1.6 Supported Employment - Increasing Employment for People with Disabilities
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1.6 Supported Employment - Increasing Employment for People with Disabilities

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  • What is it? Does it work? How do you do it? How do I pay for it?
  • Health —Overcoming or managing one’s disease (s) as well as living in a physically and emotionally healthy way; Home —A stable and safe place to live that supports recovery; Purpose —Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors and the independence, income, and resources to participate in society; and Community —Relationships and social networks that provide support, friendship, love, and hope. #1 – Prevention of Substance Abuse and Mental Illness #2 – Trauma and Justice #3 – Military Families #4 – Recovery Support #5 – Health Reform #6 – Health Information Technology #7 – Data, Outcomes, and Quality #8 – Public Awareness and Support
  • Increase the proportion of individuals with mental and/or substance use disorders who are gainfully employed and/or participating in self-directed educational endeavors. Develop employer strategies to address national employment and education disparities among people with and without identified behavioral health problems. Improve the employment and educational outcomes among individuals with mental and/or substance use disorders served by SAMHSA., Implement evidence-based practices related to employment and education for individuals with mental and/or substance use disorders throughout all service systems. To recover, people need meaningful work and the ability to enhance their skills through education . Employment by its very nature helps integrate individuals in society and acknowledges their ability to contribute. In 2009, unemployed adults were classified with substance dependence or abuse at a higher rate (16.6 percent) than were full- or part-time employed adults (9.6 percent and 11.2 percent, respectively).87 The income employment produces enables people to improve their living situation, reducing exposure to violence and other stressors that may adversely affect behavioral health. Conversely, being unemployed is associated with increased rates of mental disorders, especially among men,88 and with relapse to substance use.89,90,91,92 Employment is recognized as a factor in preventing and ending homelessness among people with disabilities; for many individuals, it helps develop motivation and hope for the future. Nevertheless, individuals with mental disabilities have the lowest earning level and household income of any disability group.93 People who are unemployed show higher rates of substance dependence or abuse than those who are employed full or part time.
  • Faithful implementation to the practice… leads to desired outcomes
  • Supported Employment is regular competitive jobs in the community that anyone can apply for which pay prevailing wage, including part-time and full-time jobs “ intended for people with significant barriers to work”
  • There is no correlation between employment outcomes and psychiatric diagnoses 1 , overall psychiatric symptoms 1 , or severity of symptoms 3 Work history is associated with employment outcomes 3 and total earned wages 1 Negative symptoms can adversely impact employment 2 Social support is correlated with employment outcomes 3
  • Randomized Controlled Trials of EBSE In all 11 studies, EBSE had significantly better competitive employment outcomes than controls Mean across studies of consumers working competitively at some time: 62% for EBSE 25% for controls Bond, G.R. (2004). Supported employment: Evidence for an evidence-based practice. Psychiatric Rehabilitation Journal, 27 (4), 345-359. Bond, G. R. (2004, December 14). Critical ingredients of supported employment: Research evidence. Paper presented at the UNC/Duke Mental Health Seminar , Durham, NC. Latimer, E., Lecomte, T., Becker, D., Drake, R., Duclos, I., Piat, M., Xie, H. Supported employment for people with severe mental illness: Implications for the first Canadian randomized trial, The Journal of Mental Health Policy and Economics, 8 (1), March 2005. Twamley, E.W., Bartels, S.J., Becker, D., & Jeste, D.V. Individual Placement and Support for Middle-aged and Older Clients with Schizophrenia. International Association of Psychosocial Rehabilitation Services , San Diego, CA, May 2004.
  • In 2005, responding to an increasing consumer desire for employment and long waiting lists for the SE services in the county, the board of directors and management team of TripleCsawan opportunity to develop an in-house SE program to meet the needs of its consumers. Furthermore, the management team considered the SE project as a springboard to transform the agency from a traditional residential service provider to a recovery-oriented psychiatric rehabilitationprovider. They recognized that such a paradigm shift demanded a new organizational culture that values employment and promotes recovery.
