Iowa Community of Practice March 31, 2015 Mental Health & Employment Best Practices Doug Crandell, Griffin-Hammis and Institute on Human Development and Disability at the University of Georgia Iowa Community of Practice March 31, 2015

Part I: Tenants and Competencies of Evidence-Based Supported Employment Values drive the core principles The principles define metrics The metrics outline the implementation Fidelity to the process examines the quality of implementation (both programmatically and for the entire community mental health agency/system)

IPS-SE Competencies and Fidelity Summary Points How do Employment Specialists (ES) perform specific functions? What does the ES do in collaboration with the MH system and VR? How well? How are employer engagement tasks performed and tracked? In IPS, the agency’s performance related to core competencies is measured as well.

IPS Core Principles That Drive Competencies Focus on Competitive Employment Eligibility Based on Choice (Zero Exclusion) Integration of Rehabilitation and Mental Health Services Attention to Preferences (Person-centeredness) Personalized Benefits Counseling Rapid Job Search Systematic Job Development (Employer Engagement) Time-Unlimited and Individualized Support Dartmouth  Psychiatric  Research  Center, Revised  March  2014

The Employment Specialist and Phases of SE Intake, Engagement, Assessment, Job Development, Placement, On-going support. 20 or fewer job seekers Employment Specialists provide only SE services. (In many Community Mental Agencies, hybrid positions exist. This impacts the delivery of IPS to fidelity).

Integration Competency Employment Specialists are part of up to 2 MH teams. ES actively participates in weekly team meetings. ES helps the team think about work as an essential part of recovery. Necessary Knowledge, Skills and Abilities (KSAs) Knowledge of multi-disciplinary teams and their functions. Skillful in communicating with other team members. Ability to galvanize the team around the notion that employment is possible (immediately) with the right supports and focus.

Rehabilitation Competency ES works collaboratively with VR counselors. Necessary Knowledge, Skills and Abilities (KSAs) Knowledge of the VR system, and its processes. Skillful in coordinating needed documentation for rapid and seamless collaboration. Ability to navigate the MH and VR systems to embrace jointly-supported job seekers. Ability to keep VR counselor involved, engaged, and informed regarding IPS supported employment services.

Choice Competency Zero Exclusion Necessary Knowledge, Skills and Abilities (KSAs) Knowledge of the research related to this core principle in order to gain broad team support. Skillful in supporting job seekers to rapidly find employment after another job has ended. Ability to communicate Zero Exclusion in practice. (The team as support rather than a lone ES)

Disclosure Competency Disclosure and Employment Necessary Knowledge, Skills and Abilities (KSAs) Knowledge of the pros and cons of disclosing. (Career Profile) Skillful in supporting the job seeker in making decisions surrounding accommodations (work-site related) Ability to assess and discuss disability disclosure decisions if job seeker has not become employed or is having trouble on the job. Ability to enlist peer/recovery staff to support and advise job seeker regarding disclosure.

Career Planning Competency Necessary Knowledge, Skills and Abilities (KSAs) Knowledge of the values and processes of person-centered career planning. Skillful in translating information from multiple POVs into a coherent document that guides specific job development related preferences. Ability to encourage other team members (VR, MH and in some cases prescribers) to focus on the strengths and necessary elements for employment success---and rely less on traditional forms of assessment (Work Adjustment, Day Treatment, etc)

Rapid Engagement Competency Necessary Knowledge, Skills and Abilities (KSAs) Skillful in balancing the initial career profiling sessions with face-to- face employer contact. Skillful in building social capital with local businesses to meet individualized job searches. Ability to schedule 6 or more face-to-face employer contacts each week. Ability to balance multiple job seekers and their on-going needs for support. Ability to efficiently record these efforts using field notes that populate VR, MH and other data collectors.

Long-Term Support Competency Post-Employment Supports Necessary Knowledge, Skills and Abilities (KSAs) Knowledge of the role different teams members can have providing follow-along supports. Skillful in enlisting team members in supporting problem- solving related to medication changes, natural supports, benefits issues, motivation and encouragement, and peer and recovery supports. Ability to advocate for the person to have increased hours, reassignment of duties, and other job accommodations as necessary.

Outreach Competencies Necessary Knowledge, Skills and Abilities (KSAs) Knowledge of the principles of assertive engagement and motivation. Skillful in keeping the job seeker apprised of progress, including the use of recovery tools such as the WRAP for Work. Ability to provide outreach in community settings to re-engage a job seeker that has become less motivated and discouraged. Ability to work in conjunction with peer specialist staff to reenergize the job seeker to pursue recovery.

