Evidence-Based Practices: Shaping Mental Health Services Toward Recovery Supported Employment

Recovery People with severe mental illness can and do recover. Recovery refers to the process in which people are able to live, work, learn, and participate fully in their communities.

Recovery Recovery is: A process of regaining one’s life to a usable form; reclaiming one’s personal power from one’s illness. Adapted from Webster’s II by: Molly Clouse

Recovery Former SAMHSA Administrator, Charles Curie’s favorite quote: … that individuals with severe mental illness will be able to live in a home of their own, have a job and a date on the weekend.

Services that Promote Recovery Treatment & Rehabilitation Treatment – Reduces emotional distress by reducing symptoms through diagnosis, medications, treatment planning, and therapy.

Services that Promote Recovery Rehabilitation- Provides skills and supports to maintain and sustain independence and addresses the consequences of the illness and the rebuilding of a positive self image. This is done through goal setting, skills teaching, resource coordination, and supports development.

Supported Employment Supported Employment is a Rehabilitation Service that promotes recovery.

Employment For many people, work is an important part of the recovery process. For most of us, work is part of our identity. Work provides structure and routines. It is one way of fulfilling a need to contribute- doing something that really matters. Job income gives us more choices about what to buy, where to live, and gives us a chance to build savings.

Employment When researchers have asked consumers if they want to work, nearly 7 out of every 10 consumers said they would like to have a job. Research shows 6 out of every 10 consumers can work at a job in the community if they are provided with the right types of services and supports.

Employment Unfortunately, assistance with employment is a major unmet need in most mental health programs: less than 15% of consumers nationally are competitively employed at any time. In Kentucky, only about 10% of consumers are competitively employed.

Supported Employment Works Researchers have studied different types of programs that help consumers find and keep employment. These studies compare supported employment to many other vocational approaches and they consistently find that supported employment assists more consumers with getting and keeping their jobs than any other approach.

Other Approaches Work Adjustment Training (Assessment and Training) is a training period used to assess a person’s employment skills. During this assessment, areas are identified in which a person shows their employment strengths and also areas that may need improvement. (Assessments may take 1 week to 2 months). Center Based Employment - Sheltered Workshops. Transitional Employment (TE) develops temporary, entry-level, part-time employment in the community for several people who job share. Job Coaches, employers, and members work together to help stabilize the employment placement.

What is Supported Employment? Supported employment is an approach to vocational rehabilitation for individuals with disabilities that emphasizes helping people obtain competitive work in the community, and providing the supports necessary to ensure success at the workplace. The emphasis in supported employment programs is on helping individuals find jobs paying competitive wages in integrated settings in the community.

What is Supported Employment? Supported employment programs help people find competitive jobs, (that is, jobs that pay at least minimum wage that any person can apply for) that are based on the person’s preferences and abilities.

The Evidence Supported Employment as an EBP The evidence for the effectiveness of supported employment comes mainly from two types of research: day treatment conversion studies and experimental studies

Day Treatment Conversion Studies Four studies examined what happens when day treatment programs were replaced with a supported employment program. In every case there was a substantial increase in employment rates. The percentage of consumers obtaining competitive jobs quadrupled after conversion of day treatment to supported employment, while competitive employment rates in centers not converting their services were unchanged. No negative outcomes were reported in any of these studies, except a small minority of consumers who missed the social contact in day treatment.

Experimental Studies 9 carefully controlled experimental studies compared supported employment to traditional vocational approaches (e.g., skills training preparation, sheltered workshops, transitional employment). All 9 studies showed better employment outcomes for consumers receiving supported employment. These studies suggest that supported employment is superior to other vocational approaches in both urban and rural areas, for persons of different ethnicities, for both men and women, and for a wide range of other consumer characteristics.

Supported Employment based on Six Principles Eligibility is based on consumer choice. No one is excluded who wants to participate. Supported employment is integrated with treatment. Employment specialists coordinate plans with your treatment team: your case manager, therapist, psychiatrist, etc. Competitive employment is the goal. The focus is community jobs anyone can apply for that pay at least minimum wage, including part-time and full-time jobs.