  • Standardized tests, work sample and situational assessments can present a barrier to consumers interested in jobs and can screen out people who do poorly in test situations Does not attend to consumer’s goal.
  • I do intend to seek employment, but it will be at a time and place of my own choosing
  • to learn the needs of the employer, convey what the SE program offers to the employer, describe client strengths that are a good match for the employer.
  • Support throughout the agency from the CEO and board on down; Gowdy-difference between successful programs and those that weren’t was that everyone especially the administration talked positively about the clients potential for success.
  • Flat affect changed when describing his childhood in Hawaii when he sailed; aob to DVR meeting; challenged their denial; have started a CD group for clients who want to go to work and have CD issues; attending regularly; using a volunteer job as a reference and assessment…
  • Often the lynchpin in coordinating clinical and housing services.. Only way we are going to achieve our goals Housing staff know our clients the best – see them in their own environment 24 hours a day can be there before and after job iterview or work
  • What can we do to change your mind? The gentle Art of persuasion
  • Consumers and family members must lead and drive the Public Mental Health System to change!
  • Be able to identify EBP-SE

1.6 Supported Employment - Increasing Employment for People with Disabilities 1.6 Supported Employment - Increasing Employment for People with Disabilities Presentation Transcript

  • Improving Employment Outcomes for Homeless Job Seekers with Disabilities Supported Employment John Rio Advocates for Human Potential Mike Donegan Downtown Emergency Services Center
  • What is it ?
  • Work is part of recovery…
    • SAMHSA’s goal is a high-quality, self-directed, satisfying life integrated in a community for all people in America. This includes:
    • A Healthy Life
    • A Home
    • A Purpose
    • A Community
  • Success is the Pursuit of Purpose
    • Increase gainful employment and educational opportunities for individuals with or in recovery from mental and substance use disorders.
  •  
  • Traditional Vocational Services: Typical Features
    • Stepwise: Training or sheltered work first.
    • Work readiness criterion: Clients screened for placement.
    • Brokered: different agencies provide vocational and mental health services.
    • Short-term: Services reduced when job is found.
  • Employment Approaches with People Experiencing Homelessness
    • Social Purpose Ventures
    • Transitional Jobs
    • Place-based employment service
    • Customized Employment
    • Supported Employment
  • Evidence Based Practices What is an EBP?
    • Practices validated by research
    • Standardized guidelines describing critical ingredients
    • Replicable and teachable
    • A practice that has an operations manual and quantifiable measurable criteria (fidelity scales)
  • EBP Philosophy
    • People, including those with behavioral health conditions, and families have the right to access services that are known to be effective
  •  
  • Features of Supported Employment (EBP)
    • The goal is to assist consumers in obtaining competitive and satisfying jobs in community
    • The work pays at least minimum wage
    • People are employed in a work setting that includes nondisabled co-workers
    • Service agency provides ongoing support
    • Intended for consumers with a desire to work
    • Includes people with the most severe disabilities
    • Eligibility for SE services is based on consumer choice
    • Consumer preferences are important
    • SE is integrated with mental health treatment
    • Competitive employment is the goal
    • Job search process starts soon after a consumer expresses interest in working
    • Follow-along supports are continuous for employed consumers
  • Cross-over core principles
    • Supported Employment
    • Mainstream job in the community.
    • Clients choose employment options
    • Minimum wage or above.
    • Integrated work setting/integrated teams.
    • Ongoing supports from service agency.
    • Most Seriously Disabled.
    • Supported Housing
    • Mainstream housing in the community.
    • Clients choose housing options.
    • Integrated housing setting/integrated teams.
    • Ongoing supports from service agency.
    • Most Seriously Disabled.
  • “ Recovery may be a journey; but if you never get anywhere, it can easily become a treadmill” Joe Marrone
  • http://store.samhsa.gov/product/Supported-Employment-Evidence-Based-Practices-EBP-KIT/SMA08-4365 Get This
  • Does it work?
