1. SUPPORTED EMPLOYMENT Improving Lives Through Work Deborah R. Becker Dartmouth Psychiatric Research Center Webcast - CIMH February 28, 2006

2. Traditional Vocational Services: Typical Features Stepwise: Training or sheltered work first Stepwise: Training or sheltered work first Work readiness criterion: Clients screened for placement Work readiness criterion: Clients screened for placement Brokered: Different agencies provide vocational and mental health services Brokered: Different agencies provide vocational and mental health services Short-term: Services reduced when job is found Short-term: Services reduced when job is found

3. Competitive Employment for People with Serious Mental Illness n Say they want to work: 70% n Are currently working: <15% n Current access to supported employment: <5%

4. Definition of Supported Employment Mainstream job in community Mainstream job in community Pays at least minimum wage Pays at least minimum wage Work setting includes people who don’t have a disability Work setting includes people who don’t have a disability Service agency provides ongoing support Service agency provides ongoing support Intended for people with most severe disabilities Intended for people with most severe disabilities

5. Definition of Competitive Employment Pays at least minimum wage Pays at least minimum wage Integrated community setting Integrated community setting “Owned” by the worker “Owned” by the worker Not set aside for people with disabilities Not set aside for people with disabilities

6. Evidence-Based Practice Program model validated by rigorous research (different investigators) Program model validated by rigorous research (different investigators) Has guidelines describing critical components Has guidelines describing critical components Has a treatment manual Has a treatment manual

7. Primary Evidence for Supported Employment 5 day treatment conversion studies 5 day treatment conversion studies 13 completed randomized controlled trials 13 completed randomized controlled trials 3 correlational studies of work and program implementation 3 correlational studies of work and program implementation

8. Competitive Employment Rates in 12 RCTs of Supported Employment

9. Conclusions: Randomized Controlled Trials of Supported Employment In 13 of 13 studies, SE had significantly better competitive employment outcomes than controls In 13 of 13 studies, SE had significantly better competitive employment outcomes than controls Mean across studies of consumers working competitively at some time: Mean across studies of consumers working competitively at some time: –60% for supported employment –22% for controls

10. Long-Term Follow Up 3 supported employment research studies - 8-12 years 3 supported employment research studies - 8-12 years Similar findings Similar findings –Most worked for pay –Current jobs were mostly competitive –People held multiple jobs over time

11. Positive Outcomes from Competitive Work Higher self-esteem Higher self-esteem Better control of psychiatric symptoms Better control of psychiatric symptoms More satisfaction with finances and with leisure More satisfaction with finances and with leisure (Bond et al., 2001 )

12. What Does Supported Employment Cost? Some programs, $2,000-$4,000 per client per year (Clark, 1998). Some programs, $2,000-$4,000 per client per year (Clark, 1998). Latimer (2004) $2,449 per full-year equivalent client. Latimer (2004) $2,449 per full-year equivalent client. Figures vary according to severity of disability, local wages of employment specialists, caseload sizes, and how much indirect costs and costs of clinical services are included. Figures vary according to severity of disability, local wages of employment specialists, caseload sizes, and how much indirect costs and costs of clinical services are included.

13. Evidence-Based Principles Eligibility is based on consumer choice Eligibility is based on consumer choice Personalized benefits planning is provided Personalized benefits planning is provided Supported employment is integrated with treatment Supported employment is integrated with treatment Competitive employment is the goal Competitive employment is the goal Job search starts soon after a consumer expresses interest in working Job search starts soon after a consumer expresses interest in working Follow-along supports are continuous Follow-along supports are continuous Consumer preferences are important Consumer preferences are important

14. Eligibility Is Based on Consumer Choice Consumers are not excluded because they are not “ready” or because of prior work history, hospitalization history, substance use, symptoms, or other characteristics. Consumers are not excluded because they are not “ready” or because of prior work history, hospitalization history, substance use, symptoms, or other characteristics. No one is excluded who wants to participate. No one is excluded who wants to participate.

15. Referral Make referral process simple! Make referral process simple! Have minimal eligibility criteria Have minimal eligibility criteria –Unemployed (or working non- competitively) and wants competitive employment, or –Employed, but not receiving employment supports, and wants such support Involve multiple stakeholders Involve multiple stakeholders

16. Engagement Build trusting, collaborative relationship Build trusting, collaborative relationship Assume contacts are mostly outside mental health setting Assume contacts are mostly outside mental health setting Maintain ongoing contact Maintain ongoing contact Involve family, treatment team, and other supporters Involve family, treatment team, and other supporters

17. Personalized Benefits Planning Is Provided Benefits planning and guidance help consumers make informed decisions about job starts and changes. Benefits planning and guidance help consumers make informed decisions about job starts and changes.

