Transcript SUPPORTED EMPLOYMENT - Illinois Co

The Illinois Employment &
Recovery Revolution
Emerging Options for
Persons with Co-Occurring
Disabilities
Regions I & II
Overview of the day
EBSE & MISA research, principles,
practice, org. structure
 EBSE & Recovery in consumers
voices
 VR unique contributions
 Opportunities for collaboration &
leadership

Why Focus on Employment?
 Viewed
by many as an essential
part of recovery
 Most consumers want to work
 A typical role for adults in our
society
 Cost-effective alternative to
day treatment
Positive Outcomes from
Competitive Work
 Higher
self-esteem
 Better control of psychiatric
symptoms
 More satisfaction with
finances and with leisure
(Bond et al., 2001)
Is Work Too Stressful?
 As
compared to what?
 Title of an article:
“If you think work is stressful, try
unemployment.”
 Stresses of work do not translate
into higher rates of
hospitalization
Negative Effects of
Unemployment in General
Population
 Increased
substance abuse
 Increased physical problems
 Increased psychiatric disorders
 Reduced self-esteem
 Loss of social contacts
 Alienation and apathy

(Warr, 1987)
Competitive Employment for
People with Severe Mental
Illness
 Say
they want to work: 70%
 Are currently working: <15%
 Current access to supported
employment: <5%
J
&
J-Dartmouth
Project
mMental health-vocational rehabilitation
collaboration
iImplement evidence-based SE
LLocal programs selected by states
DDartmouth provides training, consultation,
and evaluation
FFirst states: CT, DC, KS, MD, OR, SC, VT
NNew states: IL, MN, OH
–
(Drake, 2006)
J&J Project Strategies
SStart
with “early adopters”: states &
programs
VVR-MH collaboration: Consistent finding
LLongitudinal training
OOutcome-based supervision
PProblem solving by local experts
–
(Drake, 2006)
Overview for
Narcoleptics
SSupported
employment is an effective
evidence-based practice
LLong-term perspective is even better
IImplementation is critical
AAmplifying effectiveness: more
people and more hours
Narcoleptics (cont.)

Illinois leads through partnerships

VR & SA role is unfolding

Cross-fertilization of SA, MH, VR
models and methods in our state
What Is Evidence-Based Practice?
 A practice
validated through
rigorous research
 Has guidelines describing
critical ingredients
 Ideally, has been successfully
implemented in a wide range
of settings
Randomized Controlled Trials
(RCTs) of Supported Employment
 Strongest
scientific design for
evaluating whether a treatment
works
 Studies include:
–4 conducted before evidence-based
principles articulated by IPS
model
–13 used full implementation of IPS
Competitive
Employment
Rates
in
90%
80%12 RCTs of Supported Employment
70%
60%
50%
40%
30%
20%
10%
0%
96 94 04 04 04 05 05 99 95 00 05 97 02
NH NY CA IL CT SC HK DC IN NY QUE CA MD
(IPS) (SE) (IPS) (IPS) (IPS) (IPS) (IPS) (IPS) (SE) (SE) (IPS) (SE) (IPS)
Supported Employment Control Control 2
117
Current Status RCTs
studies: add UCLA , EU,
Thresholds, Australia
660% vs. 22% employment
FFindings very consistent
RRecent IPS studies over 70%
employment – early intervention
Indirect Impact on
RRelated
to sustained
competitive
Other
Outcomes
employment
IImproved self-esteem, symptom
control, life satisfaction
NNo changes with sustained sheltered
employment
(Bond, 2001)
Studies of Long-Term Outcomes
from
Supported
Employment
TTest: 10 years
MMcHugo:
3.5 years
BBond: 3.5 years
SSalyers: 10 years
BBecker: 8-12 years
DDrake: 10 years
10-Year Follow-up of Day
Treatment
to
SE
Conversion
992% worked during follow-up