    • “ Nothing that I have studied has the same kind of impact on people that employment does. Medication, case management, and psychotherapies tend to produce a small impact on people’s overall adjustment. But the differences are often striking and dramatic with employment”
    • - Robert Drake, M.D., VCU Web Course, Supported Employment for Persons with Severe Mental Illness
  • Competitive Employment for People with Serious Mental Illness
    • Say they want to work: 60%-75%
    • Are currently working: <15%
    • Have access to Supported Employment Programs <15%
  • SE research is robust and compelling
      • The IPS (Individual Placement and Support) model was the foundation for EBP-SE principles
      • Superior employment outcomes are produced when fidelity to the core practices is maintained
      • Higher employment outcomes
      • 40-80% vs. 10-21% for traditional models
      • There is no evidence that anything “adverse” happens to employed persons with psychiatric disabilities (increase in symptoms/hospitalizations) (Bond, 2001)
  • Competitive Employment Rates in 12 RCTs of Supported Employment
  • The competitive employment rates among Triple C (supportive housing) tenants at the start of the initiative were 13%. The employment rates increased to 26% after 12 months, 54% after 24 months, and the rate had since remained steadily above 50%.
    • Gao, N., Waynor, W. R., & O’Donnell, S. (2009). Creating organizational commitment to change: Key to consumer employment success in a supportive housing agency. Journal of Vocational Rehabilitation, 31(1), 45-50.
  • EBP SE Benefits
    • Responds rapidly to an individual who desires to work.
    • Streamlines the service delivery process.
    • The entire treatment/service team shares responsibility for the employment outcome.
    • Employment specialists are supported by the agency in all aspects of their work with consumers.
    • Extensive research evidence demonstrating effectiveness, when applied with fidelity.
    • Improves a consumer’s sense of
      • self-worth and symptom control;
      • reduces social isolation;
      • enhances quality of life; and
      • satisfaction with finances and leisure.
  • How do you do it?
  • Principles of EBP-SE
      • Employment is integrated with service/ treatment team
      • Participation in the SE program is open to all who want to work “Zero Exclusion”
      • Job finding is individualized with attention to consumer preferences
      • A rapid job search approach is used
      • Competitive employment is the goal
      • Long-term supports are proactive and ongoing
      • Ongoing work incentives and benefits counseling is used to educate consumers on the effects of earnings on benefits (e.g. federal, state, and local benefits).
    • Same Staff
    • Same Team
    • Same Organization
    • Same Case Record
      • Why Integrate?
      • Lower dropout rate for consumers/customers
      • Better communication
      • Clinicians get involved
      • Clinical information incorporated into employment plan
            • -Bond, 2001
    1. Behavioral health, supportive services and employment services are Integrated .
  • 1. What is a service or treatment team?
    • Regular daily contact
    • Ideally, ESs are co-located with Team
    • Meet as least weekly to discuss cases & share clinical information
    • Shared decision making (job seeker makes the final call)
    • ESs coordinate plans with team.
    • Ideally one integrated case record
    Treatment or Services Team Case Managers Substance Abuse specialist Psychiatric Nurse Psychologist Public VR Counselor Employment Specialist Housing Supports SW’s Other Allied Professionals Psychiatrist Person
  • Dealing with the Unexpected: Getting beyond the day to day Crisis
  • 1. Employment services are integrated with treatment and supportive services
    • ES regular attendance at team meetings and a regularly scheduled presence at the mental health program/agency is important
    • State VR Counselor is part of the treatment team
    • Collaboration with only a case manager, a psychologist or a housing program is not considered integration with a team.
  • 2. Participation is open to all who want to work “ We don’t seem to do well at predicting who can work and who cannot”
  • What do we mean by “Zero exclusion”
    • Diagnosis
    • Substance Use
    • Symptoms
    • Age
    • Hospitalization History
    • Education
    • Gender
    Better Employment Outcomes
  • All who want to participate can participate
      • Individuals are not screened out because of substance abuse lapses.  MH and Employment specialists work with individuals to fully support a recovery lifestyle.
