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Guidance on Implementing Supported Employment

Supported Employment specialists Sarah Swanson and Deborah Becker tackle questions on funding, lack of staffing, and client engagement.

In part two of a series, Sarah J. Swanson and Deborah R. Becker, authors of Supported Employment: Applying the Individual Placement and Support Model to Help Clients Compete in the Workforce, answer audience questions from their National Council webinar on vocational support for people with mental health disorders.

Q: Is there some information somewhere that has jobs listed for our consumers, or jobs that will hire our consumers?

A: The goal of IPS is to help people enter the competitive job market just like anyone else. These are regular jobs that anyone can apply for, regardless of disability status. Employment specialists attempt to help clients find jobs related to their interests and preferences, rather than creating set-aside jobs with a limited number of employers. People who find jobs related to their preferences stay at those jobs longer that people who don't find jobs related to their preferences.

Q: It has been my experience that for individuals to be successful in their employment goals, it is important for them to have medication management and behavioral management. Do you see this as being the case? We typically link individuals to other services while assisting with job search. Is this beneficial?

A: We definitely believe that IPS works best when an integrated team approach is used. That is, employment specialists meet weekly with the mental health treatment team and connect between meetings so that every member of the treatment team is supporting the client's work or school goals. However, if a person chooses not to use medication to treat her illness, she would still be eligible for IPS. The employment specialist would help the person begin working on her goals just as he would with any other client in the program.

Q: How does someone become an IPS Supported Employment fidelity scale assessor?

A: Typically, a person who wanted to become a fidelity reviewer would go out to conduct reviews with others who have experience in this area. In addition, the Dartmouth IPS website includes information about IPS fidelity and an IPS Fidelity Kit may be ordered from the site: http://www.dartmouth.edu/~ips/.

Q: It would seem obvious that this current economy could have a great deal of impact on job searches, particularly when now even over-qualified people are competing for basic jobs. It's a bear out there---any suggestions with this economy in mind?

A: Building relationships with employers, regardless of whether or not there are any job openings, may be more important than ever. When employment specialists do this, they learn about the needs and preferences of employers before jobs are advertised and then ask to introduce their client. The employer knows that the client has a strong support system and is also made aware of the person's strengths as they relate to the job.

Q: Please share any advice/resources you have for consumers who may have been convicted of various criminal offenses in their past which interferes with or is an obstacle to employment.

A: Please go to http://www.dartmouth.edu/~ips/ and select "Justice Involvement."

Q: I have a client who refuses to improve his hygiene. What do you do then? His clinical team has been unsuccessful. He wants a job but refuses to improve his appearance, despite him saying that he knows he needs to. He says if he had a job, he would clean himself up. Three weeks of this same conversation. Although, according to his clinician, he loves to meet with me and he hasn't missed or canceled an appointment in a month, which is unheard of.

A: It's great that he is so motivated to work. Why don't you begin to go out with him and help him apply for jobs? It may be that he will dress up a bit because he is excited to apply for jobs. If he doesn't work on his appearance, you might ask an employer that you know to donate 15-minutes of his time to give him your client a mock interview. You could prep the employer to give your client feedback about his appearance. This would take you out of the role of "nagging" the person and might be more meaningful to your client because the feedback would come from a real employer.

Q: Are there websites that organizations can go to get more information on Supported Employment?

A: You can find videos, program tools and information about IPS supported employment at the Behavioral Health Evolution website and at the Dartmouth site: http://www.dartmouth.edu/~ips/. You can also find information and practical guidance on implementing an IPS Supported Employment program in our book Supported Employment.

Q: The team meetings that have been mentioned, they include the person receiving IPS supported employment as part of the team/meeting, right?