447%
currently working
333% worked at least 5 years
MMany reported increases in hope, self-esteem,
relationships
(Salyers, 2004)
8-12 Year Follow-up of
SE
771% working at follow-up
NNearly
all in competitive jobs
–77% sheltered, 10% volunteer
771%
worked more than 50% of FU
BBut 90% still receiving benefits
(Becker, 2006)
Current Status of
SE
EEveryone
who wants to work should
receive SE
MMost will succeed and difficult to predict
LLimitations of current SE
CCurrent efforts to improve outcomes
Limitations of SE
OOne-fourth
do not work
MMost people do not work full-time
MMost people stay on benefits
Amplifying the Effects
–SSkills training (Marder)
–EVR role (Illinois/Dartmouth)
–BBenefits counseling (Tremblay)
–MMotivational interviewing (Corrigan, Drebing)
–CContingency management (Drebing)
–CCognitive training (McGurk)
–CCompensatory mechanisms (Velligan)
–MMedications (MATRICS)
Explaining Variance
225%
local economy
225% SE fidelity
550% individual practitioner
–
(Becker, 2006)
Definition of
Supported Employment
 Mainstream
job in community
 Pays at least minimum wage
 Work setting includes people who
are not disabled
 Service agency provides ongoing
support
 Intended for people with most
severe disabilities
Evidence-Based Principles
 Eligibility
is based on consumer choice
 Supported employment is integrated with
treatment
 Competitive employment is the goal
 Personalized benefits planning is provided
 Job search starts soon after a consumer
expresses interest in working
 Follow-along supports are continuous
 Consumer preferences are important
Eligibility Is Based on
Consumer Choice
 No
one is excluded who wants to
participate.
 Consumers are not excluded
because they are not “ready” or
because of prior work history,
hospitalization history, substance
use, symptoms, or other
characteristics.
Supported Employment Is
Integrated with Mental Health
Treatment
 Employment
specialists
coordinate plans with the
treatment team, which
includes case managers,
therapists, and psychiatrists.
Valued Gateway
Client :
Do Client Characteristics Predict
Success in Supported Employment?
Inserted slide
 Co-occurring
substance use does
not lead to lower employment rates.
 Consumers generally do better in
supported employment than in
alternative programs regardless of
background characteristics such as:
– gender, education, ethnicity,
diagnosis, hospitalization history,
cognitive functioning
Competitive Employment
Is the Goal
 The
agency needs to devote
sufficient resources to supported
employment to permit full access
to all consumers who seek
competitive employment.
 Consumers interested in
employment are not steered into
day treatment or sheltered work.
Personalized Benefits
Planning Is Provided
 Benefits
planning and
guidance help consumers
make informed decisions
about job starts and changes.
Job Search Starts Soon After A
Consumer Expresses an
Interest in Working
 Pre-employment
assessment,
training, and counseling are kept
to a minimum.
Follow-Along Supports
Are Continuous
 Supported
employment staff
continue to stay in regular
contact with consumer and
(when appropriate) the
employer without arbitrary
time limits.
Consumer Preferences Are
Important
 Job
finding is based on
consumers’ preferences,
strengths, and work
experiences, not on a pool of
jobs that are available.
Job Preferences Are Important
Key Factors in
Implementation
 Build
Consensus
 Maximize Financing
 Examine Agency Philosophy
 Identify Leadership
 Key on Organizational Structure
 Provide Ongoing Training
 Make Time Commitment
 Track Process and Outcomes
Examine Agency
Philosophy
 Determine
if service agency’s
philosophy, mission
statement, and service
paradigm are consistent with
recovery-oriented, evidencebased approach to supported
employment.
Build Consensus
 Commitment
of state mental
health authority is not enough
 Better to involve all
stakeholders - consumers,
family members, providers, and
local and state MH, VR, SA,
etc. administrators
Maximize Financing
Determine how supported employment
services can be funded
 Explore funding through Mental Health,
Vocational Rehabilitation, and Medicaid (Ill.
DRS/DMH co-funding model)
 Reallocate resources to supported
employment when feasible (DMH Rule 132
changes)

What Does Supported
Employment Cost?
 Some
programs, $2,000-$4,000 per
client per year (Clark, 1998).
 Latimer (2004) $2,449 per full-year
equivalent
 Figures vary according to severity of
disability, local wages of employment
specialists, and how much indirect
costs and costs of clinical services are
included (Illinois Model – VR $5117)
Ticket to Work
Revisions in the Social Security
employment support program designed
to support EBSE programs.
 Milestone payments in 3 phases, up to
60 months
 Milestone I in Phase I triggered when
an individual earns $335 in a month
 Employment Networks (EN)

Ticket (cont.)
EN be any entity except an individual
and a federal agency
 Partnership Plus: VR and community
programs
 Considering becoming an EN: Contact
CESSI (877 743-8237 v/tty)
 Getting started: Contact Maximus (866
968-7842 v, 866 833-2967 tty)

