Work as a Priority Strategies for Employing People with Psychiatric and Cooccurring Disabilities who

1
Work as a PriorityStrategies for Employing
People with Psychiatric and Co-occurring
Disabilities who are Homeless

• Sponsored by
• The California Institute for Mental Health
• Facilitated by
• Gary Shaheen
• Laura Ware
• Advocates for Human Potential, Inc.
• 518-475-9146, ext. 243
• gshaheen_at_ahpnet.com

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DAY 1 Learning Objectives

• Learn about factors resulting from homelessness
  that affect peoples ability to obtain and retain
  employment
• Understand how recovery and rehabilitation
  principles and practices can provide the
  foundation for employment success.
• Understand how to address factors of motivation,
  self esteem, powerlessness that affect employment
  success
• Apply information through scenario exercises

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Larry MeredithIn Hooked by Lonny Shavelson 2001

• If we are going to make a difference, then we
  have to realize that drug abuse mental health
  is related to housing is related to health care
  is related to joblessness is related to poverty.
  You cant deal with any one of those without
  dealing with all of them.

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RJ

• I have been homeless for five years
• I have schizophrenia and have been drug addicted
  since the age of six
• I smoked crack
• Did some time a few years back on a burglary
  charge
• I dont know where Im going to sleep tonight
• Shelters are bad places where they rob you and
  beat you up. The staff looks the other way.
• I am an artist. I could be a millionaire if I
  could get money to make and sell my paintings
• If the Mayor can spend millions building a new
  city hall he should be able to give us money to
  help us get jobs and a decent place to live.

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Disincentives to Employment

• Distrust
• Focus on immediate needs
• Co-occurring disabilities
• Learned helplessness and emotional instability
• Functional limitations
• Cognitive limitations
• Illiteracy
• Communication deficits
• Physical/emotional trauma
• Poor self-esteem
• Fragmented or inadequate services/supports

• Mobility
• Skills mismatch
• Fear
• Legal issues custody convictions, judgements,
  probation
• Lack of personal documentation
• Child care
• Transportation
• Earning disincentives
• Lack of permanent address and phone
• Lack of hope
• Lack of skills regarding how to work towards a
  sustained goal, not just immediate gratification

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Program-Level Challenges

• Lack of knowledge, experience
• Paradigm paralysis
• Different providers speak different languages and
  often cant share much information
• Readiness prerequisites
• Ethnic/cultural sensitivity
• Different outcome expectations
• Different roles and turf issues
• Not enough or in the wrong places
• Lack of coordination, communication
• Promising more than can be delivered

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Service System Challenges

• Different systems are not aware of each other,
  and are resistant to change
• Fragmentation-funding sources, priorities, roles,
  criteria, etc
• Political priorities and issues that may prevent
  effective communication
• Stigma
• Lack of
• Lack of cross-systems training
• EBPs not understood

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Breaking the Cycle

• Trust-building is fundamental
• Recognize/utilize personal strengths
• Provide factual information
• Teach by example
• Recognize and address complex needs
• Affirm personal dignity and self-worth
• Reinforce personal responsibility, choice and
  empowerment
• Facilitate discussions to help individual see how
  previous choices and decisions can be done
  differently
• Adapt vocational approaches to meet needs
• Provide comprehensive, long-term supports

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Common Themes

• Jobs that people want and can
• manage well
• Linking Housing First/Work First
• Entrepreneurial approaches
• Clear reasonable expectations
• for all parties
• Flexible outcomes
• Redefining failure
• Provide personal service supports
• No arbitrary time limits
• Hire consumers as staff
• Cultural competence/relevance
• Link to treatment, rehabilitation, recovery
  services

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Guiding Principles 1

• Treat people on the basis of facts and inherent
  capabilities, not generalizations and stereotypes
• Provide genuine, effective, and meaningful
  opportunity (provide reasonable accommodations
  and modifications) in integrated mainstream
  environments

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Guiding Principles 2Social Justice and Equity

• XXX of all people who are homeless are persons
  of color
• Stigma, discrimination is a triple whammy-
• 1) homelessness mental illness substance
  abuse criminal justice issues
• 2) poverty and disenfranchisement
• 3) racial stereotyping, prejudice and
  discrimination
• You should consider the impacts of these factors
  on employment as well!

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Guiding Principles 3 FULL PARTICIPATION

• Involve people in decision-making at the
  individual, management and systems levels
• Ensure informed choice and share information
  using various mediums
• Provide support for self-determination,
  empowerment and self-advocacy

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UPENN RESEARCH-MAJOR FINDINGS

• Homelessness is a Revolving Door Phenomenon
• Point in Time vs. Longer Time Frame
• Identified 3 Subgroups
• Transient
• Episodic
• Chronic

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CULHANE S SUBPOPULATIONS

• Transient 80 of overall population, single,
  economically caused episode, low rates of illness
• Episodic 10 of overall population, multiple
  episodes of homelessness over time
• Chronic 10 of overall population, multiple,
  complex problems, long term homelessness

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Resources

• Changing for Good-Prochaska, Norcross
  DiClemente, 1994
• Motivational Interviewing Preparing People to
  Change Addictive Behavior-Miller Rollnick,
  2002
• PATHPROGRAM.COM-Click on Technical Assistance
• Implementing Interventions for Homeless
  Individuals with Co-Occurring Mental Health and
  Substance Abuse Disorders-Winarski, 1998