What KSAs or other Characteristics make for a High-Performing IPS-SE Employment Specialist? The ES can alter their performance based on data related to job development, employment rates, and rapidity of engagement. A strong grasp of specific system language (VR, MH, Recovery) and the ability to translate these languages among team members to achieve employment outcomes. Masterful in balancing timelines and schedules. High emotional intelligence, which can be used to build social capital across stakeholders (job seekers, MH team, employers, and VR). Understands when customization is necessary based on preferences, and/or multiple barriers to labor-driven positions.

Eight Core Principles Taken together, and implemented as a whole, these principles represent a tested and consistent approach to providing supported employment to people with severe and persistent mental illnesses. Because IPS-SE is a model, or specific approach, trying to provide just “some” or a “few” of the core principles results in lower employment rates.

Individual Placement and Supports (IPS) Supported Employment Individual Placement and Supports is a very specific type of Supported Employment. The IPS approach assumes everyone can work with the right supports. The person decides when and how they want to go to work. There are no prerequisites (work adjustment, pre-vocational, transitional, group models or otherwise). Unlike other approaches, IPS-SE has been researched and proven to get higher rates of employment for people with severe and persistent mental illness. Providers are reviewed regularly using a fidelity instrument

What is a fidelity review? Dartmouth SE Manual 2012 A fidelity scale is a tool to measure the level of implementation of an evidence-based practice (EBP). Defines the critical ingredients of IPS in order to differentiate between programs that have fully implemented the model and those that have not. You can think of the IPS Supported Employment Fidelity Scale as a roadmap or a compass that can help practitioners obtain better outcomes. After completing a fidelity visit, the fidelity reviewers provide feedback to the agency by sending a completed IPS Supported Employment Fidelity Scale form and a written report that includes observations, assessments, and recommendations for program improvement.

IPS-SE Research

Example of Entire Team collaborating on IPS-SE: 40% of participants experienced co-occurring disorders, 60% experienced primary substance use disorders, and 70% had histories of felony convictions. Emphasis was on recovery as well as employment. Integrated team was made up of Peer Specialists, Case Managers, Supportive Housing staff and Employment Specialists. The impact of the IPS model found that 71 percent of the 319 individuals enrolled in the employment program were successful in securing integrated and competitive employment over 2 years. Average wage was $9.96/hour **Study was developed at the Dartmouth Psychiatric Research Center by Robert Drake and Deborah Becker, and research was conducted by Heidi Herinckx, independent evaluator and Assistant Director of the Regional Research Institute for Human Services at Portland State University.

Implementing IPS-SE: Key metrics and enactment points Caseloads of 20 Six face-to-face employer contacts a week per ES ES or job seeker meets with an employer within 30 days of 1st IPS appointment ES meets weekly with treatment team Integrated Supports are provided by a variety of people, including treatment team members (e.g. housing staff, clinicians, family, friends, co-workers, employment specialists, VR counselor, etc. ) Local collaboration between VR and MH approaches the RCTs rate of competitive employment (60%) or better

IPS-SE Collaboration specifically... Features of strong collaborations between VR and IPS programs included the following: Expertise (Training and Technical Assistance) Consistency (Fidelity Adherence/Zero Exclusion) Accessibility (Joint Referrals) Integration (Tx Team, SE Steering Committee, jointly gathered metrics that reflect performance of both systems) Oulvey, G. Psychiatric Rehabilitation, March 2013

IPS-SE Collaboration specifically... Five recommendations were developed from themes expressed in focus groups: (a) enhance mutual knowledge and understanding between VR and IPS practitioners (b) examine and modify VR regulations and guidelines that conflict with IPS principles (c) create clear guidelines for VR participation on IPS teams (d) create guidelines for good relationships between VR and community mental health centers (e) develop tools to promote accountability in VR staff and provider systems to improve employment outcomes for people with mental illness. (Oulvey, G. Psychiatric Rehabilitation, March 2013)

Part II: Factors for Teams and Organizations Utilizing the Model The assumption that IPS-SE is a team-based approach is paramount. In some cases, the local VR office and MH entity have already been implementing shared practices, though they are rarely evidence-based. In other areas, they do not know much about one another’s system and doubt collaboration. In order to collaborate, we must trust and understand. Social capital plays an important role in any collaboration. More training and technical assistance is needed to open up collaboration. And that’s okay!

Level 1: Basic adapted and excerpted from: VR-SE Partnership www Level 1: Basic adapted and excerpted from: VR-SE Partnership www.ohioseccoe.case.edu VOCATIONAL REHABILITATION and Integration of SE within Tx Team • Local VR office designates counselor (s) to receive IPS-SE referrals. • Designated counselors are trained in IPS-SE and have a basic knowledge of MH system and Tx team involvement. • Designated counselor attends multidisciplinary team meeting at least a few times per year.

Level 1: Basic adapted and excerpted from: VR-SE Partnership www Level 1: Basic adapted and excerpted from: VR-SE Partnership www.ohioseccoe.case.edu VR counselor provides 1:1 intake appointment (rather than group orientation). • VR informs MH of scheduled appointments. • VR counselor develops a plan within 30 days for at least 40 percent of SE consumers. • The job goal is driven by the consumer and includes input from the employment specialist and other mental health providers.

