Supported Employment Fidelity Report
Submitted by Rebecca Shoai of the Mental Illness Research, Education and Clinical Center (MIRECC) in January, 2009
Purpose
This report describes the progress to date of the implementation of supported employment (SE) services at New Directions North as part of the SAMHSA funded grant, “Evaluation of New Directions North’s Supported Employment Program for Homeless Veterans”.
Method:
Over the course of several days in late August and early September 2008, Shirley Glynn and Rebecca Shoai visited New Directions North to observe the implementation of supported employment services, most specifically the Individual Placement and Support (IPS) vocational services model. During the visits we attended a treatment team meeting, observed supervision of the employment specialist, and met with both the employment specialist and her supervisor. We met with residents who are currently receiving SE services and reviewed their charts. We also interviewed the program director, program manager, clinical director, and 2 case managers.
The Supported Employment Fidelity Scale was completed following the visit. Attached to this report is a copy of the completed scale. Overall, the New Directions North program obtained a “good” fidelity rating, which is a notable achievement for a novice SE program. The scale is divided into three sections, including staffing, organization, and services. Each item is rated on a 5-point response format, ranging from 1 = no implementation to 5 = full implementation, with intermediate numbers representing progressively greater degrees of implementation. Agencies that fully implement supported employment according to the scale criteria have been shown to have higher competitive employment rates than those that do not. The following section addresses the three areas based on the visits.
Observations
For staffing, there is one fulltime employment specialist (DV), who carries a case-load of under 25 cases (currently, she has been assigned 22 cases). She is supervised by a team leader (BS), who oversees employment activities, both at the main New Directions program and at New Directions North. The employment specialist’s time is devoted exclusively to employment-related activities. She provides all aspects of the employment process, including benefits counseling, engagement, development of a vocational profile, job search, and individualized follow-along supports.
Regarding organization, the IPS program is structured to integrate rehabilitation with the mental health treatment being provided at New Directions North by having the employment specialist become a member of the treatment team, and having her attend weekly team meetings. At this point, the team is comprised of case managers, clinicians, and the employment specialist. Informal meetings with New Directions mental health and residential staff are more frequent. Psychiatric care is provided by the VA Greater Los Angeles Healthcare System and there is no formal integration of psychiatric care with the services provided at New Directions North.
The employment specialist has an office on the first floor of the New Directions North building which is easily accessible to residents as well as other staff members. The employment specialist meets weekly with the employment team leader; in these meetings, cases are reviewed, progress of cases in the program is monitored, and implementation issues are problem-solved. In addition, the employment specialist meets biweekly with an experienced IPS consultant, who reviews her activities with an eye to assuring fidelity to the IPS mode.
For services, vocational assessment is continuous and based on experiences in competitive jobs. Clients are assisted in making employer contacts within one month of entry into the program. The employment specialist assists clients with individualized job searches that are based on clients’ preferences, skills, and experiences. A unique feature of the New Directions program is that, after initial training by the employment specialist, there is a nearby computer lab in which clients are encouraged to work independently on job searches. The employment specialist provides job options that are diverse and in different settings. The employment specialist assists clients in obtaining competitive jobs that have permanent status rather than volunteer jobs or jobs that have temporary or time-limited status. She helps people terminate jobs when appropriate and offers to help find other jobs. She provides flexible follow-along supports that are individualized and ongoing. The employment specialist spends about half of her time in the community developing jobs, interacting with employers, and engaging and supporting clients. The employment specialist provides assertive engagement and outreach if clients miss appointments; these efforts are facilitated by the fact that this is a residential program and other staff are also attempting to monitor clients’ activities.
Eligibility for the program is based on criteria set by the administration of the New Direction North staff and includes: 1) four months of abstinence in the residential program, 2) expressed interest in obtaining work, and 3) capacity to give informed consent. The first criterion of mandatory abstinence is not fully consistent with the “open eligibility” criterion envisioned for IPS. As New Directions North is a specialized residential program for persons with dual disorders, all participants have a recent past history of substance use, homelessness or risk of homelessness, and a concurrent psychiatric disorder—most often depression and/or PTSD, although a sizeable proportion of residents also have a diagnosis of bipolar illness or schizophrenia. While requiring abstinence from substance use is not fully consistent with the principles of IPS, it is a criterion that is fundamental to the substance abuse treatment model that NDN supports.
Assessment and Recommendations
The New Directions North program incorporates many of the critical components of IPS, an evidence-based approach to supported employment. The employment team leader and the IPS consultant meet frequently with the employment specialist (at least every other week), and help her stay focused on the principles of IPS and client progress through the program.
Community-based job development is a critical aspect of IPS, and includes both general employer contacts and client-specific employer contacts. Because many of the New Directions North clients choose not to disclose their psychiatric disability to potential employers, and are looking for more skilled (not necessarily entry level) jobs, the employment specialist is often working “behind the scenes” and has to be creative in her attempts to do client-specific job development in the community. In addition to her occasional work in the community with individual clients, since implementation of SE services at NDN, the employment specialist has spent a great deal of her community-based time networking with potential employers, attending trainings on employment issues related to persons with criminal backgrounds and/or psychiatric illness, and joining local organizations that promote hiring for these individuals. This creativity is laudable, but we recommend that the employment specialist have at least one initial meeting with each client in the community (and more would be preferable) at the beginning of the job search to assess his level of community functioning, including ease in social situations and capacity to manage critical tasks such as riding buses, counting change, etc. These community-based meetings could involve going to a potential employer to observe the client (the employment specialist would not need to make her presence known to the employer) or to a public setting like a library or a coffee shop.