Identify Leadership
 You
need a champion!
–Identify committed leader with
sufficient authority to oversee and
ensure implementation
 Leaders at all levels visibly show
support for supported employment
 Center director buy-in is critical
 Leadership from Vocational
Rehabilitation integral to the
collaboration
Leadership Roles
 Provide
necessary resources
 Seek buy-in from consumers,
families, and practitioners
 Give recognition to staff and
consumer for successes
 Rapp’s finding – Critical role of
supervisor in program success
Problem Solving
 What
does consumer want?
 Are SE principles being followed?
 Is leader ensuring staff has skills
to implement supported
employment?
 Have training and resource
materials been utilized?
Provide Ongoing
Training
 Initial
training for all team
members, including medical
staff
 Continuing access to expert
consultation (e.g. Ill. T.A. Team)
 Ongoing supervision that is
outcomes-oriented
Make Time
Commitment
 Typically,
6 - 12 months
needed to develop skills,
interest, and confidence for
implementing evidencebased supported employment
Track Implementation
Process and Outcomes
 Track
employment outcomes
monthly
 Set goals: 40% rate of competitive
employment is achievable
 Service agencies should use
Supported Employment Fidelity
Scale to measure implementation
of evidence-based practice
(Becker et al., 2008)
Supported Employment Unit:
Recommended Basic Structure
 Minimum
of 2 full-time staff
 Staff devoted exclusively to SE
 Full-time leader/supervisor who
also provides employment
services
 Offices physically located in
mental health center
Supported Employment Unit
 Individual
caseloads, but help
each other (with job leads, etc.)
 Caseloads of about 20
consumers or less
 Weekly team meetings +
individual supervision
Roles of an Employment
Specialist
 Problem-solver
 Team
player
 Networker
 Employment specialist
–Customer-oriented
–Community-oriented
–Outcome-oriented
Characteristics of Effective
Employment Specialists
 High
energy
 Optimistic
 Likes to meet new people
 Good listener
 Knows the community
 Creative
 Projects confidence and
professionalism
Employment Coordinator
Duties
 Manages
referrals
 Hires and supervises employment
staff
 Ensures employment specialists are
learning and using effective skills in:
Engagement
Job development
Assessment
Job support
More Employment
Coordinator Duties
 Role
model good employment
practices
 Provide supported employment
information and training to all staff,
including upper management
 Ensure employment services are
integrated with treatment teams
Referral
 Make
referral process simple!
 Have minimal eligibility criteria
– Unemployed (or working noncompetitively) and wants
competitive employment, or
– Employed, but not receiving
employment supports, and wants
such support
 Involve multiple stakeholders
Valued Gateway
Client :
Collaboration With
Vocational Rehabilitation
What about the
collaboration?
This slide is not
very informative
 VR
counselor meets consumers
at mental health agency
 VR counselor is part of the
treatment team
 VR counselor conveys same
message as rest of team
Vocational Rehabilitation
-- VR has a corporate culture that values work-first
and assumes anyone is capable of employment.
-- VR staff have job placement/development skills
& networks.
-- VR staff have expertise in multi-disability work
accommodations.
-- VR staff have access to an array of resources.
Vocational Rehabilitation (cont.)
-- VR system designed to monitor quality of
services at local – regional – state levels
e.g. fidelity to best practices.
-- VR staff collaborate across systems.
Enhanced Shared Practice:
-- Career counseling (Motivational Interviewing)
-- Strength - Based Case Management
Engagement
 Build
trusting, collaborative
relationship
 Assume contacts are mostly
outside mental health setting
 Maintain ongoing contact
 Involve family, treatment team,
and other supporters
Vocational Profile
 Gather
comprehensive
information from variety of
sources over 2-3 sessions
–Consumer
–Family, friends
–Former employers
–Treatment team
Disclosure of
Psychiatric Status
 Disclosure
is the consumer’s
choice
 Nature of disclosure
–When to disclose?
–How much to disclose?
–Who to disclose to?
A Vignette: Gloria
 Gloria,
“I don’t want my
boss to know that I have a
mental illness. I will be
treated differently.”
 What would you, the
employment specialist, say?
Benefits Counseling
 Fear
of losing benefits is major
barrier to employment
 Concerns of consumers and families
often underestimated by clinicians
 Rules and regulations are
complicated
 Benefits counseling provides
consumer-specific information
A Vignette: Paul
 Paul,
“I don’t know what I want
to do. Maintenance work would
be okay. I will do anything. I
want to make money.”
 What would you, the employment
specialist, say?
Employment Plan
 Explore
jobs by visiting work
sites
 Develop employment plan
 Revise assessment and
employment plan based on
consumer’s experiences
Job Search
 Begin
soon after referral
–Employer contacts within 1 month
 Preparatory work
–Resumé
–Job application
–Two forms of identification
–Practice interviewing
–Release of information
Individualized Job Search
 Base