      • Assertive outreach is provided to engage persons who are reluctant to participate or drop out
      • Differing levels of readiness to participate in employment is accepted and encouragement to become engaged in employment is continuous.
      • Standardized tests, work samples and situational assessments/work experiences do not predict outcomes,
  • It’s time for a new paradigm! Can you shift your paradigm?
  • 2. Reframing “Readiness for employment”
    • Paradigm shift:
    • People will accept services that they want
    • The role of professionals is to help people get those services that they say they want AND provide necessary supports
    • People are ready to work when they say they are ready to work
  • 3. Preferences are Important
    • Job finding is based on preferences, strengths, and work experiences , not on a pool of jobs that are available
  • Job Seeker preferences may include:
    • Number of hours
    • Type of job
    • Workplace environment
    • Work shift
    • Disclosure (or no disclosure)
    • Location
    • Types and Frequency of support
  • Job Seeker Preferences
    • Job seeker choice is fostered and respected
    • Effort is made to help job seekers make informed decisions
    • Research has shown that people with severe mental illness generally have realistic ideas about what work they can do, how many hours a week they can work and what work environments are good or bad for them.
  • Employment Specialists Duties
    • Employment Specialists only provide vocational services, they do not perform general case management duties
    • Employment specialists provide the full range of SE services including: job development, job coaching and job supports
  • 4. Rapid Job Search
    • You track employer contacts
    • First face-to-face contact with an employer about a competitive job is on average within 30 days after program entry.
    • 6 face-to-face employer contacts per week
    • Multiple in person visits to an employer to build a relationship
    • Employment specialists spends 65% of time in community
    • Jobs obtained are diverse
  •  
  • Outline of Job Development Process
    • Prepare for employer engagement
    • Get an appointment with a decision maker
    • Establish rapport
    • Navigate the employer interview
      • Listen for employer needs
      • Learn about the work environment
      • Test possible solutions
    • Follow-up with employers
    • Present your solutions
      • Representing job seekers
      • Demonstrating SE services
    • Maintain & nurture employer relationships
  • Rapid Job Search
    • No research shows that participation in extensive pre-vocational assessment, work adjustment and job skills training programs improves employment success
    • Community-based work assessments/work experiences/situational assessments can help career exploration and develop confidence
    • Services can be more timely when agreements with VR presume eligibility
  • 5. A competitive job is the goal
    • Competitive jobs
      • pay at least minimum wage;
      • are in the community; and
      • are open to anyone, not just people with mental illnesses or other disabilities.
    • Volunteer work and other pre-placement services such as trial work experiences are used sparingly and ONLY in response to individual preferences.
  • 6. Time Unlimited Support
    • Follow along supports should be highly individualized, but can include:
    • on site coaching
    • off site supports
    • family supports/
    • interventions
    • help reporting
    • income
    • transportation options
    • supports to employer
    • AM phone calls
    • help with grooming/dress
    • social skills training
    • money management
    • medication adjustment
    • help tracking schedule
    • And on and on!
  • What are sources of ongoing supportive services?
    • Most commonly, case managers in housing, treatment or other service programs
  • 7. Personalized benefits planning
    • Starts at the beginning of vocational planning not only when people secure a job
    • Informing people helps allay anxieties and fears about losing coverage
    • Continues beyond initial employment, to assist consumers in coping with reporting requirements, raises, etc.
  • SE at the Downtown Emergency Services Center, Seattle
    • After other agencies labeled Nancy &quot;not housing ready&quot;, DESC placed Nancy into her own studio apartment at The Union. She now actively participates in supportive services, and is looking forward to finding a part-time job in landscaping or working in a nursery with plants.