A: Usually, the IPS team meets once a week as a vocational unit to discuss people who are receiving IPS services and to share job leads. That meeting does not include clients. There is also a weekly meeting with mental health practitioners and their assigned employment specialist(s) to talk about people on the mental health team caseload. That might include talking about people who are receiving IPS services, as well as those who aren't in the IPS program. That meeting does not include clients. However, a mental health practitioner and employment specialist might meet together with a client when working on a treatment plan, when providing outreach services, or when a person appears to be having trouble meeting his or her employment goals. The reason that clients aren't invited to the two team meetings is that those meetings might cover a large number of people and it wouldn't be feasible to include clients in all of the conversations. Instead, the team tries to brainstorm strategies to help each client move forward with his or her goals, and then someone on the team agrees to take those ideas to the client for his or her feedback.

Q: I am in Washington state where they are cutting funds that are state allocated money as well as Medicaid dollars. [Do you have] other ideas for funding?

A: You might investigate Ticket to Work--a Social Security initiative. You can find information about this program at the Social Security Administration website by searching for Ticket to Work. State vocational rehabilitation is also able to pay for some IPS services on a case-by-case basis.

Q: We have a continual waitlist for services. Where is the funding for Supported Employment to hire more specialists? Everyone talks about this wonderful evidence-based practice, but there are not the proper resources to support it.

A: We agree. At present, programs cobble together funding the best that they can by using some funds from Vocational Rehabilitation, state general funds( if present), Medicaid (depending upon the state's Medicaid plan), Ticket to Work, grants, and sometimes converting HUD positions. It can be very cumbersome, and we hope that in the future the federal government will consider a single payer source for IPS.

Q: Our three specialists follow the fidelity scale; however, we did fall short on the treatment team meetings. Clinicians do not have time for weekly meetings.

A: It's understandable that practitioners are very busy, but the meetings can be helpful to both clinicians and employment specialists. Meetings provide practitioners opportunities to stop and think about more effective ways to provide services. However, by co-locating employment specialist's office space with the clinicians and encouraging frequent communication you may be able to improve integration to some degree. You might also encourage administrators at your agency to consider a pilot program that would allow for twice monthly integrated meetings as a way to move in the direction of better integration.

Q: As an Employment Specialist with 20-25 people on my caseload how can I possibly meet with the treatment team every week. [That's] 20 meetings a week? I usually correspond by email to the treatment team regularly.

A: There would not be 20 meetings a week if you are part of a multidisciplinary team that meets weekly to discuss clients that they serve. Instead, you would join a weekly meeting that the mental health team has to talk about people they are serving--some who may be on the IPS caseload and some who are not. Employment specialists are only asked to attend one or two meetings each week, depending upon the number of mental health teams from which they receive referrals.

We recommend that you try it for awhile and then decide if it is worth your time. One IPS program we know was reluctant to take the time to join mental health team meetings for more than a year. After the team finally starting meeting with the mental health practitioners, they told us it was the best thing that they had ever done. The team was able to coordinate services so that case managers were helping people get to their new jobs, the psychiatrist wasn't making medication changes that could negatively affect a job, etc. You may find that the mental health practitioners are willing to get involved and help with employment as they begin to see you as their team member.

Q: What about on the job training?

A: Employment specialists do sometimes provide on-the-job-training (job coaching) for some clients, though most people are able to learn their jobs without having a specialist at their side.

Q: What about the possibility that a substance user can get a job and then have that money to continue using?

A: This does happen at times. However, the IPS approach supports the notion that clients should be encouraged to make choices for their own lives. Further, people do learn from their experiences. It's possible that someone will increase substance use after going to work and then lose the job. That might help the person think about the ways that substance use is affecting his goals. Some people may make changes based upon one negative experience, while others go through several negative experiences before thinking about making changes in their lives. During this process, the integrated treatment team provides support for employment (because that is something positive that the person is doing), gently points out ways that substance use is affecting the person's goals and offers help with money management and substance abuse treatment.

Q: Please speak to your experience with VR agencies and use of the IPS model (coordination). The VR process typically would not move as quickly as the IPS model alone.

A: Within a thirteen-state project that is coordinated through Dartmouth Psychiatric Research Center, many, if not most, VR offices attempt to expedite their eligibility process. VR counselors are motivated to obtain the best outcomes possible and have been willing to make changes in order to obtain good outcomes through the evidence-based practice of IPS. State leaders within the VR system have helped to facilitate these changes.


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