A major responsibility of employment specialists is developing relationships with employers and expanding employer networks through repeated contacts with employers. We recommend that the program develop a system for tracking employer contacts, updating it weekly, and reviewing information on a regular basis. Information on date of contact, name of business, name of contact person, employer’s needs (skills and experiences of job applicants) and activated openings should be logged. We recommend that a portion of the weekly supervision meetings be spent discussing employer contacts; there should be a minimum of 6 client-specific contacts per week for job development. While the employment specialist is doing some work in the community, at least sixty percent of her work week should be spent outside of the office meeting with employers and engaging and supporting clients in their work efforts. Thus, the employment specialist should be increasing her time in the community, especially time spent with clients and on client-specific contacts As part of this effort, the employment specialist should also be reaching out more frequently to the State of California Department of Rehabilitation to identify job leads for challenging cases and request support for clients.
A core aspect of IPS is multiple employment specialists working together as a team to share job leads and problem-solve difficult work issues. As New Directions North has only one employment specialist, she has few opportunities to meet with other IPS employment specialists (although she does meet with vocational counselors from the main New Directions setting). We recommend that the employment specialist reach out to other IPS employments specialists at the VA to form an informal network which could support each other, perhaps by having lunch together once or twice a month.
At 22 cases, the employment specialist is slightly over the maximum recommended per specialist, which is 20. Managing a larger case load is a complicated aspect of IPS. We recommend the employment specialist and the treatment team meet and evaluate whether there are individuals on the employment specialist’s case load who could be discharged back to their case managers, who can provide employment support as needed. This would be appropriate if:
1) the client has been stable on a job for a year and is doing well in other areas of his life, or
2) the client does not indicate an interest in putting effort into looking for work at the current time, despite repeated prompting and encouragement from the employment specialist and the rest of the New Directions North team.
A major challenge of the New Directions North Treatment program is integrating mental health and vocational rehabilitation programming. While the New Directions North staff includes clinicians and case managers, clients’ psychiatric care is provided by the VAGLA hospital and there is no formal agreement regarding sharing information among the New Directions North staff and the psychiatric team. This is a significant omission, as a key aspect of IPS is integrating information from all providers to develop possible job leads and monitor the impact of work on mental health. The employment specialist has begun to address this problem by going to psychiatric appointments with her clients (with their permission). This is a good first step to remedying this problem. Another step could be to have clients provide informed consent for sharing of information between the two treatment teams in order to further support clients’ work efforts.
Both clients and the other New Directions North staff made many positive statements about the performance of the employment specialist. Clearly, they have a high regard for her work. There are, however, two issues that merit attention. First, there was widespread concern that many clients had difficulty obtaining jobs because of their criminal histories. This is a source of frustration for all. While finding “felony-friendly” employers is challenging, it is clear that this must be an even greater priority in the employment specialist’s work. New SE participants should be educated that their job search is likely to be lengthier because of this challenge. While it is a positive aspect of the program that participants are encouraged to take on more responsibility for directing their own job searches, they could use more guidance and direction from the employment specialist in light of some of the impediments they confront in job seeking.
A second area of concern is the relative emphasis on competitive employment vs. the VA compensated work therapy (CWT) program. The CWT program involves temporary placements for disabled veterans, and is thus not consistent with the IPS goal of finding competitive employment in the community. However, CWT positions can be easier to obtain and many clients in New Directions North initially would like to obtain CWT positions. There appears to be some confusion among clients about whether the employment specialist will help them obtain CWT positions, and whether she should. The confusion about the suitability of CWT positions in the IPS program has been a source of frustration among clients, who need more assistance in understanding the IPS guidelines and their rationale.
Overall, the Supported Employment program at New Directions North has been quite successful in implementing the IPS model, especially considering that this is a fairly new addition to their array of services. The employment specialist is very competent and has been well-supported by the other New Directions North staff. However, there are some areas that could be improved. We feel that the implementation of the recommendations in this report would further strengthen the program and result in a higher fidelity score at the next fidelity assessment point.
Summary of Recommendations
1) The employment specialist should have at least one initial meeting with each client in the community at the beginning of the job search to assess his level of community functioning, and generally should be increasing her time in the community, especially time spent with clients and on client-specific contacts.
2) The employment specialist should develop a system for tracking employer contacts, updating it weekly, and reviewing information on a regular basis.
3) A portion of the weekly supervision meetings should be spent discussing employer contacts; there should be a minimum of 6 client-specific contacts per week for job development.
4) The employment specialist should reach out to other IPS employment specialists at the VA to form an informal network which could support each other.
5) The employment specialist and the treatment team should meet and evaluate whether there are individuals on the employment specialist’s case load who could be discharged back to their case managers, who can provide employment support as needed.
6) The program should continue to explore options for integrating their treatment team and the clients’ psychiatric care, provided by the VAGLA hospital.
7) The employment specialist should provide more education, guidance, and direction to clients with significant criminal histories and to clients who are seeking CWT positions.