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FOUR PHASES OF TREATMENT

• Engagement
• Persuasion
• Active Treatment
• Relapse Prevention

Source Osher and Kofoed (1989)
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STAGES OF TREATMENT
ACTIVE TREATMENT
ENGAGEMENT
RELAPSE PREVENTION
PERSUASION

• Develop
• Relationship
• - Outreach Skills
• - Interpersonal Skills
• Provide Basic Supports
• Peer Intervention

• Hospitalization
• Outpatient Treatment
• Residential Treatment
• - Medication
• - Individual Therapy
• - Group Therapy
• - Peer Support
• Psycho-education
• Drug-education
• Rehabilitation Skills for
• Supported -
• Housing
• Education
• Employment
• Peer Interventions

• Community/Peer Support
• Individual/Group Therapy
• Psycho-education
• Identify Signs/Triggers
• for Relapse
• Rehabilitation Skills for
• Supported -
• Housing
• Education
• Employment
• Peer Interventions

• Develop
• Relationship
• - Outreach Skills
• - Interpersonal Skills
• Provide Basic Supports
• Develop Readiness
• - Enhance Motivation
• Peer Intervention

Case Management - Planning - Linking
- Advocating
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RECOVERY
A UNIFYING CONCEPT
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Consumer Self-Report of Items Important to
Recovery (Ralph,R)

• Ability to have hope
• Trusting my own thoughts
• Enjoying my environment
• Feeling alert and alive
• Increased self-esteem, spirituality
• Knowing I have a tomorrow
• Having a job

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How MH Professionals Help (Ralph,R)

• Encourage my independent thinking
• Treat me like an equal in planning my services
• Give me freedom to make my own mistakes
• Listen to me and believes what I say
• Recognize my abilities
• Work with me to find the resources/services that
  I need

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UNDERSTANDING RECOVERY

• Recovery Occurs for All People
• Recovery Occurs at Multiple Levels
• and at Variable Rates The Centrality of Loss
• Recovery Follows a Non-Linear Course

Source Winarski and Dubus (1995)
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FACILITATING RECOVERY

• Create Environments that are Conducive
• to Recovery.
• Attend to Motivational States.
• Respond to Mental Health Substance Use
• Disorders Simultaneously.
• Create Community.
• Define Expectations.

Source Winarski and Dubus (1995)
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Role Recovery is.

• Obtaining and sustaining a valued role as a
• Worker
• Family-member
• Friend
• Homeowner/tenant
• Partner, etc
• By overcoming personal losses, setbacks,
  obstacles, and limitations
• Obtaining the skills and trust from others needed
  to perform that role
• Educating others re personal abilities
• Using natural and professional supports as needed

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Worker Role Recovery-Two Dimensions

• SKILL
• DEVELOPMENT
• Setting work goals
• Testing work preferences
• Evaluating skills, personal strengths and
  supports against goals
• Skills Teaching tasks and work habits, as well
  as pursuing, obtaining and managing success
• Support Service planning

• INSIGHT DEVELOPMENT
• Identify values preferences, choices
• Prepare for change personal and environmental
• Honest self-assessment
• Trust in self and others
• Hope for the future

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ASSESSMENT
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ASSESSMENT IS ON-GOING

• Longitudinal approach collect and interpret
• information during each contact.
• Focus on signs and symptoms rather than
• making diagnosis.
• Comprehensive assessments may take many
• weeks and/or months.

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THE ASSESSMENT PROCESS IS INTEGRATED WITH THE
HELPING RELATIONSHIP

• Assessment takes place concurrently with
  activities
• that facilitate connection to the program.
• Information is most effectively gathered in the
• context of a trusting relationship.
• Gather information in an environment free from
• distractions.

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ASSESSMENT PROCESS
Observe/Listen
?
Collect and Interpret Information
Ask Critical Questions
Source Bassuk (1994)
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Tips for Effective Interviewing

• Choose between open-ended and closed-ended
  questions.
• Avoid leading questions.
• Structure chronological answers.
• Divide the experience into parts.
• Share experiences by generalized feelings.
• Be aware of non-verbal communication
• Conclude the interview.

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Common Errors in Interviewing

• Imposing values.
• Offering false reassurance.
• Asking double questions.
• Interrupting answers.
• Discouraging or forbidding the expression of real
  feelings.
• Saying I understand inappropriately.

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Techniques for Identifying Dual Disorders

• Screen-expectation not an exception. Increase the
  Index of suspicion.
• Self-report
• Signs and Symptoms
• Chemical testing
• Collateral information
• Correlates or predictors of substance use
  disorders
• Indirect measures (e.g. Family history -Car
  accidents).

Assess 1
Source Drake (1993)
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Ongoing Support as Needed for Re-Placement, Job
Acquisition, Advancement
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Employment-Centered Outreach

• Make work part of the conversation about engaging
  in services
• Prompt and listen to peoples stories about jobs
  they had and jobs they may want
• Encourage stories that help the individual to see
  unidentified yet transferable skills
• Provide information
• Assess the value of an offer of work as a hook
  to influence positive change
• Understand the stages of change

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Principles/Practices 1Linking Employment and
Housing

• Challenges
• People may not be interested in services once
  they are in the housing unit
• They are not sure what they want to do and avoid
  staff
• They are engaged in behavior they are trying to
  hide from staff
• Staff try to over engage or overstep
  boundaries and push participants away
• Staff may not maintain proper boundaries with
  participants, especially if he/she can relate to
  a particular challenge or situation
• Lack of cultural sensitivity to the background,
  needs, challenges and goals of a specific
  participant

