Transcript Level 3- self presentation

Vocational
Rehabilitation
Ravenswood and Southfield
OT Department
28 June 2010
Outline of Presentation
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Evidence Base for Vocational Rehabilitation.
Vocational Pathway.
Current work projects.
Projects in relation to patients functional levels
with case studies.
Barriers and benefits of work.
Outcome measures.
Future projects.
Questions.
Why is Work Important?
To work in paid employment is to become part
of society, to be included rather than excluded.
(College of Occupational Therapists 2009)
And not only OT’s believe this!
National Drivers
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Four key mental health and employment
documents published in December 2009.
Working our Way to Better Health, New Horizons
and Work, Recovery and Inclusion…..
representing a cross-government commitment to
mental health and employment.
Responding to the recommendations made in
the independent Perkins review, Realising
Ambitions: better employment support for people
with a mental health condition.
The Key Points
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Employment should be at the heart of the
‘recovery vision’ for mental health services.
Mental health service providers and
commissioners should promote a focus on
employment for the populations they serve.
Employment will increasingly be seen as a key
indicator that will need reporting on.
Local commissioning decisions should be
influenced by what we know works on
supporting people into work.
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Only 14% of people leaving Medium Secure
Accommodation obtain work.
(Davies Et al 2007)
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Only 10% of offenders enter employment on
release.
(Home Office 2006)
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Only 3.4% of people with a serious mental illness
on CPA receiving secondary mental health
services are in employment.
(DOH HM Gov. 2009)
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Yet…….70-90% want to return to work.
(Grove1999, Rinaldi & Hill 2000, Secker & Seebohn 2001)
Someone who has been on incapacity
benefits for two years has only a 2%
chance of returning to work.
(BSRM 2001)
 Offenders are less likely to re-offend if in
employment.
(Home Office 2005)
 The longer a person is on incapacity
benefit, the more difficult it becomes for
them to return to work and the less likely
they are to return to work at all. (DWP 2004)
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Relative Employment Rates
(DOH 2009)
Static risk factors, for example criminal
history cannot be altered, it is through the
dynamic risk factors, for example
education, employment and substance
misuse, that reoffending can be reduced.
(Bonta, Cited in Home Office Research Study 2006)
Individual Placement & Support (IPS)
Becker, Drake & Concord, 1994
Competitive employment is the goal
 No selection criteria, beyond expressed
motivation
 Focus on client preference
 Rapid job search: place then train
 Relies on close working with CMHT
 Individual support, ongoing
 Access to benefits advice
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Forensic Environment
Loss of Roles + Restrictive environment
Occupational deprivation, disruption & imbalance.
Average length of forensic admission almost five years.
Loss of Worker identity
Loss of work skills/performance capacity
Loss of self efficacy and personal causation.
Drop in volition
Vocational Rehabilitation
An integral part of the Occupational
Therapy process.
 One part of the functional assessment
(work, personal management, social,
leisure).
 Led by patient’s own goals in relation to
work.
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Vocational
Assessments
•Vocational Wheel
•MOHOST
•Worker Role Interview
•MoCA
Graded Intervention
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Prevocational skills:
 Self
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care, time management
Basic skills:
 Reading,
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writing, I.T
Social skills/interaction:
 Groups,
community trips
Work, Education & Training
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Paid work
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Librarian, clothes shop assistant, workshop co-op, ward
representatives.
Community Links
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Voluntary work
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Shaw Trust, Maximus Employment, Groundwork Solent
League of Friends Shop.
Working groups.
Local Volunteer bureaus... Fareham, Southampton
Community placements…shops, conservation, cafes e.g. EBD
Poster design
Education
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Basic skills…maths & literacy qualifications…..LSC
CLAIT computer qualification…..LSC
Learn Direct courses
Open University qualifications
Local colleges
Paid Roles – Application Process
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Job description/person specification.
Application form.
1:1 support available (disclosure advice).
Interview.
MDT act as Occupational Health.
Contract (Trust Band 1).
Induction.
Support & Supervision & Appraisal.
Encourage community bank accounts for wages.
Individual Needs
IPS model (support in job).
 Unit jobs adapted to meet individual need.
 Example: League of Friends Shop and
Library.
 Voluntary jobs e.g. poster design, indoor
golf.
 Patient shelter.