Level 1: Basic adapted and excerpted from: VR-SE Partnership www Level 1: Basic adapted and excerpted from: VR-SE Partnership www.ohioseccoe.case.edu SE authorizations are developed within 60 days of first appointment. (Exceptions may include situations when consumers have other disabilities or short-term medical issues that require additional planning.) Counselors only support competitive jobs in integrated settings. Counselors assist with career development goals based upon the use of the Career Profile and Tx Team participation. When consumers experience job problems after a case has been closed “26”, VR counselors re-open the case for post employment services.

Level II: Intermediate adapted and excerpted from: VR-SE Partnership www.ohioseccoe.case.edu Local VR office designates 1 to 2 counselors to receive SE referrals. Designated counselors have access to technical assistance. Designated counselor(s) meets with consumers at the mental health center approximately once a month. Designated counselor attends multidisciplinary team meeting at least once every other month. Designated counselor(s) participate in at least one SE training event each year after having base-line IPS-SE training.

Level II: Intermediate adapted and excerpted from: VR-SE Partnership www.ohioseccoe.case.edu All Level I person-centered approaches are followed, as well as: VR counselor develops a plan within 20 days for at least 60 percent of SE consumers. The job goal is driven by the consumer and includes input from the MH-provider employment specialist and other mental health professionals. When consumers find employment before meeting with a counselor, in most cases, the VR office opens a case within 48 hours for intensive follow-along services.

Level II: Intermediate adapted and excerpted from: VR-SE Partnership www.ohioseccoe.case.edu Counselors practice “zero exclusion” by authorizing job placement services for most SE consumers referred to VR. SE authorizations are developed within 30 days of first appointment. Counselors only support competitive jobs in integrated settings. Counselors assist with career development goals based upon the use of the Career Profile and Tx Team participation. No one is referred to work adjustment, and/or prevocational services. When consumers experience job problems after a case has been closed “26”, VR counselors re- open the case within one week.

Level III: Comprehensive adapted and excerpted from: VR-SE Partnership www.ohioseccoe.case.edu All elements from Levels I and II are followed. Designated counselor(s) uses an office at the MH center at least once each week (preferably on the day that the multidisciplinary team meets). Case managers and SE team know when to expect the counselor(s). Designated counselor(s) participate in treatment team meetings at least twice a month or more. Designated counselor(s) participate in at least two SE training event each year to remain current on IPS-SE research, practice and implementation.

Level III: Comprehensive adapted and excerpted from: VR-SE Partnership www.ohioseccoe.case.edu VR counselor provides 1:1 intake appointment (rather than group orientation). VR counselor uses MH documents for eligibility. VR counselor develops a plan within 10 days for at least 80 percent of SE consumers. The job goal is driven by the consumer and includes input from the employment specialist and other mental health providers. When consumers find employment before meeting with a counselor, the VR office works with the SE program to open the case within 48 hours for intensive follow-along services for the period allowed by VR regulations.

Level III: Comprehensive adapted and excerpted from: VR-SE Partnership www.ohioseccoe.case.edu Counselors practice “zero exclusion” by authorizing job- placement services for all SE consumers referred to VR. SE authorizations are developed within 14 days of first appointment Counselors only support competitive jobs in integrated settings. When consumers experience job problems after a case has been closed “26”, VR counselors re- open the case within one week.

Fidelity is About the Program, Stakeholders and the Agency! Executive Director and Clinical Director demonstrate knowledge regarding the principles of evidence-based supported employment. At least one member of the executive team actively participates in SE leadership team (steering committee) at least quarterly. Committee develops written action plans aimed at developing or sustaining high fidelity services.

More expectations... The agency CEO/Executive Director communicates how SE services support the mission of the agency and articulates clear and specific goals at least annually (i.e., SE Kickoff, all- agency meetings, agency newsletters, etc.). This item is not delegated to another administrator. The SE program leader shares information about EBP barriers and facilitators with the executive team (including the CEO) at least twice each year. The executive team helps the program leader identify and implement solutions to barriers.

Next Steps to improve mental health and employment supports: Read and discuss the NAMI July 2014 report. Road to Recovery: Employment and Mental Illness. www.nami.org/work Build upon Peer Specialist staff, and train this recovery workforce across the spectrum (benefits navigation, IPS, VR, and customization options). Consider how to engage local and state businesses in conversations around stigma, myth and the impact on economic development.

ODEP EFSLMP National Subject Matter Expert Contact Information Doug Crandell ODEP EFSLMP National Subject Matter Expert 770-896-5812 or 678-715-8598 crande@uga.edu dcrandell@griffinhammis.com