• Suggested Responses
• Offer incentives in order to develop their
  interest
• Keep the conversation focused on what the
  participant is thinking or feeling, and what
  he/she wants to do about it
• Be aware of how your body language or other
  non-verbal communication
• Remember that the staff role is to guide and
  support, not direct, over-invest, mother a
  participant, or become emotionally involved
• Suggest meeting in an open space such as outdoors
  or in a private space such as a counseling room
• Try to never force an interaction unless
  absolutely necessary, or unless someones safety
  is at risk
• Vocationalize the housing environment by having
  a variety of available activities that offer
  opportunities for engagement around work

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Vocationalizing

• Creating a culture that expects work - verbally,
  mentally, environmentally and literally.
• Arranging things, activities and resources to
  include and/or support employment.
• Assign accountability for employment outcomes to
  all staff.
• Develop and maintain organizational policies and
  practices that support client employment
• Begin tracking employment outcomes.

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Mary

• Mary accepts housing but refuses to consider
  employment. Even though the Personal Services
  Coordinator reminds her that the program is
  offered only to those who want to work as well as
  get a place to live, she says she is not ready
  and wont discuss it any further.
• What are some ways you might help Mary address
  motivation to work?

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Principles and Practices 4Helping Mary
Develop Motivation for Work

• Typical Challenges
• Sense of hopelessness about vocational goals
  based on experience to date
• Numerous setbacks in general or negative work or
  other vocational experiences
• Many think of jobs or tasks that have
  historically been available without a great deal
  of creativity
• Some may be struggling with depression or other
  clinical/medical issues that make it difficult to
  get motivated
• Current stresses in life that make feeling
  motivated difficult
• Negative consequences of work such as child
  support payments, credit debts, SSI/DI
  disincentives, etc

• Suggested Responses
• Motivation as a State not a Trait it can change
  over time and be influenced
• Ambivalence is Good Tease out both sides, help
  tip balance towards change
• Resistance is not a Force to be Overcome-Roll
  with it
• Focus on Person as Ally, not Adversary
• Recovery, Change and Growth are intrinsic to
  being Human
• Remember that People who have suffered many
  losses may relinquish hope to survive
• Paint a picture of immediate incentives that can
  trigger motivational thinking

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STAGES OF BEHAVIOR CHANGE

• Pre-contemplation No awareness of problem or
  need to change
• Contemplation Emerging Awareness, ambivalence
• Preparation Identify, anticipate hot spots,
  planning, rehearsal, identify skills, supports
• Action Plan implementation with feedback loop
• Maintenance Reinforce what works
• Relapse Prevention Anticipate and plan for
  relapse, viewed as learning opportunity

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FACTORS THAT INLUENCE CHANGE READINESS

• Perception of Need Persons experience of
  discrepancy between the pain of the present and
  the potential for future improvement
• Belief that Change is Possible Positive outcome
  is achievable in reasonable time period
• Sense of Self Efficacy Believes they can succeed
• Makes Stated Intention to Change

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MOTIVATIONAL TASKS

• Pre-contemplation educate, raise doubt re
  perception of risk, identify other areas of high
  motivation
• Contemplation Tip the Balance- evoke reasons to
  change and risk of not changing
• Preparation Choose best strategies, anticipate
  difficulties, plan, rehearse
• Action Frequent monitoring of progress and
  ongoing lessons
• Relapse Help reframe as learning opportunity,
  not failure, plan
• Describe a time in your life you attempted
  change-how difficult? Who helped? Outcome?

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Principles and Practices 2Integrated Team
Planning

• Typical Challenges
• Developing effective relationships with staff of
  other partners, especially when they are located
  elsewhere
• Creating a project culture that encourages
  joint decision making
• Effectively documenting services for overall
  reporting, informational and evaluation purposes
• Seeing regular , consistent meetings as crucial,
  useful and a priority
• Developing centralized systems and procedures for
  intake, assessment, r intervention, communication
  processes, follow-up, referral, contacts with
  outside community
• Avoiding turf issues

• Suggested Responses
• Clarify for all staff and organizational
  partners, in writing, who is responsible for each
  role and component of the project
• Sponsor a series of shadowing or job
  switching opportunities
• Include discussion of partner and staff roles in
  regular staff meetings
• Facilitate regular case meetings, at which all
  staff working with a specific participant are
  present and asked to share information as well as
  next steps
• Create opportunities for staff to talk about
  successes and challenges, and for other staff to
  assist in problem-solving
• Designate a team leader

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John

• John says that there is no use in trying to find
  a job, because all he will do is fail at it
  anyway. He used to be a good carpenter but that
  was many years ago. Years of living on the
  street has eroded those skills and reduced his
  stamina. He says he feels hopeless of ever
  finding anything better than dishwashing or
  carrying out garbage.
• How would you help John develop an employment
  goal?