Supported Employment Six Principles Job search starts soon after a consumer expresses interest in working. There are no requirements for completing extensive pre-employment assessment and training, or intermediate work experiences (like prevocational work units, transitional employment, or sheltered workshops).

Supported Employment Six Principles Follow-along supports are continuous. Individualized supports to maintain employment continue as long as consumers want the assistance. Consumer preferences are important. Choices and decisions about work and support are individualized based on the person’s preferences, strengths, and experiences.

SAMHSA Supported Employment Toolkit http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/employment/ www.mentalhealthpractices.org http://www.apse.org/

SAMHSA Supported Employment Toolkit Table of Contents User's Guide Selected Articles Information For Consumers For Families & Other Supporters For Practitioners & Clinical Supervisors For Mental Health Program Leaders For Public Mental Health Authorities

SAMHSA Supported Employment Toolkit Implementation Tips for Mental Health Program Leaders Tips for Public Mental Health Authorities Cultural Competence Fidelity Scale Supported Employment Fidelity Scale - Implementation Questions Using Fidelity Scales for Evidence-Based Practices General Organizational Index Monitoring Client Outcomes Simple Employment Outcome Measures

SAMHSA Supported Employment Toolkit Workbook for Clinical & Practical Supervisors Videotapes Introductory Videotape Practice Demonstration Videotape

Information for Consumers Does SE Consider What I Want? Yes, in supported employment, the employment specialist assists consumers in identifying their career goals and personal abilities. The employment specialist then helps consumers find jobs that fit their personal preferences, strengths, and experiences.

Information for Consumers Can I Work Part Time? Yes, the goal of supported employment is to help people find jobs that fit their career goals and their lifestyles. For some people, this may mean starting with only a few hours of work each week

Information for Consumers Will Work Mess Up My Benefits? Supported employment includes benefits planning. Employment specialists help consumers obtain accurate benefits information so that they can make informed decisions. Most people are able to work and continue to receive some benefits.

Information for Families What happens if my family member is not able to work, even with the help of the supported employment program? Will other services still be available? Consumers are still eligible for other services even when they are not working or stop receiving supported employment services. Whatever other types of services are provided in your community should still be available to your family member. A case manager can help your family member access what services are needed.

Information for Clinicians Work is stressful. Will consumers experience increased symptoms if they obtain a competitive job? Generally speaking, people who work do not experience symptoms at any higher rate than people who do not work. For many consumers, symptoms improve through the planned, purposeful activity of work. In supported employment, the assessment of an individual’s strengths, coping strategies, and symptoms helps identify a good job and work environment for each person. It should also be remembered that not working is also stressful, often more stressful than working.

Information for Mental Health Program Leaders What Elements of Supported Employment are Most Critical? focus on competitive employment rapid job searches jobs tailored to individuals time-unlimited follow-along supports integration of supported employment and mental health services zero exclusion criteria (that is, no one is screened out because they are not ready)

Information for Public MH Authorities How is Supported Employment Funded? Funding mechanisms vary from agency to agency and state to state. Funds are generally used from state divisions of Vocational Rehabilitation, Division of Mental Health, and Medicaid. State leaders from the agencies generally work out a mechanism to pool monies that can be used to reimburse the services of supported employment programs. Medicaid rules have been rewritten to allow reimbursement for selected supported work activities. Consultation with other state agency or system administrators who have successfully worked out a plan provides useful ideas and strategies.

What does Supported Employment Cost? There is variability in the costs reported by different programs and states for providing supported employment. Some programs have found the cost ranges from $2,000 to $4,000 per client, per year. The cost figures vary according to many factors, including the severity of disability of the consumers served, the local wage scales for employment specialists, and the degree to which indirect costs and costs of clinical services are included in the estimates.

