Transcript SUPPORTED EMPLOYMENT - Illinois Co

Individual Placement & Support
Employment and Education
Services
MISA Cross-Divisional
Conference 2010
Overview of the day

EBSE & MISA research, principles,
practice, org. structure
 EBSE & Recovery in consumers voices
 IPS/Mot. Intv. & practice skills
 VR Ill. & other states
 Opportunities for 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?
 Joe Marrone, an employment
trainer:
“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: DE, IL, MN, OH, Ky, WI. Mo.
–
(Drake, 2006)
J&J Project Strategies
SStart
with “early adopters”: states &
programs
VVR-MH collaboration
LLongitudinal training
OOutcome-based supervision
PProblem solving by local experts
–
(Drake, 2006)
Thresholds/Dartmouth NRTC
PPart ofon
Dartmouth
Medical School
Evidence-Based
SE
PPhase I: $30 million, ½ Thresholds ½ Dartmouth
EEndowed Chair, 4 Resource Centers in Ill.
TTraining of practitioners including VR staff
SServices to customers including employers
RResearch priorities: ex-offenders, improve
mental/physical health, less need public benefits, outcome
measurement tools, public policy re SE & employment
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
Employment
OOnly 10-15% of people with psychiatric

disabilities are working
770-80% want to work
WWork improves self-esteem, income, and
recovery
TTraditional programs are ineffective
SSupported employment is effective
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
– 9 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
Competitive Employment Rates in
11 Randomized Controlled Trials of
Individual Placement and Support
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
96 NH
07 IL
04 CT
08 HK
IPS
08 AUST
06 SC
Control
99 DC
08 CA
Control 2
07 EUR
06 QUE
02 MD
1
Current Status RCTs
660%
vs. 22% employment
FFindings very consistent
RRecent IPS studies over 70%
employment
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)
–EErrorless learning (Kern)
–BBenefits counseling (Tremblay)
–MMotivational interviewing (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)
“There are a range of effective
treatments for people with mental
illness. . . if these effective treatments
were more efficiently delivered through
our mental health services system
….Millions of Americans would be
more successful in school, at work, and
in their communities.”

Michael Hogan, Chairman
Quotes from Consumers
 “I
feel so much better about myself
now that I have a job.”
 “Holding down my job is not always
easy but it has helped my self esteem.”
 “When I go to work I don’t hear the
voices.”
 “Now that I am working again I can
buy my daughter presents.”
Quotes from Family
Members
“I worried that if my son got a job he would
get stressed. But just the opposite happened.
He is doing so much better than before.”
 “I feel better that she tries working when she
has the support of mental health.”
 “I was really glad that my son’s employment
counselor asked me about work ideas. He
landed a job that I suggested.”

Quotes from Employers
“Andre is as good as any worker that I
have.” Automotive parts store manager.
 “I count on Juanita. If she is feeling
stressed, she sits in the back room for
awhile. That’s OK; she gets the job
done.” Bakery supervisor.
 “The employment counselor helped me
understand why Tony paces. It’s okay in
the security business.” Security business
owner.

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.
Do Client Characteristics
Predict Success in Supported
Employment?
Valued Gateway
Client :
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
S E Unit:
Recommended 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
 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 :
What about the
collaboration?
This slide is not
very informative
Collaboration With
Vocational
Rehabilitation
 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
A federally funded program available in all states
that assists persons with severe mental, physical,
cognitive, or sensory disabilities to return to or
enter into employment.
A federal program since 1920. Authorized under
the federal Rehabilitation Act.
Persons with mental illness added in 1943.
Vocational Rehabilitation (cont.)
Referral can be from any source.
State VR Counselor determines eligibility based
upon a review of the records or new information.
Typical services can be:
-VVocational Evaluation
-CCareer Counseling
-JJob seeking skills trng., job development, job placement
- Consultation on job site accommodations
Vocational Rehabilitation (cont.)
Medical/psychiatric case management
-RReferral to and assistance with medical, psychiatric, etc.
services necessary to complete the goals of the IEP
-SSponsorship in vocational or academic training
-BBenefits planning
-SSupported Employment and Supported Education
-SSupport services such as transportation, purchase of
work clothing/uniforms, van conversions, etc.
To locate your state VR program go to:
www.nchr.okstate.edu/pages/states-VR.html
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.
IPS section of VR
Casework Manual

10 days from referral to IPS
 Up to 14 days back dating if employed
at referral
 Mandates VR liaison counselor meet
with the rest of the IPS team at least 1x
per month
 Any LPHA can certify diagnosis
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 1-2 weeks
– 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 consumerspecific 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
 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 > 50% 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
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
15-item 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 startup
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)
PRJ Article: Neuchterlein et al.
IIPS
effective for assisting youth with
severe mental illness to sustain
employment
AAlso effective for assisting youth to
complete schooling, including advanced
education
EEvidence of recovery, long-term
studies
Early Psychosis Study
(Nuechterlein, 2005)
% of Employment or
school
IPS Supported Employment for Clients with Firstepisode Schizophrenia
100
80
IPS
SAU
60
40
20
0
Baseline
6 Months
12 Months 18 Months
Case example:
Transtions, Inc., Rock Island
FFormed
partnership with local school
system, spec. ed., social worker, Transitions
Specialists
AAssist in-school with m.h. issues - part of
team
AAssist with job site issues
FFollow youth who dropped out
FFacilitate transition to adult employment &
treatment services as needed
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
 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
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
Examples of other
funding options
 PASS
& PESS Plans
 Enhanced Medicaid support
 Individual Development
Accounts
 School & education systems ?
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 augments
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
Provide Ongoing
Training
 Initial
training for all team
members, including medical
staff
 Continuing access to expert
consultation
 Ongoing supervision that is
outcomes-oriented
Make Time
Commitment
 Typically,
6 - 12 months needed
to develop skills, interest, and
confidence for implementing
evidence-based supported
employment
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