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Principles and Practices 3Helping John Create
Employment Goals

• Typical Challenges
• Many people have not thought about having
  vocational or employment goals, since their first
  goal on the streets has been survival
• Many are focused on immediate gratification, such
  as earning a bit of money or paying off a debt
• They may have had negative vocational or
  employment experiences because of the barriers
  they face
• They have trouble thinking about small steps that
  will lead to achieving a vocational or employment
  goal
• Some may not be currently motivated to pursue
  vocational or employment activities, and are
  content to maintain current status or activities
• Some may need help to identify how current
  interests, activities or desired participation
  can be seen as vocationally-oriented

• Suggested Responses
• Create opportunities in which they can have a
  sense of immediate success or achievement
• Focus on a persons perceived or inherent
  strengths, gifts, skills and interests
• Work with them to acknowledge all achievements
  (including survival on the streets) and make them
  visible to them as sources of strengths and
  knowledge that may have a job application,
• Focus on immediate goals first, and how these can
  lead to a larger goal.
• Give timeframes to specific goals as a way of
  motivating participant and yourself as a staff
• Make sure all goals are developed or agreed-to by
  the participant
• Make sure goals of any type are clearly defined
  and fleshed out by the participant and staff so
  that they are real and true

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Principles and Practices 6Implementing a
Standing Offer of Work (In-House Jobs)

• Typical Challenges
• Changing attitudes and expectations of all
  parties
• Acquiring jobs with built-in flexibility and
  opportunities for growth and transition
• Finding effective partners and employers-internal/
  external
• Resolving alcohol/substance abuse and mental
  health issues affecting work
• Staff and new worker training
• Providing supervision and support
• Fulfilling employment services contract/performanc
  e requirements
• Funding the effort
• Fit with SE Evidence based practices

• Suggested Responses
• Assume employability
• All staff supports peoples desire to work
• Look internally as well as externally for
• Provide direct, tangible workplace-based support
  to break down barriers
• Avoid lengthy prerequisites rapid access to a
  low-impact job
• Allow multiple work options-one job does not fit
  all
• Understand peoples needs, abilities and values
• Communicate your work expectations
• Celebrate all degrees of success
• Weave in conversations and support for the next
  step

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LAMP Village527 S. Crocker, Los Angeles, CA
90013 [phone]

• Drop-in Center/Crisis Shelter
• Lamp Lodge-50 unit permanent housing
• VILLAGE INDUSTRIES
• - Linen Services
• - Public Laundromat
• - Public Showers Toilets
• 1/3 of staff are consumers
• Employs 35 people per day

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Principle - Connecting to MH/SA Treatment
Services

• Typical Challenges
• People may not be ready to accept treatment
• People are fearful of treatment
• Their friends are not good influences and may
  disapprove of a persons decision to enter
  treatment
• Stigma
• Side effects

• Suggested Responses
• Establish referral relationships so that the
  services are accessible to participants when
  needed
• Help people understand the implications on goals
  they chose and commit to achieving
• Enlist the support of peers to help people
  understand the positive effects of accepting
  treatment
• Be clear about the rules regarding substance
  abuse on site at HUD housing

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Step-Back/Step-Out/Step-UpA Practical Strategy
for Keeping the Door Open for Employment

• WHAT IT IS
• a) A strategy for helping people address their
  treatment issues and impact on work
• b) A way of keeping people involved in employment
  services while they deal with their substance use
  and/or MH treatment issues
• c) A plan for putting together a support plan
  emphasizing growth
• WHEN At engagement, involvement, continuation
• WHO Implemented by staff, peers
• WHERE Shelters, employment programs, housing
  sites

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Step Back

• Offer alternatives to terminating program
  involvement for people when substance use
  interferes with their ability to get or keep
  employment
• Focus on how substance use prevents someone from
  getting or keeping a job, not the behavior
  itself.
• Provides alternative step-down
  employment-related services that do not risk the
  safety of the person or others
• Step downs still require people to be
  substance-free while they participate
• Examples employment counseling, presentations by
  peers or staff, resume writing, low-impact, P/T,
  time-limited in-house work experience, shadowing,
  P/T volunteer work
• Expected Outcomes Maintain connection, use
  stages of change strategy to change behaviors,
  show consequences (eg person may lose job but
  staff never go away)

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Step Out

• Some people may not be ready to deal with their
  treatment issues that affect their jobs and they
  may need to step out of the program.
• Although you may have to get to the place of
  reinforcing rules of enrollment-try to maintain
  contact (through outreach staff, shelter staff,
  peers, friends, etc) and let them know that the
  door is open for them to try again.

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Step Up

• The job placement is only the first success
• Dealing with treatment issues affecting work is
  an ongoing process owned by the individual
• Advancement and stepping out of poverty is the
  goal and is negatively affected by job and
  housing loss due to treatment issues
• Ongoing, follow-along support by an IST to
  support both treatment and work goals
• Support needs to accommodate for success as well
  as address challenges
• Involve peers as counselors or mentors showing
  how people can overcome fears of change and
  advancement and maintain balance
• Expect relapses and have a plan in place that
  deals with them
• Expected Outcomes Staff realize the job doesnt
  end at placement participants see the benefits
  of treatment and job retention and advancement
  they have access to wrap around supports 24/7

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Day 1 SummaryBreaking the Readiness Model

• Assume employability
• All staff supports peoples desire to work
• Avoiding lengthy prerequisites and rigid
  sequencing
• Allow multiple options-one best practice does
  not fit all
• Understand peoples needs, abilities and values
• Understand what employers want
• Understand how to make a good job fit
• Celebrate all degrees of success

52
Day 2Learning Objectives

• Learn about employment services practices being
  used throughout the country
• Understand tools and strategies for helping
  people choose, get, keep and advance in jobs
• Understand how to use partnerships to improve
  program delivery
• Learn about critical staff competencies for
  providing employment services
• Address challenges and strategies using scenarios
  and exercises

53
Customization of Employment Best Practices- A
Challenge for the Field

• Why?
• Replace staff-driven employment services with
  more person-centered approaches
• How?
• Modify existing practices like
• TEP Each time-limited job is individually
  negotiated/the person AND the job can change
• What Outcomes?
• Improve outcomes-satisfaction, tenure, growth