What Should Training for Supported Employment Include? Some training institutes offer multimodal training that includes the implementation resource kit materials plus, introductory training to supported employment practice skills training job shadowing at agencies that have implemented supported employment post-training consultations post-training supervision post-training fidelity measures post-training outcome measures

How will MH Authorities Know if They Have a Successful Program? How successful a supported employment program is in improving outcomes depends, in part, on how closely the program follows the supported employment practice. Programs that only partially adopt the practice or that are allowed to “drift” back into old ways of providing services may not produce the beneficial outcomes associated with supported employment.

Supported Employment Fidelity Scale The Supported Employment Fidelity Scale is a 15-item scale that measures adherence to supported employment. Evidence indicates that programs that score high on this fidelity scale have better employment outcomes.

Supported Employment Fidelity Scale Staffing: Caseload size: Employment specialists manage vocational caseloads of up to 25 clients. Vocational services staff: Employment specialists provide only vocational services. Vocational generalists: Each employment specialist carries out all phases of vocational service, including engagement, assessment, job placement, and follow-along supports.

Supported Employment Fidelity Scale Organization: Integration of rehabilitation with mental health treatment: Employment specialists are part of the mental health treatment teams with shared decision making. They attend regular treatment team meetings. Vocational unit: Employment specialists function as a unit rather than a group of practitioners. They have group supervision, share information, and help each other with cases.

Supported Employment Fidelity Scale Organization: Zero exclusion criteria: No eligibility requirements such as job readiness, lack of substance abuse, no history of violent behavior, minimal intellectual functioning, and mild symptoms.

Supported Employment Fidelity Scale Services: Ongoing, work-based vocational assessment: Vocational assessment is an ongoing process based on work experiences in competitive jobs. Rapid search for competitive job: The search for competitive jobs occurs rapidly after program entry.

Supported Employment Fidelity Scale Services: Individualized job search: Employer contacts are based on clients’ job preferences (relating to what they enjoy and their personal goals) and needs rather than the job market. Diversity of jobs developed: Employment specialists provide job options that are different settings.

Supported Employment Fidelity Scale Services: Permanence of jobs developed: Employment specialists provide competitive job options that have permanent status rather than temporary or time-limited status, e.g., TEPs. Jobs as transitions: All jobs are viewed as positive experiences on the path of vocational growth and development. Employment specialists help clients end jobs when appropriate and then find new jobs

Supported Employment Fidelity Scale Services: Follow-along supports: Individualized follow-along supports are provided to employer and client on a time-unlimited basis. Employer supports may include education and guidance. Client supports may include crisis intervention, job coaching, job counseling, job support groups, transportation, treatment changes (medication), networked supports (friends/family).

Supported Employment Fidelity Scale Services: Community-based services: Vocational services such as engagement, job finding and follow-along supports are provided in natural community settings. Assertive engagement and outreach: assertive engagement and outreach (telephone, mail, community visit) are conducted as needed.

Where Does Kentucky Stand? Kentucky has Supported Employment available in Five Regions; Bluegrass Regional MH/MR Board Seven Counties Services Lifeskills NorthKey River Valley Behavioral Health

How is it Funded? Block Grant Funds - $75,000 Some Vocational Rehabilitation Funding Some creative use of State General Funds for Mental Health Services. Funded by SCL Waiver for adults with MR/DD And Acquired Brain Injury Medicaid Waiver and Traumatic Brain Injury Trust Fund for adults with a brain injury.

Possible Funding Medicaid Rehabilitation Option or Case Management Dollars (many restrictions). Additional Block Grant Funding. More Flexibility in Mental Health Planning.

What Can We Do To Promote Supported Employment? Find out about Supported Employment in your community. Attend Supported Employment Training offered by the Department for Mental Health and Mental Retardation Services or Interdisciplinary Human Development Institute (IHDI). http://mhmr.ky.gov/KDMHMRS/default.asp http://www.ihdi.uky.edu/kyseweb/

What Can We Do To Promote Supported Employment? Research Supported Employment on line. http://www.apse.org/ http://www.nami.org/ http://www.bu.edu/cpr/ http://www.uspra.org/ Work with the Association for Persons in Supported Employment (APSE) and the National Association for the Mentally Ill (NAMI) to promote Supported Employment.