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Vocational Rehabilitation Pathway
No Leave = Red
Initial Assessment
Interest Checklist
Model of Creative Ability Assessment
Basic Skills Assessment
WRI / OCAIRS
Vocational Rehab Plan
Future Aspirations
Set Long Term Aims
Set Short Term Goals
Developing Work Skills
In Unit
Develop routines
Attendance at groups
Undertake Roles and
responsibilities
Self Care
Life Skills
Voluntary Work
In unit
League of Friends Shop
Co-facilitation of groups
Unescorted
Community
Leave =
Green
Adult Education
Liaise with local colleges on risk assessment
Learndirect centres
Applying for courses
Help obtaining funding
Information Gathering
Past education
Past employment/work experience
OT Specific Assessments
AMPS
MOHOST
MCA
Basic Skills in unit
Maths
English
CLAIT
Developing Work Skills
In Community
Using public transport
Cycle Proficiency
Budgeting
Voluntary Work
In Community
Patient needs led
voluntary work
+
VQ
ACIS
Education in unit
Open University
Learn direct and other internet based
distance courses
Music Theory
Pre Vocational Work in Unit
1:1 Vocational Planning
C.V Building, Application form Training
Interview Skills Training
IT/ electronic communication Skills
Disclosure of illness/offending history
Paid Work Opportunities
In Unit
Ward Representatives
Librarian
Clothes Shop assistant
Workshop Co-op
Paid Work Opportunities
In Community
Expert Patient
Joint Working with Other Agencies
Shaw Trust/Maximus - Local to discharge destination
Next step
Adult Directions
Pathway to Work
Progress to Work
Individual Voluntary Organisations
MOCA Levels and Mental Health Services
Level 6 - Active
Participation
Level 5 – Imitative
Participation
Level 4 – Passive
Participation
Level 3 - Self Presentation
Level 2 - Self
Differentiation
Level 1 - Tone
Community
outpatient
Forensic fast track
Rehab/day hospital
Forensic slow track
rehab
Acute Care / PICU
Forensic
admission ward
Normalised
Community work
paid or voluntary
Supported work
roles in structured
environments
Mainly hospital /
occasionally
community
Basic life skills on
ward
Level 1 and 2
(Pre) pre-vocational
Clinical presentations
 Little awareness/response to others
 Bizarre behaviour , outbursts, aggression
 Needs prompting with all self care
 Little awareness of routine/ responsibilities
 Often seen pacing
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NOT READY FOR WORK
Aims: -prevocational
 Focus on basic skills for engagement e.g. focus of attention, social
contact, awareness of self
Level 3 - Self Presentation
Clinical presentation; Beginning to show interest in doing but may
change their mind often
 Requires quick gratification or give up easily
 Very little initiative, need support to participate
 Basic communication, usually to meet own
needs
 Reduced ability to sustain effort (20-30minutes)
 Self care inconsistent
Level 3 - Work ability
(Pre-vocational / Full assistance)
Identified strengths
 Curious to try new things
Identified limitations
 Sustaining motivation
 Reduced concentration
 Decreased planning and
organisation
 Reduced ability to complete
tasks
Support for successful work
 Need constant staff supervision and
intermittent staff assistance
 Work roles to be limited to maximum of 30
minutes
 Need tasks to be fully structured and
assistance given with organising task
 Work needs to have simple expectations/
standards of performance
 Work role model and prompting / continual
verbalisation of role
Example
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Patient
MC has worked in league
of Friends shop, now
works in clothes shop
Motivated by pay not
learning skills
Minimal communicationNeed to repeat same
information every week,
Effort not sustained, sits
down during shop loses
interest, wants to leave
early.
Little initiative
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OT Involvement
Fully supervised
Given direct prompting
Given physical
assistance with jobs
Has written instruction
for till but needs
prompting to look at it
Has to be directed to
start any tasks e.g. lets
hang up the new clothes
Needs assistance with
decision making
Level 4 - Passive
Clinical presentation:
 Able to follow clear instructions or learn
straightforward tasks
 Social skills fair but not able to manage
social conflict, assertiveness
 More consistent in routine / effort
 Behaviour reasonable
 Some awareness of abilities
Level 4 - Work ability
(Structured employment / Part time)
Identified strengths
 Can do regular tasks without
assistance
 Want to learn skills
Identified limitations
 Need support with problem solving
 Higher level social skillsassertiveness, conflict
 Overwhelmed at times
 Anxiety present
 Work quality fair
Support for successful work
 Identify supervisory role
 Plan tasks together at start- give
overt expectations
 Alter levels of support when
required
 Familiar work patterns encourage
independence
 Supervision to discuss and jointly
evaluate
 Work 1-4 hours duration.
