The Illinois Employment & Recovery Revolution

1. The Illinois Employment & Recovery Revolution Emerging Options for Persons with Co-Occurring Disabilities Regions I & II

2. Overview of the day • EBSE & MISA research, principles, practice, org. structure • EBSE & Recovery in consumers voices • VR unique contributions • Opportunities for collaboration & leadership

3. Why Focus on Employment? • Viewed by many as an essential part of recovery • Most consumers want to work • A typical role for adults in our society • Cost-effective alternative to day treatment

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

5. Is Work Too Stressful? • As compared to what? • Title of an article: “If you think work is stressful, try unemployment.” • Stresses of work do not translate into higher rates of hospitalization

6. Negative Effects of Unemployment in General Population • Increased substance abuse • Increased physical problems • Increased psychiatric disorders • Reduced self-esteem • Loss of social contacts • Alienation and apathy • (Warr, 1987)

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

8. J & J-Dartmouth Project • mMental health-vocational rehabilitation collaboration • iImplement evidence-based SE • LLocal programs selected by states • DDartmouth provides training, consultation, and evaluation • FFirst states: CT, DC, KS, MD, OR, SC, VT • NNew states: IL, MN, OH • (Drake, 2006)

9. J&J Project Strategies • SStart with “early adopters”: states & programs • VVR-MH collaboration: Consistent finding • LLongitudinal training • OOutcome-based supervision • PProblem solving by local experts • (Drake, 2006)

10. Overview for Narcoleptics • SSupported employment is an effective evidence-based practice • LLong-term perspective is even better • IImplementation is critical • AAmplifying effectiveness: more people and more hours

11. Narcoleptics (cont.) • Illinois leads through partnerships • VR & SA role is unfolding • Cross-fertilization of SA, MH, VR models and methods in our state

12. What Is Evidence-Based Practice? • A practice validated through rigorous research • Has guidelines describing critical ingredients • Ideally, has been successfully implemented in a wide range of settings

13. Randomized Controlled Trials (RCTs) of Supported Employment • Strongest scientific design for evaluating whether a treatment works • Studies include: • 4 conducted before evidence-based principles articulated by IPS model • 13 used full implementation of IPS

14. Competitive Employment Rates in 12 RCTs of Supported Employment

15. Current Status RCTs • 117 studies: add UCLA , EU, Thresholds, Australia • 660% vs. 22% employment • FFindings very consistent • RRecent IPS studies over 70% employment – early intervention

16. Indirect Impact on Other Outcomes • RRelated to sustained competitive employment • IImproved self-esteem, symptom control, life satisfaction • NNo changes with sustained sheltered employment • (Bond, 2001)

17. Studies of Long-Term Outcomes from Supported Employment • TTest: 10 years • MMcHugo: 3.5 years • BBond: 3.5 years • SSalyers: 10 years • BBecker: 8-12 years • DDrake: 10 years

18. 10-Year Follow-up of Day Treatment to SE Conversion • 992% worked during follow-up • 447% currently working • 333% worked at least 5 years • MMany reported increases in hope, self-esteem, relationships • (Salyers, 2004)

19. 8-12 Year Follow-up of SE • 771% working at follow-up • NNearly all in competitive jobs • 77% sheltered, 10% volunteer • 771% worked more than 50% of FU • BBut 90% still receiving benefits • (Becker, 2006)

20. Current Status of SE • EEveryone who wants to work should receive SE • MMost will succeed and difficult to predict • LLimitations of current SE • CCurrent efforts to improve outcomes

21. Limitations of SE • OOne-fourth do not work • MMost people do not work full-time • MMost people stay on benefits

22. Amplifying the Effects • SSkills training (Marder) • EVR role (Illinois/Dartmouth) • BBenefits counseling (Tremblay) • MMotivational interviewing (Corrigan, Drebing) • CContingency management (Drebing) • CCognitive training (McGurk) • CCompensatory mechanisms (Velligan) • MMedications (MATRICS)

23. Explaining Variance • 225% local economy • 225% SE fidelity • 550% individual practitioner • (Becker, 2006)

24. Definition of Supported Employment • Mainstream job in community • Pays at least minimum wage • Work setting includes people who are not disabled • Service agency provides ongoing support • Intended for people with most severe disabilities

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

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

27. Supported Employment Is Integrated with Mental Health Treatment • Employment specialists coordinate plans with the treatment team, which includes case managers, therapists, and psychiatrists.