18. Benefits Counseling Fear of losing benefits is major barrier to employment Fear of losing benefits is major barrier to employment Concerns of consumers and families often underestimated by clinicians Concerns of consumers and families often underestimated by clinicians Rules and regulations are complicated Rules and regulations are complicated Benefits counseling provides consumer- specific information Benefits counseling provides consumer- specific information

19. Supported Employment Is Integrated with Mental Health Treatment Employment specialists coordinate plans with the treatment team, e.g., case manager, therapist, psychiatrist, etc. Employment specialists coordinate plans with the treatment team, e.g., case manager, therapist, psychiatrist, etc.

20. Supported Employment Unit Individual caseloads, but help each other (with job leads, etc.) Individual caseloads, but help each other (with job leads, etc.) Caseloads of about 20 consumers or less Caseloads of about 20 consumers or less Weekly team meetings + individual supervision Weekly team meetings + individual supervision

21. Effective Structure of Integrated Services Co-located at the same agency Co-located at the same agency Integrated records Integrated records Frequent contact between employment staff and treatment team members Frequent contact between employment staff and treatment team members Employment specialists in treatment team meetings Employment specialists in treatment team meetings

22. 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 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. Consumers interested in employment are not steered into day treatment or sheltered work.

23. Vocational Profile Gather comprehensive information from variety of sources over 1-2 weeks Gather comprehensive information from variety of sources over 1-2 weeks –Consumer –Family, friends –Former employers –Treatment team

24. Employment Plan Explore jobs by visiting work sites Explore jobs by visiting work sites Develop employment plan Develop employment plan Revise assessment and employment plan based on consumer’s experiences Revise assessment and employment plan based on consumer’s experiences

25. Disclosure of Psychiatric Status Disclosure is the consumer’s choice Disclosure is the consumer’s choice Nature of disclosure Nature of disclosure –When to disclose? –How much to disclose? –Who to disclose to?

26. Job Search Starts Soon After A Consumer Expresses Interest In Working Pre-employment assessment, training, and counseling are kept to a minimum. Pre-employment assessment, training, and counseling are kept to a minimum.

27. Individualized Job Search Base on person’s preferences, strengths, abilities, experiences, and deficits (e.g., substance use) Base on person’s preferences, strengths, abilities, experiences, and deficits (e.g., substance use) Seek: Seek: –Permanent competitive jobs –Diverse jobs suiting individual consumers –Different settings

28. Ways to Find Jobs Identify leads primarily through networking Identify leads primarily through networking Include family and treatment team Include family and treatment team Attend job fairs Attend job fairs Use Chamber of Commerce and community organizations (e.g., Rotary Club) Use Chamber of Commerce and community organizations (e.g., Rotary Club)

29. More Ways to Find Jobs Newspaper (However, lots of others seeking same job) Newspaper (However, lots of others seeking same job) Internet Internet Previous employers Previous employers Tell everyone you meet Tell everyone you meet Track contacts Track contacts Stay persistent Stay persistent

30. Employer Questions Why is the applicant with an employment specialist (or not)? Why is the applicant with an employment specialist (or not)? What is the role of the employment specialist? What is the role of the employment specialist? Are there fees? Are there fees? Why are there work gaps ? Why are there work gaps ? Can the person do the job? Can the person do the job?

31. Benefits to Employer Work Opportunities Tax Credit Work Opportunities Tax Credit Pre-screening Pre-screening Assessment of skills and strengths Assessment of skills and strengths Guidance regarding accommodations Guidance regarding accommodations Short-term job coaching Short-term job coaching Ongoing assistance available to employer and employee Ongoing assistance available to employer and employee

32. 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. Supported employment staff continue to stay in regular contact with consumer and (when appropriate) the employer without arbitrary time limits.

33. Reasonable Accommodations Communication Communication –Temporary job coach –Written instructions –Co-worker buddy/mentor –Change in supervisor –Praise and positive reinforcement

34. Reasonable Accommodations Flexible Scheduling Flexible Scheduling –Part-time hours –Self-paced workload –Frequent work breaks –Clinic appointments –Paid/unpaid hospital leave

35. Reasonable Accommodations Work Setting Work Setting –Access to water –Access to rest area –Changes in work station –Remove/reduce distractions –Use of headsets or white noise

36. Reasonable Accommodations Work Tasks Work Tasks –Additional training time –Gradual increase in job duties –Job sharing –Restructuring job with essential features

37. Job Endings Each job viewed as learning experience Each job viewed as learning experience Job transitions are considered normal Job transitions are considered normal With a job loss, consumer and entire (SE and treatment) team strategize for next step With a job loss, consumer and entire (SE and treatment) team strategize for next step

38. 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 finding is based on consumers’ preferences, strengths, and work experiences, not on a pool of jobs that are available.