54
Transitional Employment (TEP) (Est. 1964
Fountain House, NYC)

• Primary vocational services of Clubhouses
• Time-Limited Part-Time Competitive
• Negotiate job slots set aside for rotating
  workers
• Usually entry level jobs
• Agency guarantees the job will be done
• On and Off-Site Job Coaches, peer supports
• Disadvantages
• Time limitations
• Agency is responsible for performing the job
• Dependency issues

55
ACT/PACT

• Continuous 24 hour treatment planning approach
• Employment specialist is member of
  multi-disciplinary Team
• Rapid placement, continuous follow-along and
  reassessment
• Recognizes that work is integral to the community
  treatment process
• Focus on work first on-the job learning,
  adaptation and accommodation
• Clash between short-term funding and long-term
  support needs

56
Customized Employment (NCWD)

• Individualizing the employment relationship
  between job seekers and employers to meet the
  needs of both.
• Determine the strengths, requirements, and
  interests of a person with a complex life.
• It is not a program, but rather a set of
  principles and strategies that result in
  employment.
• Builds on supported employment and results in
  individually designed services, supports, and
  jobs negotiated to fit the needs of a specific
  job seeker or employee.

57
Customized Employment (NCWD)

• Customized Planning
• Profiles, portfolios, etc to capture, organize,
  and represent the information that was collected
  during exploration
• Negotiating
• Negotiating job duties and employee expectations.
  Can include job carving, negotiating a job
  description, job creation, job sharing, etc.
• Self-Employment
• A recognized CE option

58
Career Mapping-A New Approach to Assessments and
Job Planning (Based on materials developed by
Sowers, McLean and Shelton Empowerment for Life
Project-Portland, OR)

• Recognizes the complex impacts of homelessness
  and disability on employment
• Seeks to bridge issues of trust
• Uses interactive group or individual techniques
• Results in pictographs (maps) that are the
  basis for referral to career services
• Assumes the result is mainstream employment with
  support services planning

59
Key Elements of Mapping

• LIFE HISTORY -draw correlations to past
  experiences. Identify patterns over their life
  span and recognize reoccurring themes, interests,
  and passions
• STRENGTHS, GIFTS and CAPACITIES - Identify what
  they are able to do, what they enjoy doing, and
  what they have done in the past to develop a job
  goal
• WHAT WORKS - Create a list of job characteristics
  that work well for them and those that do not
  work well for them
• POSSIBLE RESOURCES - Community-based resources
  available to them, as well as resources within
  the One Stop system
• POSSIBLE JOBS - List of possible jobs for
  themselves using strengths, gifts and capacities
  and what works as the only criteria
• REFFERAL Work with staff to develop a plan to
  get the job they want

60
A Map in Progress
Works Doesnt Work Spirituality Fear of
dying Early mornings Pushy people Hands on
learning Night work Exercise daily Noisy
settings Right medications Wrong medications
61
SAMHSAS MODEL FOR EBPsSAMHSA National Registry
of Effective Programs and Practices (NREPP)
http//modelprograms.samhsa.gov

• Evidence-Based Programs
• Conceptually sound and internally consistent
• Program activities related to conceptualization
• Reasonably well implemented and evaluated

• Promising
• Some positive outcomes

• Effective
• Consistently positive outcomes
• Strongly implemented and evaluated

• Model
• Availability for dissemination
• Technical assistance available from program
  developers

62
Why Use Evidence Based Approaches?

• Evidence based practices yield better outcomes
• Evidence based programs have fidelity measures
• SAMHSA acknowledges that the evidence base is
  limited in some areas
• SAMHSA supports promising practices where
  evidence of effectiveness is based on
• Formal consensus among recognized experts
• Evaluation studies not yet published

63
IPS/SE Fidelity (Bond 2003)

• Fidelity is important because programs that
  faithfully implement evidence based practices
  have better outcomes.
• Fidelity Scales assess the adequacy of
  implementing an evidence based practice

64
Supported Employment EBP (Drake, et al)

• Basis for SAMHSA Toolkit on Supported Employment
• Blending of assertive case management and
  supported employment
• Has been used to replace continuing/day treatment
• Work is considered both treatment and outcome
• Employment specialist is member of tx. Team
• Vocational assessment is continuous and obtained
  from multiple sources
• Focus on work first - learning through doing
• Services in the community on flexible schedule
• Has established a fidelity scale with
  staff/customer ratios

65
Social Enterprises Meeting the Market with a
Mission

• Businesses which affirmatively employ persons
  with disabilities and who have been homeless
  and/or other disadvantages
• Achieve social change
• More people get jobs
• Achieve Economic Change
• Build healthy business
• communities

66
Social Enterprises

• Characteristics
• Agency-sponsored businesses employing people with
  disabilities, people who have been homeless
  and/or other disadvantages
• Objectives
• Exposure and experience, skills development
• Add to the available jobs in the marketplace
• Advantages
• Agency owns the jobs
• Business to business potential
• Disadvantages
• High risk-requires sound business planning
• Can create numerous issues of roles and
  boundaries for staff and clients

67
COMMUNITY VOCATIONAL ENTERPRISES 1425 Folson
St., San Francisco, CA 94103 [phone]

• Training and employment
• for persons with mental illness
• other people with
• disadvantages
• Service Master Partnership
• Transitional employment in
• 4 agency-run businesses
• Professional development seminars
• Support services/Case management
• Enrolls 200 persons/year. 50-70 persons employed
  at any one time

