Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

1
Evidence-Based Practices Shaping Mental Health
Services Toward Recovery

• Supported Employment

2
Recovery

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

3
Recovery

• Recovery is
• A process of regaining ones life to a usable
  form reclaiming ones personal power from ones
  illness.
• Adapted from Websters II
• by Molly Clouse

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Recovery

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

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Services that Promote Recovery

• Treatment Rehabilitation
• Treatment
• Reduces emotional distress by reducing symptoms
  through diagnosis, medications, treatment
  planning, and therapy.

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Services that Promote Recovery

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

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Supported Employment

• Supported Employment is a Rehabilitation Service
  that promotes recovery.

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Employment

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

9
Employment

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

10
Employment

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

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Supported Employment Works

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

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Other Approaches

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

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What is Supported Employment?

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

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What is Supported Employment?

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

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The Evidence Supported Employment as an EBP

• The evidence for the effectiveness of supported
  employment comes mainly from two types of
  research
• day treatment conversion studies and
• experimental studies

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Day Treatment Conversion Studies

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

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Experimental Studies

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

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Supported Employment based on Six Principles

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

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Supported Employment Six Principles

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

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Supported Employment Six Principles

• Follow-along supports are continuous.
  Individualized supports to maintain employment
  continue as long as consumers want the
  assistance.
• Consumer preferences are important. Choices and
  decisions about work and support are
  individualized based on the persons preferences,
  strengths, and experiences.

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SAMHSA Supported Employment Toolkit

• http//www.mentalhealth.samhsa.gov/cmhs/communitys
  upport/toolkits/employment/
• www.mentalhealthpractices.org
• http//www.apse.org/

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SAMHSA Supported Employment Toolkit

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

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SAMHSA Supported Employment Toolkit

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

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SAMHSA Supported Employment Toolkit

• Workbook for Clinical Practical Supervisors
• Videotapes
• Introductory Videotape
• Practice Demonstration Videotape

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Information for Consumers

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

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Information for Consumers

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

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Information for Consumers

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

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Information for Families

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

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Information for Clinicians

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

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Information for Mental Health Program Leaders

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

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Information for Public MH Authorities

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

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What does Supported Employment Cost?

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

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What Should Training for Supported Employment
Include?

• Some training institutes offer multimodal
  training that includes the implementation
  resource kit materials plus,
• introductory training to supported employment
• practice skills training
• job shadowing at agencies that have implemented
  supported employment
• post-training consultations
• post-training supervision
• post-training fidelity measures
• post-training outcome measures

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How will MH Authorities Know if They Have a
Successful Program?

• How successful a supported employment program is
  in improving outcomes depends, in part, on how
  closely the program follows the supported
  employment practice.
• Programs that only partially adopt the practice
  or that are allowed to drift back into old ways
  of providing services may not produce the
  beneficial outcomes associated with supported
  employment.

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Supported Employment Fidelity Scale

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

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Supported Employment Fidelity ScaleStaffing

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

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Supported Employment Fidelity ScaleOrganization

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

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Supported Employment Fidelity ScaleOrganization

• Zero exclusion criteria No eligibility
  requirements such as job readiness, lack of
  substance abuse, no history of violent behavior,
  minimal intellectual functioning, and mild
  symptoms.

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Supported Employment Fidelity ScaleServices

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

40
Supported Employment Fidelity ScaleServices

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

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Supported Employment Fidelity ScaleServices

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

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Supported Employment Fidelity ScaleServices

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

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Supported Employment Fidelity ScaleServices

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

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Where Does Kentucky Stand?

• Kentucky has Supported Employment available in
  Five Regions
• Bluegrass Regional MH/MR Board
• Seven Counties Services
• Lifeskills
• NorthKey
• River Valley Behavioral Health

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How is it Funded?

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

46
Possible Funding

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

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What Can We Do To Promote Supported Employment?

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

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What Can We Do To Promote Supported Employment?

• Research Supported Employment on line.
• http//www.apse.org/
• http//www.nami.org/
• http//www.bu.edu/cpr/
• http//www.uspra.org/
• Work with the Association for Persons in
  Supported Employment (APSE) and the National
  Association for the Mentally Ill (NAMI) to
  promote Supported Employment.