39. Job Preferences Are Important

40. Competitive Jobs Landscaper Landscaper Machine Operator Machine Operator Photographer Photographer Receptionist Receptionist Reporter Reporter Sales Clerk Sales Clerk Security officer Security officer Welder Welder

41. More Competitive Jobs Baker’s assistant Baker’s assistant Childcare Worker Childcare Worker Data Entry Data Entry Deli Meat Cutter Deli Meat Cutter Grocery Bagger/Carriage Attendant Grocery Bagger/Carriage Attendant Housekeeper Housekeeper Dishwasher Dishwasher

42. Role of Practitioners Provide encouragement and support - foundation for realizing potential Provide encouragement and support - foundation for realizing potential Point out strengths and gifts - translate into job opportunities Point out strengths and gifts - translate into job opportunities Coordinate clinical and vocational services Coordinate clinical and vocational services

43. More Roles Problem solve employment needs Problem solve employment needs Be positive Be positive Develop transportation plan Develop transportation plan Help obtain supplies/equipment for job Help obtain supplies/equipment for job Assist with 2 forms of ID, applications, researching jobs and businesses Assist with 2 forms of ID, applications, researching jobs and businesses

44. More Roles Help plan good job matches Help plan good job matches Help people manage their illnesses Help people manage their illnesses Help people manage substance use Help people manage substance use Help people manage interpersonal issues on job Help people manage interpersonal issues on job Provide follow-along support Provide follow-along support

45. Role of Employment Specialists Engage people Engage people –Listen –Be respectful –Promote self efficacy Develop vocational profile Develop vocational profile Assist consumer with employment plan Assist consumer with employment plan

46. More Roles Ensure access to benefits counseling Ensure access to benefits counseling Discuss disclosure (ongoing) Discuss disclosure (ongoing) Job search Job search Employer education Employer education Job support Job support Team player Team player

47. Role of Consumers Develop your work plan Develop your work plan Access comprehensive benefits counseling Access comprehensive benefits counseling Identify job choices Identify job choices Participate in job search Participate in job search Connect with working peers Connect with working peers Update support plan Update support plan

48. Collaboration with Vocational Rehabilitation Overcome system differences Overcome system differences Learn each other’s system Learn each other’s system Define roles Define roles Serve together Serve together

49. VR Services VR counselors VR counselors –purchase services –arrange services from other agencies –provide guidance and counseling

50. VR Services Training Training Situational assessment Situational assessment Job shadowing Job shadowing Job-related equipment, supplies Job-related equipment, supplies Tuition Tuition Placement Placement Planning Planning Support Support

51. Role of Employers Hire qualified employees Hire qualified employees Learn ways to support employees Learn ways to support employees Communicate with employment specialist Communicate with employment specialist Tell other employers about untapped workforce Tell other employers about untapped workforce

52. Mental Health Agency’s Role Employment is an agency goal Employment is an agency goal Employment is viewed as part of quality of life Employment is viewed as part of quality of life Agency demonstrates importance of employment Agency demonstrates importance of employment Culture of recovery Culture of recovery

53. Key Factors in Implementation Build Consensus Build Consensus Maximize Financing Maximize Financing Examine Agency Philosophy Examine Agency Philosophy Identify Leadership Identify Leadership Key on Organizational Structure Key on Organizational Structure Provide Ongoing Training Provide Ongoing Training Make Time Commitment Make Time Commitment Track Process and Outcomes Track Process and Outcomes

54. SE Fidelity Staffing Staffing –Caseload Size –Vocational Services Staff –Vocational Generalists Organization Organization –Integration of Rehab. + MH Treatment –Vocational Unit –Zero Exclusion Criteria

55. SE Fidelity cont. Services Services –On-going Work-based Assess. –Rapid Job Search –Individualized Job Search –Diversity of Jobs –Permanence of Jobs

56. SE Fidelity cont. Services Services –Jobs as Transitions –Follow-along Supports –Community-based Services –Assertive Engagement and Outreach

57. What About Supported Education? Consumer choice always a primary consideration Consumer choice always a primary consideration Education and training expand options Education and training expand options SE program should help consumers enroll in community programs (GED classes, colleges, technical schools) SE program should help consumers enroll in community programs (GED classes, colleges, technical schools)

58. Resources Dartmouth Vocational Publication List Dartmouth Vocational Publication List karendunn@dartmouth.edu karendunn@dartmouth.edu 603-448-0263 603-448-0263

59. More Resources A Working Life for People With Severe Mental Illness- Becker and Drake, Oxford University Press, 2003 A Working Life for People With Severe Mental Illness- Becker and Drake, Oxford University Press, 2003 Supported employment resource kit Mentalhealth.samhsa.gov Supported employment resource kit Mentalhealth.samhsa.gov

60. Summary People with severe mental illness can work in competitive employment People with severe mental illness can work in competitive employment Programs following evidence-based principles of supported employment have better outcomes Programs following evidence-based principles of supported employment have better outcomes Programs must address implementation factors to be successful Programs must address implementation factors to be successful