 Job security not dependent on
quality/ rate of performance –
limited work pressures
Example
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Patient
Stuart - Male patient with Bi-Polar
Disorder
Memory problems - ECT
Independent with all daily activities
Struggles with concentration
Very motivated to move on and
succeed
Interest in fitness
Wants to study at college
Wants to attain a job
Paid ward rep post at Ravenswood
Level 4 MoCA …
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Skills - manages his time, pursues
interests, wants to learn etc.
 Areas for development – high level
social skills, problem solving,
sustaining interest when
challenged.
OT Involvement
Education
 Assessed during education
sessions – Level 2 maths
 Supported to study at local skills
centre
 Encourage realistic college aims
 Offered support during unit
based education sessions
Work
 Encouraged to start slow
 Arranged Vol Bureau interview
 Couldn’t manage decision
making and struggled to problem
solve
 Communication skills limited
 Struggled to plan ahead
 Gave up easily
 Didn’t pursue initial goal to work
Level 5 - Imitative
Clinical presentation:
 More able to manage higher level social skills
 Effort sustained despite problems which arise
 Shows some initiative
 Personal management good- transport, self
care,
Level 5 - Work ability
(Community / Normalised work)
Identified strengths:
 Good standard of product/
performance
 Can collaborate and suggest
ideas
 Uses initiative
 Higher level social skills
Identified limitations;
 Skills vary based on individualattitude, experience, personality
Support for successful work
 Supervision and support tailored
to meet individual needs
 Specific training appropriate e.g.
college courses, apprenticeships
 Need occasional guidance/
supervision
 Working in teams appropriate
Example
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Patient
Beth - Female patient with BPD
Strong desire to work and live
independent lifestyle
Motivated to achieve
Managed time well
Good community skills
Articulate and well mannered
Good social skills
Previously worked as Unit Librarian
Studied at college before being an
inpatient
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OT Involvement
Highlighted interests
Voluntary Bureau
Disclosure letter
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CRB check and subject access
check
Interview for Christian
café/bookshop assistant
On job training
Trial period
OT attended workplace
Meeting with BB, OT and Work
supervisor – sort out issues
Regular liaison between
workplace and OT Dept
Planned appraisal style meeting
but D/ch’d so handed over to
Care-Coordinator
Problems which may arise in work
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Changes to initial work roles- S.R
communication of work and Ravenswood
Disclosure- patients not wanting to/ disclosing
too much/ managing in work place
Mental state/ risk changes;
Changes in staff support / work colleagues
Expectations of patients
Barriers to getting into work
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Stigma- staff in hospital as well as outside agencies
Funding to set up projects/ running costs
Disclosure - mental health/ offences
Leave, escorts, staff shortages
Suitable work opportunities- recession
Timings - college courses 7-9.30pm, early starts, course start dates
Benefits/ loans – costs to patients
Travel/ location of hospital/ bus timetables
Risks with working with vulnerable people
Mismatch in skills
Outcome Measures
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Over the last 6 years we have employed:
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24 librarians
12 clothes shop assistants
10 League of friends volunteers
15 ward representatives
8 woodwork co-operative members
Outcome Measures
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Over the last 5 years patients have
achieved the following educational
qualifications:
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11 Diploma in CLAIT
6 Level 1 in CLAIT
15 Partly completed course
9 Level 1 Literacy (D-below)
2 Level 2 Literacy (A-C)
Other Outcomes
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Voluntary work.
Open University courses.
Picture Project – Southfield & Bluebird.
Shelter for grounds.
Clothes Shop self funding and making profit.
Co-op self funding and car wash.
Recognition from Quality Network.
Additional Benefits
Improved motivation and mood leading to
enhanced ability to engage with
treatments.
 Shorter admissions.
 More success in community placement.
 Decreased involvement in violence and
aggression.
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(NACRO 1997, Fletcher et al 1998, Hollin and Palmer 1995)
Future Projects
Car Wash
 Courtyard Maintenance
 Odd Job Team
 Leaflet design
 Groundwork Solent
 Mobile shop/library service
 Bike shelter
 Vocational Wheel
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References
British Society of Rehabilitation Medicine. (2001) Vocational Rehabilitation- the way forward: report of a working party
(Chair Frank AO). London: British Society of Rehabilitation Medicine.
