Alysia Pascaris New York Work Exchange, CVMHA Rita Liegner and Richard Meador

1. Integrating Employment Services with Community-Based Clinical Programs: Lessons Learned from the Ways to Work Demonstration Project Alysia Pascaris New York Work Exchange, CVMHA Rita Liegner and Richard Meador Riverdale Mental Health Association Karin Abrahamian and Anthony Cox Brooklyn Bureau of Community Services Colleen Gillespie Center for Health and Public Service, NYU Wagner NYAPRS Conference September 30, 2004 New York Work Exchange

2. Why We’re Here Today and Who We Are • Why?: To share multiple and practical perspectives on the process of integrating employment services • Who we are (and what we’ll talk about)? • Person who conceived of and oversees the implementation of the Ways to Work Demonstration • Why implement the Ways to Work Project? • Immediate and more long-term goals • Evaluator of the Ways to Work Demonstration • What are the outcomes of these programs? • How did these programs implement this new approach? • Organizational change, staff change, consumer change • Staff from two of the Ways to Work Projects (including both clinical and vocational staff) • What lessons did they learn from setting up and running these programs? New York Work Exchange

3. What is the Ways to Work Project? • Demonstration Project: Integrating Supported Employment and Clinical Services • Research Project: Process and Outcome Evaluation • Learn from Staff • Administrators, Clinicians and Vocational Staff • Learn from Consumers • A Bridge Between Research and Practice • Application of Lessons Learned • Increase Employment Goals • Support Organizational Change Process New York Work Exchange

4. What is the Ways to Work Project…(continued) • Training and Technical Assistance • NH-Dartmouth Psychiatric Research Center • Principles of Evidence-Based Supported Employment • The Role of Work in Recovery • Off-site and On-site • New York Work Exchange • Program of Study • Workshops • Seminars New York Work Exchange

5. Why Do Ways to Work? • Trends in Mental Health Policy • Accountability and Outcomes • Funding • Evidence-Based Practice • Consumer Needs and Preferences • Doing More than the Status Quo New York Work Exchange

6. Requests for Proposals Guidelines: Core Evidence-Based Principles of SE Competitive, Integrated, Minimum Wage Integrated Rehabilitation and Mental Health Choice and Preferences Rapid Job Search Ongoing Support Staffing Funds Employment Staff Eligibility Expressed Desire Minimum Exclusionary Criteria Outcomes Work-related Outcomes Beginning Ways to Work New York Work Exchange

7. The Ways to Work Programs • 5 agencies • Brooklyn Bureau of Community Services CDTP Project Moving On • Jewish Board of Family & Children’s Services CDTP Coney Island CSS Program • Riverdale Mental Health Association CDTP • Transitional Services, Inc CDTP Jamaica Consultation Center • Postgraduate Center for Mental Health CDTP & Clinic Westside CDTP and Outpatient MH Clinic New York Work Exchange

8. Diversity of Agencies Hosting Ways to Work Programs • Location • 4 NYC Boroughs (Bronx, Brooklyn, Manhattan, Queens) • Community location ranges from vibrant, resource-rich to isolated, barren neighborhoods • Size • From about 1,500 clients served/yr to 55,000 • Emphasis/Expertise • Some with little employment/vocational experience • Others with extensive employment/vocational experience New York Work Exchange

9. Ways to Work Clinical Settings • Clinical Settings • 4 programs associated with CDTPs • 1 program associated with both CDTP and clinic • Size of Clinical Settings • CDTPs: 50 – 100 participants • Clinic: approximately 250 participants New York Work Exchange

10. Ways to Work CDTP Populations • Age (mostly adults, 18 – 55) • One program serves mostly older adults, 75% > 40 • One program serves more younger adults • Varied Housing • adult home residents • homeless individuals • 40% agency-associated housing • Gender • 3 programs have a majority of men, 2 a majority of women • Race/Ethnicity • 3 programs majority white (50% - 55%) • 2 programs majority African American (52% - 76%) • Representation of Latinos/as same across all 5 (15% - 24%) New York Work Exchange

11. The Ways to Work Approach Determine Who Wants To Work Consumer Choice (e.g., sign-up list) CDTP/Clinic Participants Other Supports Psychosocial Clubs Family Education Housing Benefits Counseling Ways to Work Program Assessment Job Profile Career Interests/Goals Rapid Job Search Individualized Job Development Individualized Job Placement Job Support (Follow Along Supports) Job Coaching Peer Support Family Support • On-the-Job Assessment • Regular Communication • Management of • Medications • Symptoms Work Incorporated Into All TX Goals/Plans • Integration of Work & Clinical Goals • Team Meetings/Case Conferences • Regular Communication Integration with CDTP and Mental Health Treatment Services New York Work Exchange

12. 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 non-disabled co-workers Service agency provides ongoing support Intended for consumers with a desire to work Includes people with the most severe disabilities Eligibility for Supported Employment services is based on consumer choice Consumer preferences are important Supported employment 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 Principles of Supported Employment New York Work Exchange

13. Consumer Experience of the Ways to Work Program: One Example • 40 yr old man • Realized several years ago that he wants to work • Cares about what people in the “real world” feel about “people like him” • Wants to prove to doctors, therapists, family members that he can take care of himself, get a job (tired of people telling him what to do and what he can do) • Pays his own bills, does own laundry and shopping, self medicates • Has been enrolled in CDTP for about 2 ½ years • Hears voices but knows he can work through the voices because they have been with him all his life • Scant work and education background • Worked 3 summer jobs in the 1960s • 6 mos of high school New York Work Exchange