on consumer’s preferences,
strengths, abilities, experiences,
and deficits (e.g., substance use)
 Seek:
–Permanent competitive jobs
–Diverse jobs suiting individual
consumers
–Different settings
Ways to Find Jobs
 Identify
leads primarily through
networking
 Include family and treatment
team
 Attend job fairs
 Use Chamber of Commerce and
community organizations (e.g.,
Rotary Club)
More Ways to Find Jobs
 Newspaper
(However, lots of
others seeking same job)
 Internet
 Previous employers
 Tell everyone you meet
 Track contacts [employer log]
 Stay persistent
Engaging Employers
 Present
confidently and professionally
 Help solve employer problem
–Recommend qualified applicant
 Respect employer’s time
 Identify next step: Meet job
candidate?
 Be dependable: Do what you say you
will do
Job Support
 Individualized
and time-unlimited
support
 Mostly away from work site
 Include consumer’s support
network (treatment team, family,
friends, employer, coworkers)
 Negotiate accommodations with
employer
Common Job Accommodations
(MacDonald-Wilson, 2002)
37%
 Cognitive
(e.g., learning job,
concentrating)
26%  Social (e.g., interacting,
reading social cues)
21%  Emotional (e.g., managing
symptoms, tolerating stress)
16%  Physical (e.g., stamina)
Job Endings
 Each
job viewed as learning
experience
 Job transitions are considered
normal
 With a job loss, consumer and
entire (SE and treatment) team
strategize for next step
A Vignette: Marguerite
 Marguerite
worked for three
weeks at a dry cleaners. She
was let go because of slow
work speed.
 What would you, the
employment specialist, say?
Community-Based Services
 Employment
specialists in
community > 65% time
 Best way to contact consumers,
families, employers
 Services do not generalize well to
different settings
 People reveal more about who they
are outside of the agency
Time Management
 Focus
on spending time with a few
consumers nearing employment vs.
meeting everyone each week
 Take phone book, cell phone, maps,
newspapers, address book if possible
when job developing
 Review daily/weekly schedule with
supervisor
The Dreaded Paperwork
 Comes
with territory
 As much as feasible, supervisor protects
staff from busy work
 Important paperwork:
– Vocational profiles
– Employment plans
– Fidelity checks on
program implementation
– Monitoring outcome
Track Outcomes
 Track
employment outcomes
monthly
 Set goals: 40% rate of
competitive employment is
achievable
 Things
that you pay attention to are
more likely to be improved
Percent Competitively Employed in 24 month period
40
Percent competitively employed
35
30
25
Standard
IPS
20
PSR
15
10
5
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Study Time
15
16
17
18
19
20
21
22
23
24
Track Implementation
 Use
SE Fidelity Scale to measure
implementation of evidence-based
practice
 Staff in supported employment
program can see if they are on
track
 Basis for giving objective feedback
Hartford Study: Stable and high
fidelity over time after short start-up
Total Score
IPS Fidelity
75
70
Capital Region
65
60
1
2
3
4
5
6
7
Number of Assessment
What About Supported
Education?
 Consumer
choice always a primary
consideration
 Education and training expand
options
 SE program should help consumers
enroll in community programs (GED
classes, colleges, technical schools)
What About Dual Diagnosis
and Work?
 Work
to support sobriety
 Money as a cue
 Same SE process
Motivation and Work
 State
vs. trait
 Hopelessness as part of illness
 What has been offered?
 Program norms –support Recovery?
 What ES and practitioners say
 What does consumer want?
 Change over time
Stages of Change
Pre-contemplation
Contemplation
Determination
Action
Maintenance
Relapse
Motivational Interviewing
Five Early Strategies
Aask
open-ended questions
Llisten reflectively
Aaffirm
Ssummarize
Esolicit self-motivational statements
What are these?: problem recognition,
expression of concern, intention to change,
optimism about change
Five Basic Principles of
Motivational Interviewing
Eexpress
empathy
Ddevelop discrepancy
Aavoid argumentation
Rroll with resistance
Ssupport self-efficacy
Motivational Interviewing
Enhancement technique for behavioral change
through identifying and resolving ambivalence and
discrepancies between verbal and behavioral actions.
costs/benefits
analysis
discuss
the readiness ruler
engage
with active listening
promote
avoid
change talk
arguments
IPSMI Intervention Framework
Review Handout (Appendix N)
Stage of Change Intervention
Outcome
Pre-contemplation Motivational Int.
Move to
contemplation
Contemplation
Motivational Int.
Determination
IPS
Move to
determination
Set job goals
Action
IPS
Locate job
Maintenance
IPS
Maintain job
Relapse
Motivational Int.
Problem-solve
Move to earlier
stage
IPSMI Tips
Continually
assess stages of change
Contextually
based application
Modify
Problem-solve
Practice
Role-play
Summary
 Programs
following evidence-based
principles of supported
employment have better outcomes
 Effective employment coordinators
are key to good implementation
 Resource materials complement
training and supervision
Information: books,
videos, research articles
KKaren
Dunn
[email protected]
6603-448-0263
www.mentalhealth.samhsa.gov