28. Valued Gateway Client : Inserted slide Do Client Characteristics Predict Success in Supported Employment? • Co-occurring substance use does not lead to lower employment rates. • Consumers generally do better in supported employment than in alternative programs regardless of background characteristics such as: • gender, education, ethnicity, diagnosis, hospitalization history, cognitive functioning

29. Competitive Employment Is the Goal • The agency needs to devote sufficient resources to supported employment to permit full access to all consumers who seek competitive employment. • Consumers interested in employment are not steered into day treatment or sheltered work.

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

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

32. Follow-Along Supports Are Continuous • Supported employment staff continue to stay in regular contact with consumer and (when appropriate) the employer without arbitrary time limits.

33. Consumer Preferences Are Important • Job finding is based on consumers’ preferences, strengths, and work experiences, not on a pool of jobs that are available.

34. Job Preferences Are Important

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

36. Examine Agency Philosophy • Determine if service agency’s philosophy, mission statement, and service paradigm are consistent with recovery-oriented, evidence-based approach to supported employment.

37. Build Consensus • Commitment of state mental health authority is not enough • Better to involve all stakeholders - consumers, family members, providers, and local and state MH, VR, SA, etc. administrators

38. Maximize Financing • Determine how supported employment services can be funded • Explore funding through Mental Health, Vocational Rehabilitation, and Medicaid (Ill. DRS/DMH co-funding model) • Reallocate resources to supported employment when feasible (DMH Rule 132 changes)

39. What Does Supported Employment Cost? • Some programs, $2,000-$4,000 per client per year (Clark, 1998). • Latimer (2004) $2,449 per full-year equivalent • Figures vary according to severity of disability, local wages of employment specialists, and how much indirect costs and costs of clinical services are included (Illinois Model – VR $5117)

40. Ticket to Work • Revisions in the Social Security employment support program designed to support EBSE programs. • Milestone payments in 3 phases, up to 60 months • Milestone I in Phase I triggered when an individual earns $335 in a month • Employment Networks (EN)

41. Ticket (cont.) • EN be any entity except an individual and a federal agency • Partnership Plus: VR and community programs • Considering becoming an EN: Contact CESSI (877 743-8237 v/tty) • Getting started: Contact Maximus (866 968-7842 v, 866 833-2967 tty)

42. Identify Leadership • You need a champion! • Identify committed leader with sufficient authority to oversee and ensure implementation • Leaders at all levels visibly show support for supported employment • Center director buy-in is critical • Leadership from Vocational Rehabilitation integral to the collaboration

43. Leadership Roles • Provide necessary resources • Seek buy-in from consumers, families, and practitioners • Give recognition to staff and consumer for successes • Rapp’s finding – Critical role of supervisor in program success

44. Problem Solving • What does consumer want? • Are SE principles being followed? • Is leader ensuring staff has skills to implement supported employment? • Have training and resource materials been utilized?

45. Provide Ongoing Training • Initial training for all team members, including medical staff • Continuing access to expert consultation (e.g. Ill. T.A. Team) • Ongoing supervision that is outcomes-oriented

46. Make Time Commitment • Typically, 6 - 12 months needed to develop skills, interest, and confidence for implementing evidence-based supported employment

47. Track Implementation Process and Outcomes • Track employment outcomes monthly • Set goals: 40% rate of competitive employment is achievable • Service agencies should use Supported Employment Fidelity Scale to measure implementation of evidence-based practice (Becker et al., 2008)

48. Supported Employment Unit:Recommended Basic Structure • Minimum of 2 full-time staff • Staff devoted exclusively to SE • Full-time leader/supervisor who also provides employment services • Offices physically located in mental health center

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

50. Roles of an Employment Specialist • Problem-solver • Team player • Networker • Employment specialist • Customer-oriented • Community-oriented • Outcome-oriented