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Supported Self Employment

• Characteristics
• Consumer owned and operated businesses
• Objectives
• Self-sufficiency through owning ones means of
  livelihood
• Advantages
• Consumer owns the job
• Self-reliance, independence, role shift from
  consumer to entrepreneur
• Disadvantages
• High risk-requires sound business planning
• Complications re benefits are different from
  other employment scenarios
• The buck stops here

69
Homelessness and Choosing a Job

• Need to address considerable concrete barriers,
  i.e., access to laundry, showers, clothing
• Lack of fixed address for mail or telephone to
  receive and return messages
• Personal humiliation about current homelessness
  and past record, such as criminal histories
• Poor employment histories and track record
  regarding employment
• Access to transportation
• Focus on immediate needs vs. longer term goals
• Impact of change
• Managing housing stability/recovery and work
• Unclear expectations/inadequate information
• Physical limitations

70
Getting a Job What Level of support is
needed?

• Work while choosing or job goal first?
• Identify values
• Identify strengths and gifts
• Identify preferences type of work, location,
  hours of work, wage scale
• Identify resources postings, ads, friends,
  family, staff
• Why this job? Why now?
• Sustained assistance regarding set-backs
• Support services-on and off job

71
Principles and Practices 7Employer Marketing

• Typical Challenges
• Devalued group of people with stigma
• Multiplicity of physical, psychological problems
  that could affect work
• Lack of recent solid work history
• Appearance and mannerisms
• Few resources (e.g. transportation, child care,
  etc)
• Poor self-image and lack of confidence, fear
• May not be a clear job match-negotiation may be
  necessary
• Employers understanding of the features/benefits
• Employers fears of accident liability

• Suggested Responses
• Assess employer needs and concerns
• Represent the job seeker
• Develop and use marketing tools brochures,
  testimonies, videos, etc.
• Develop sustained relationships with employers
  that allow for more non-traditional job matches
• Consider sectoral approaches
• Becoming familiar with the current labor market
  to make an informed match
• Guide job seekers on disclosure of disability and
  options for requesting reasonable accommodations.
• Provide information about work site
  accommodations to employers
• Guide job seekers on ways to address a record of
  conviction/incarceration
• Support successful job seeker interviews

72
Principles and Practices 8Job Development and
Placement

• Typical Challenges
• Force-fitting to meet program outcomes
• Passive job development
• Not following up on a regular basis with active
  and potential employers
• Focusing on the disability rather than the
  ability
• Starting with tax incentives
• Promising two for one
• Guaranteeing 100 productivity or attendance
• Offering to do all the training and supervision
• Failing to plan for the next step (advancement,
  transition)

• Suggested Responses
• Be creative- you want the same thing
• Offer examples to employers of ways part time,
  negotiated or carved jobs has helped an employer
  in the past
• Review the assessment information on an ongoing
  basis and update as needed
• Help the job seeker break down the job
  development process into attainable steps
• Select, train and support mentors
• Offer to provide disability sensitivity training
  to employers staff
• Include benefits planning as an ongoing part of
  the process

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Highlights Who Does What?
Legislative, regulatory framework for WIA
USDOL
Appoint, convene SWIB, discretionary , priority
pops
Governor
5Yr plan, policies, LWIB jurisdictions,
responsible for state performance
State WIB
LOCAL WIBs
Local plans, priority pops, administer 1 Stops,
contracts for priority pops
Core, intensive, training services, house VR
services, DPNs,
ONE-STOPS/SATELLITES
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One Stop Services

• Core services
• - Available to any job seeker
• - Self-service job search, resume development
• - Use of One Stop facilities, job fairs, employer
  presentations, etc
• Intensive services
• For those not successful in Core services
• Vocational counseling, remedial education and
  skills and support development, guided job
  search, enrollment into WIA funded training
  programs, etc
• Training services
• Enrollment in classes, specialized trades
  training, etc

75
Principles and Practices 5Connecting to
Mainstream Employment

• Typical Challenges
• Mismatch between customers readiness and the
  self-guided core services at a one stop
• Participants feel uncomfortable in One-Stop
  environments
• One Stop staff feel uncomfortable working with
  people who are chronically homeless
• Different goals regarding employment placement
• Different languages and expectations
• No history of coordination

• Suggested Responses
• Have information of relevance to people who are
  homeless at the One Stop
• Develop partnerships for targeted outreach
• Cross-train staff
• Use the resources of the DPN
• Review services forms and documents to determine
  how they are consistent with each other, and
  where they contradict each other
• Introduce people to One Stop services as a normal
  part of the employment process

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Example 1 CTWorks-Bridgeport, CT

• Operated by Career Resources, Inc.,
• Partnerships with LWIB, Bridgeport Continuum of
  Care, the CT Division of Rehabilitation Services,
  the CT Department of Mental Health and Addiction
  Services and the Veterans Employment Service.
• 50 corporate donors, the United Way, US
  Department of Education grant ,DOL Work Incentive
  Grant and Disability Program Navigator funding

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CT Works!- Why?