  • DESC
    • Downtown Seattle
    • 4,800 clients/year receiving shelter
    • 1000 units of Supportive Housing
    • 900 clients enrolled in the MH Services
  • Employment Services
    • Connection Program
      • For homeless persons not in the MH system
      • Hygiene Station -7 days a week
      • Since 2006, helped more than 700 people find work and 600 find permanent housing
      • Computers, 2 Employment Specialist, Housing Specialist, Case Managers,
      • DVR
      • Onsite GED and Adult Education Classes
    • Operating 2 years
    • 1 program manager
    • 3 employment specialists (2 in SE)
    • Staff stationed with the treatment teams
    Supported Employment
  • Supported Employment
    • Core service of the MH Program
    • 2008 - 7.6% Employment Rate
    • 2010 – 13.4% Employment Rate
    • SE has enrolled 140 people and provided consultations for at least another 100
    • Assisted participants find and keep 28 jobs
    • More jobs this year to date than all of last year
  • Process
    • Joe
      • 40 years old
      • Paranoid Schizophrenia
      • Poly substance dependence
      • No work history
      • Multiple assault and drug arrests
      • Flat affect and poor hygiene, often AOB to meetings
      • Intermittent Shelter stays from 2001 to 2009 when we were able to provide permanent housing in 2010
      • Started volunteering in our drop in while in shelter
      • Continues drinking but quit Crack
      • Observed marked affect when describing time when he had worked on a sail boat
  • Results
    • Brad
      • 49 years old
      • Diagnosed as having Paranoid Schizophrenia
      • Entered service through our street outreach in 2006
      • Sought S. E. program
      • Stable on Meds and in permanent housing
      • Still obvious symptoms
      • 3 Felony Assaults and 3 Misdemeanor Assaults between 1995 and 2005
      • No work history that could be used
      • Working 20-30 hours a month as a Janitor Assistant will increase as the company expands
  • How are we making it work?
    • Utilizing fidelity to guide our program design/changes.
    • Measuring outcomes
    • Taking the pulse of stakeholders
    • Continuously addressing issues impacting integration
      • Multi-player responsibility
      • Documentation
      • Reporting
    • Utilization of TA & Training
  • Vocationalizing our Housing
    • Including Housing Staff more deliberately in our integrated service
    • Staffing clients when they are re-engaging in the community, not just when they are having problems
    • Pilot program – Social Work Student at our newest supportive housing residence
    • Transitioning to senior staff member – will cross train
  • How do I pay for it?
  • Funding Sources
    • State Department of Mental Health
    • State Vocational Rehabilitation Agency
    • Philanthropy
    • Community Development Block Grant
    • SNAP – Employment & Training
    • Medicaid
    • Local revenue
    • US Department of Labor
  •  
  • HUD (HEARTH) Says…
    • (27) SUPPORTIVE SERVICES.—The term `supportive services' means services that address the special needs of people served by a project, including—
    • (B) the establishment and operation of an employment assistance program, including providing job training;
  • Why implement evidence-based supported employment?
    • Work, even part-time clearly gives people hope, self-esteem and an overall better quality of life
    • EBP-SE helps more people with SMI go to work
    • More income, less reliance on housing subsidies
    • Complements PSH
  • What do you say to people who say they don’t want to work?
  • Pre-Contemplation to Contemplation
  • Know what EBP-SE looks like
  • &quot;You've got to be very careful if you don't know where you're going, because you might not get there.&quot;
  • Resources
    • Financing http://www.hudhre.info/documents/FinanEmployPrgmsPresentation.pdf
    • Nine HUD Employment Lectures http:// hudhre.info/index.cfm?do = viewEmpAudioLectures
    • Work as a Priority (2003)
    • www.nrchmi.samhsa.gov/pdfs/WorkPriority.pdf
    • CHETA-Chronic Homeless Employment and Technical Assistance Center
    • www.csh.org/cheta
    • Toolkit linking PSH tenants to employment http://www.csh.org/index.cfm?fuseaction=Page.viewPage&pageId=4283&parentID=10