analyst-in-Charge), JoAnn Martinez (Analyst- in-Charge), Kaitlin Asaly, Muriel Brown, Krister Friday, and Emily Wilson  made key contributions to this report.
As the peer support workforce has grown, there has been increased attention to standardizing the competencies of peer support specialists through certification. The 21st Century Cures Act included a provision for GAO to conduct a study to identify best practices related to training and certification in peer support programs in selected states that receive funding from SAMHSA. This report, among other things, describes leading practices for certifying peer support specialists identified by program officials in selected states. GAO interviewed state program officials in six selected states and reviewed online, publicly available information about their peer support programs. GAO selected the states in part based on the state's certification program being well-established (at least 2 years old), use of SAMHSA funding for peer support, and stakeholder recommendations. The six selected states—Florida, Georgia, Michigan, Oregon, Pennsylvania, and Texas--are among the 41 states and the District of Columbia that, as of July 2016, had programs to certify peer support specialists. In addition to the state program officials, GAO interviewed SAMHSA officials and 10 stakeholders familiar with peer support specialist certification, including mental health researchers and officials from training organizations, among others. GAO provided a draft of this report to HHS for review and comment. The Department did not have any comments. According to officials from the Substance Abuse and Mental Health Services Administration (SAMHSA) within the Department of Health and Human Services (HHS), shortages in the behavioral health workforce are a key reason that individuals with mental illnesses do not receive needed treatment. In recent years, there has been an increased focus on using peer support specialists—individuals who use their own experience recovering from mental illness to support others—to help address these shortages. Program officials GAO interviewed in selected states generally cited six leading practices for certifying that peer support specialists have a basic set of competencies and have demonstrated the ability to support others.