• Meets people who are homeless with services
  where they are at
• Developed a Career Coach mobile One Stop with
  the technology on board to connect people who are
  homeless to core services
• Important partner is HVRP to connect Vets to
  core, intensive, training services
• Visionary Leadership!
• Public/private funding mix

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Example 2 SEARCH-Houston, TX

• Active member of the local Continuum of Care
• Permanent and transitional housing, daily lunch
  for 250, a food pantry, mobile outreach, day
  care, medical assistance and psychological
  evaluations, and a one-stop career center for the
  homeless
• Received JTPA and WIA Adult funding for
  employment services for homeless

79
SEARCH Works! Why?

• Realized it could not go it alone
• Offers on-site occupational skills training
  (computers, etc) for growth jobs
• Understands it needs to braid/blend funding to
  provide support services and intensive counseling

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Ending Chronic Homelessness Partnerships

• HUD, ODEP, ETA, VETS funded x 5 years
• 5 Cities LA, Boston, SF, Indianapolis, Portland,
  OR
• 297 people housing jobs
• Lead applicant is workforce development

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Progress so far.. Through 9/30/05

• Number served 357
• full or part time competitive jobs 113
• Employment rate ( placed in housing entering
  employment) 43
• Innovations (one stop satellite career mapping
  strategy, mobile one-stop)

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Accessing Mainstream Resources for Employment

• Medicaid (www.cms.hhs.gov)
• 1619(b)
• Buy-In
• Rehab Option
• HUD (www.hud.gov)
• Section 8
• CDBG
• ESG
• ROSS/Hope VI
• Tenant-Based Rental Assistance

• USDOL (www.dol.gov)
• WIA
• SSA (www.ssa.gov)
• Ticket to Work
• SSA Work Incentives
• Dept. of Agriculture (www.usda.gov)
• FSET
• RSA/VR (http//www.ed.gov/offices/OSERS)
• State VR
• HHS (http//www.acf.hhs.gov/programs/ocs/dcdp/joli
  /welcome.htm)
• JOLI

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Job Search Planning

• Assessment-skills/resources/supports
• Person-centered planning-preferences/goals, job
  expectations
• Researching employer(s)
• Complete/modify resume, cover letters,
  applications
• Obtain transcripts, credentials, references
• Resolve disclosure issue
• Address criminal justice involvement
• Identify hot buttons and plan response
• Practice interviews and how to deal with
  surprises
• Develop a schedule and plan

84
Disclosure A Personal Choice

• Disclosure of disability can occur
• At the time of the job application (by the
  applicant or by their representative)
• During the interview
• After the job is accepted
• After adjusting to the job, demonstrating
  competency and prior to the need for reasonable
  accommodation
• When asking for an accommodation
• Never
• Sometimes it is optimal to discuss the disability
  in terms of behavior and resulting behaviors

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Menu of Keep Services

• Job Coaching Follow-Along
• Educational, Professional, Peer, Natural Job
  Supports
• Professional, Peer, Natural Housing, Recovery
  Supports
• Benefits Management Advocacy
• Growth and Career Planning

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Principles and Practices 9Job Retention and
Advancement

• Typical Challenges
• Having
• New friendships/disengaging from problematic old
  relationships
• Managing new structure, scheduling and time
  demands
• Pressures to share new funds or luxuries with
  less fortunate neighbors
• New routines
• New lifestyle
• Co-worker, supervisor relationships
• Threat of success

• Suggested Responses

87
Tools and Activities Utilizing Natural
Workplace Supports

• Job coach as training consultant, not trainer
• Utilize typical employee orientation and training
  process and resources
• Assist to understand workplace culture, cues,
  politics
• Dont switchboard questions feedback
• Help people develop skills to establish their own
  natural workplace supports
• Explore possibility of training the employer to
  facilitate the best results for everyone

88
Understanding and Addressing Work-Related Triggers

• Having
• New friendships/disengaging from problematic old
  relationships
• Managing new structure, scheduling and time
  demands
• Pressures to share new funds or luxuries with
  less fortunate neighbors
• New routines
• New lifestyle
• Co-worker, supervisor relationships
• Threat of success

89
Scenario Questions Choosing, Getting and
Keeping a Job

• What are this persons strengths and assets?
• What employment goal(s) do you think they might
  choose?
• What employment program option might they prefer
  and why?
• What concrete barriers may arise or exist that
  need to be addressed? How would an integrated
  services team proceed with the participant?
• Will this person choose to disclose their
  disability or not?
• Describe how the plan for job search might look
• What natural supports does this person have
  available?
• What triggers will affect job retention?
• What are some of the elements of the employment
  support plan?

90
For Systems/Programs For People
91
Building a Culture Supporting Employment Some
Examples

• Employment is part of our Mission Statement
• Targeted increases in rate of employment is an
  agency priority
• Consumers are included in program decision-making
  
• Skill building of participants is an integral
  part of all service delivery teaching the
  participants how to meet their own needs
• We hire consumers as staff
• We have ongoing staff training on employment
• Consumers are clear on why they are participating
  in employment programs
• Staff support consumer involvement, dignity,
  choice and community integration
• Consumers, their families and staff express hope
  that employment is possible
• All staff throughout the organization are
  interested in and committed to employment
  opportunities for participants
• Formal vendors and outside partners are viewed as
  potential employers for participants

92
Developing Capacity-Examples

• We have employment program written policies and
  procedures
• We have clear employment outcome measures
• We have the goal of assisting participants in
  relevant ways with employment goals in the job
  descriptions of all staff
• We have a dedicated budget for employment
• We have a process for resource development and
  business planning
• We have employment specialists on staff
• We are risk-takers
• We have a strong management team
• We are culturally competent
• We have experience with developing partnerships
• We think of all partners and vendors as potential
  employers of our participants