14. One Man’s Story ….continued • Agreed to work with Employment Specialist as a team • Worked on resume together • Talked about his skills and interests • What things made him feel like he was accomplishing something? • What did he like and dislike doing? • What were his interests and hobbies? • Immediately began canvassing the neighborhood • Went to stores, filled out applications, went on interviews • Wore his tie and interview clothes but refused to wear his upper dentures as he felt that must hire him with the real person showing • Said he’d like to work as a messenger • Studied the NYC subway maps • Got an interview – went to interview on his own, completed the application, and even included a cover letter with his resume • HE GOT THE JOB! New York Work Exchange

15. Evaluation of the Ways to Work Programs • Two major goals • To document the outcomes of integrating employment services with clinical services • Do the Ways to Work programs work? • To describe the process of implementing and sustaining the Ways to Work projects in order to be able to share that information with other providers seeking ways to most effectively promote competitive employment within clinical settings • How do the Ways to Work programs work? • What had to change? How was that change achieved? New York Work Exchange

16. Number of W2W Participants (n=190) New York Work Exchange

17. Characteristics of W2W Participants Gender Race/Ethnicity Asian Latino/a White African American Male College Less than HS Some College HS Education New York Work Exchange

18. Characteristics of W2W Participants Housing Situation Primary Diagnosis Depression Assisted Ind/Family Adult Home Shelter Other Schizophrenia New York Work Exchange

19. Job Outcomes • 58 jobs obtained over two years • 51 unique jobs (190 participants) • 27% employment rate • Time in Ways to Work programs until employed • Year 1: 4.8 months and Year 2: 8.4 months • Job tenure (5.5 months) • Year 1: 7.7 months and Year 2: 2.6 months New York Work Exchange

20. Characteristics of Jobs • Types of Jobs • Security Guard • Newspaper Salesperson • Retail • Messenger • Maintenance • Tutor • Administrative Assistant • Telemarketer • Construction Worker • Child Care Worker • Wages • $6.75/hr • $5.75 - $15.00 • # Hours • 23 hrs/week • 6 – 40 hrs/wk New York Work Exchange

21. What Did the Ways to Work Programs DO to Help 27% of Participants Get Jobs? (1) • Changed agency structure • Integrated employment and clinical services • Employment Specialist attends all team meetings • Re-allocated resources • 1-on-1 individualized sessions, small caseload • Changed the intake process • Asked all consumers about career goals • Eliminated entry criteria • Created new way of delivering services • Not group-based • Job search begins immediately, no “readiness” work New York Work Exchange

22. What Did the Ways to Work Programs DO to Help 27% of Participants Get Jobs? (2) • Changed attitudes • Changed clinicians’ beliefs about consumers’ ability to work • Provided staff with latest evidence on what works • David Lynde, Evidence-Based Practice Project • Advertised unexpected successes • Shared information about consumers’ abilities outside of CDTP • Changed consumers expectations about what was possible • Provided role models • Encouraged peer support • Responded immediately to consumers’ job interests • Helped families support employment goals • Provided education about benefits and working New York Work Exchange

23. What Did the Ways to Work Programs DO to Help 27% of Participants Get Jobs? (3) • Changed How Jobs Were Developed • Developed specific jobs for specific people • Individualized • Explored full range of consumers’ employment-related goals to identify job matches • Used local resources • Went out into community with consumers • Encouraged staff to allow consumers to get feedback from the real world on what was realistic • Changed How Failures Were Viewed • Encouraged consumers and staff to view jobs as transitions • Failures are instructive • Failures are expected and unavoidable New York Work Exchange

24. How’d They Do All That? • Lessons Learned • Radiating impact of initial changes • Small changes paved the way for bigger changes • Strategies for overcoming barriers to change • Realistic assessments of how much effort and time is required to achieve changes • Tensions between ideal and real • Values and philosophical approaches • Situational and contextual constraints • Maintaining and sustaining changes New York Work Exchange

25. Integrating Employment Services • Communication between Clinical and Employment Staff • Sharing Information • Expertise/Training Background • Culture Clashes • Role of Employment Specialist New York Work Exchange

26. Changing Attitudes • Beliefs about CDTP Consumers and Employment • Clinicians’ Attitudes About Consumers’ and Jobs • Consumers’ Expectations About Working • Fear of Failure • Culture of Dependency • Access to Role Models/Success Stories • Benefits • Family Members • Other Providers • Housing New York Work Exchange

27. Job Coaching and Support • Interpersonal Skills vs. Job Skills • Difficulties of Disclosure • Supporting Consumer Choice • Disclosure vs. Job Coaching/Support • Disclosure vs. Reasonable Accommodations • Disclosure vs. Keeping Employer as Future Prospect • Groups vs. Individual Meetings and 1-on-1 Work • Consumers’ Expectations About Working • Fear of Failure • Culture of Dependency • Access to Role Models/Success Stories • Benefits • Family Members and Other Providers (Housing) New York Work Exchange

28. Job Development • Individualized Job Development vs. Slots • Balancing Needs of Consumers with Wanting to Maintain Employer as Future Prospect for Others • Volunteer Positions vs. Competitive Jobs • Transitional? • Varied Approaches to Match Diversity of Consumer Needs/Preferences New York Work Exchange

29. Maintaining Ways to Work Approaches • Initial Success May Wane Over Time • Most motivated, most capable consumers may get jobs fast • Remaining may need more encouragement, support, time • Jobs and job experiences that help them • Get closer to identifying their career goals • Get closer to achieving their career goals • More work in changing expectations, addressing fears • Role of the Employment Specialist • Rare set of skills (generalist w/ specialist employment skills) • Alone (no one else like them, no “home” department) • Burn-out/Turnover • Providing proper balance of challenge and support New York Work Exchange

30. Sustaining Ways to Work • Organizational Change • Attitude Change • Billing, Billing, Billing • PROS New York Work Exchange