College of Occupational Therapists/National Social Inclusion Programme. (2007) Work Matters; Vocational navigation
for occupational therapy staff. London :College of Occupational Therapists and National Social Inclusion
Programme.
College of Occupational Therapists. (2009) Occupational Therapy in Vocational Rehabilitation: A brief guide to current
practice in the UK. College of Occupational Therapists Specialist Section-Work: London.
Davies, S., Clarke, M., Hollin, C. and Duggan, C. (2007) Long-term outcomes after discharge from medium secure
care: a cause for concern. British Journal of Psychiatry. 191, pp70-74.
Department for Education and Skills, The Home Office and the Department for Work and Pensions. (2006) Reducing
Re-Offending Through Skills and Employment: Next Steps. HM Government. TSO.London.
Department of Health. (2009) New Horizons: A shared vision for mental health; HM Government. TSO.London
Department of Work and Pensions. (2010) Permitted Work - working while claiming Incapacity benefit. Available at,
http://www.direct.gov.uk/en/DisabledPeople/FinancialSupport/IncapacityBenefit/DG_10020667 [Accessed
27.04.2010]
Farnworth, L. and Munoz, J.P. (2009) An occupational and rehabilitation perspective for institutional practice.
Psychiatric Rehabilitation Journal 32/3,(192-8), pp1095-158.
Farnworth, L., Nikitin, L. and Fossey, E. (2004) Being in a secure forensic
psychiatric unit: every day the same, killing time or making the most
of it. British Journal of Occupational Therapy 67(10), pp430-38.
Grove, B. (1999) Mental health and employment: shaping a new agenda. Journal of Mental Health 8, pp131- 40.
Letts, L., Rigby, P. and Stewart, D. (2003).Using environments to enable occupational performance. Thorofare NJ:
Slack.
Lovell , D., Gagliardi, G. and Peterson, P. (2002). Recidivism and use of services among persons with mental illness
after release from prison. Psychiatric Services. 53, pp1290-1296.
References Cont.
National Mental Health Development Unit (2009). Work, Recovery and Inclusion: Employment support for people in
contact with secondary care mental health services. HM Government. London.
Perkins, R., & Rinaldi, M. (2002). Unemployment rates among patients with long-term mental health problems.
Psychiatric Bulletin, 26, 295 – 298.
Rutherford, M. & Duggan, S. (2007) Forensic mental health services: Facts and figures on current provision. Sainsbury
Centre for Mental Health; London.
Secker, J., Grove, B. and Seebohm, P. (2001). Challenging barriers to employment, training and education for mental
health service users: The service user’s perspective. Journal of Mental Health, 10 (4), 395-404.
Sneed Z, Koch D.S, Estes H, Quinn J. (2006). Employment and Psychosocial outcomes for Offenders with Mental
Illness. International Journal of Psychosocial Rehabilitation. 10(2), 103-112.
Stelter, L. and Whisner, S.M. (2007). Building responsibility for self through meaningful roles: Occupational adaptation
theory applied in forensic psychiatry. Occupational Therapy in Mental Health, 23(1), 69-83.
United Nations (1948). Universal Declaration of Human Rights. http://www.un.org/en/documents/udhr/ [Accessed
24.04.2010]
Wilcock, A. A. (2006). An Occupational Perspective of Health. 2nd Ed, Thorofare NJ: Slack.
What work has meant to our
patients
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“This job has been life changing for me. It has made me
feel more important and has given me a sense of
purpose. It’s very interesting and I look forward to
everything I do as a ward representative!”
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“It’s difficult for people with a criminal record and mental
health issues to get employment. Any job a service user
gets in the system helps; it is a stepping stone to either
continue work in service related issues or a different job.
You can prove to employers that you have done
something”.
Ward Representatives
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“It’s demoralising being locked up. We have lots of time
on ours hands. Having a job gives you hope”.
Service User
“Work was always my identity so continuing some work
related tasks was crucial to my recovery”.
Service User, Librarian
“Having a job helped my recovery. To have not done
anything would have left a big gap in my CV. Employers
expect to see something positive. It’s made it easier to
get along with daily life”.
Service User