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Opportunities-Examples

• We are aware of local hiring and economic
  development trends
• We look for non-mental health funding sources as
  part of our employment funding mix
• We have staff assigned to resource development
  and program growth
• We build coalitions among families, mainstream
  resources and institutions, peers and
  professionals to address stigma
• We are members of Chambers of Commerce
• We initiate and participate in the development of
  access to new employment sectors for our
  participants, i.e. hotel industry, specific
  unions, etc.
• We build upon the principles of the Americans
  with Disability Act, New Freedom Initiative,
  Olmstead Decision, TTW/WIA and local hiring
  goals/requirements for new program development
• We help to make sure employment is on the agenda
  for State Policy Academies

94
Working with your VR Agency Challenges

• Time-limited nature of VR services
• Incentives for VR case closures
• Demonstrate how VR, One Stop, agency staff and
  participant can build a partnership for success
• Mutual suspicion misunderstanding
• Staff training issues
• Incentives for collaboration
• Funding limitations

95
Working with your VR Agency Best Practices for
Partnerships

• Make people with mental illness and co-occurring
  disorders a priority
• Staff training
• Define milestones for payment relevant to the
  population
• Role definition and clarity
• Hire consumers as VR staff
• Co-location of counselors
• Non-traditional providers
• Involve employers in these partnerships

96
Business Improvement Districts

• Convergence of need
• Resources for outreach, engagement
• Job development
• Anti-stigma
• Opportunity for developing better understanding
  of community needs employers and participants

97
Staff competencies

• Knowledge
• Skills
• Attitudes
• Cultural sensitivity

98
Staff Competencies Knowledge

• Job Market (current and projected)
• Job features, credentials and skills (hard and
  soft) requirements
• Entitlement systems and related work incentives
• Strong understanding of vocational rehabilitation
  practices throughout all delivery of services
• Mainstream community organizations, natural
  supports, self-help peer supports,
  non-traditional (eg. Faith-based) resources
• Employer associations, Chambers, One-Stops, WIBs,
  VR
• Other potential employers small businesses and
  community-based organizations
• Agency purchasing procedures/services they are
  contracting-out
• Homeless services and coalitions
• Asset development strategies-IDAs, ITAs, etc

99
Staff Competencies Skills

• Active Listener
• Good Communicator (verbal, written, and
  telephone)
• Able to integrate vocational growth into all
  service delivery
• Consistent follow-through
• Networker and strong relationship-builder (Giant
  Rolodex)
• Teacher
• Negotiator

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Staff Competencies Attitudes

• Shared values
• Flexible
• Self-confident
• Outgoing
• Patient
• Respectful and Tolerant
• Well-trained and conscious about cultural
  differences
• Hands-on
• Tenacious
• Inventive

101
Some More Important Questions..

• How are you involving consumer leaders in
  employment program development?
• What funding sources are you using to address
  employment?
• What partnerships are necessary to increase
  employment?
• What advocacy tools do you use to promote
  employment?
• What skills must staff know to provide/support
  employment?
• How do you approach employers to achieve greatest
  number of opportunities?
• What do you need to do differently to increase
  employment?

102
Resources on the Web

• www.dol.gov/odep
• www.mentalhealthpractices.org
• www.redf.org
• http//www.psych.uic.edu/eidp/eidptoolkit.htm
• www.ahpnet.com
• www.csh.org
• www.hud.gov/offices/fheo/section3/section3brochure
  .cfm

103
Bakers Dozen To-Dos/Who Does?

• Leadership for employment within the disability
  services systems
• Unified vision re employment as a priority
  across service systems
• Share best practices
• Visible consumer leadership
• Develop a toolkit for employment implementation
• Work with employers and develop knowledge of
  employers throughout process
• Statewide training initiative to improve staff
  competencies

• Develop individual outcome measures
• Develop program accountability measures
• Develop local partnerships-business, FCBOs,
  One-Stops, VR, employer and labor sectors, etc.
• Help other systems understand employment and
  recovery
• Train housing staff on employment and recovery
• Use State purchasing power to support employment

104
Picturing a Champion

• Recognized leader
• Big and small picture knowledge
• Technical skills
• Community organizer
• Collaborator
• Familiar with and committed to issue and
  population
• Responsive
• Resources/resourceful
• Risk taker
• Passionate commitment
• Representative

105
Providing Services

• What are your challenges in providing effective,
  quality outcomes for job-seekers with psychiatric
  disabilities who are homeless?
• What strategies are you using to achieve those
  outcomes?
• What resources do you have and use to achieve
  those outcomes?
• What resources do you need to achieve those
  outcomes?
• What training opportunities would be especially
  important and useful?

106
Building Systems

• Who are your local partners?
• Describe the plan/steps for developing
  stakeholders for employment of people with
  psychiatric disabilities who are homeless
• What does each stakeholder, including employers
  and employment sectors, bring to the table that
  helps meet those outcomes?
• What challenges do you anticipate in developing
  partnerships and collaborations?
• What training, technical assistance and support
  do you need to develop and sustain these
  partnerships/collaborations?

107
Culture-Capacity-Opportunity

• What are the tools and activities you need to
  utilize to develop and/or improve the
  organizational Culture that supports employment
  in your agency, government unit, community and
  employment sectors?
• What resources and/or knowledge must you as a
  practitioner and your agency as a provider
  acquire to build your Capacity to implement
  employment?
• What Opportunities do you see to support and
  expand employment services, and how do you
  propose to address challenges that could impede
  your ability to take advantage of these
  opportunities? (e.g. funding, public policy,
  local hiring plans, employer tax incentives,
  Medicaid, DMH initiatives, initiatives by other
  sectors (faith-based, DOL, etc.)