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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Supported Employment

Implementation Tips for Mental Health Program Leaders

This document is designed to help program leaders implement supported employment at their clinical site. This document gathers the collective experience of program leaders who have successfully implemented supported employment.

Leading the Implementation
For supported employment to succeed:

a designated individual must be responsible for leading the implementation, who has the backing of senior administrators and their staff.
leaders should focus on consumer centered goals. Progress should be measured by consumer outcomes (number of people in competitive employment) rather than by process measures such as hours of therapy or day treatment¹.
the leader must advocate for funding, rally the support of the executive director or other key leaders, or bring in consultants when needed.

The task of implementing supported employment can be broken into three phases:

Building momentum for change
Enacting the change
Maintaining and extending the gains

¹For more information on the process of leading change in healthcare see Appendix 1.

Building Momentum for Change
To initiate change:

Get early buy in from key leaders in the program
Include leaders from other agencies that will collaborate in the supported employment effort (e.g., Division of Vocational Rehabilitation, vocational vendors) in planning meetings
Get the agency chief executive officer to publicly support supported employment
Work with your local National Alliance for the Mentally Ill (NAMI) and consumer groups to build consensus for change
Bring in an outside speaker to inspire the staff. Speakers tend to be more successful if they have credibility to the practitioners. Practitioners indicate that presenter credibility is increased if the presenter is a practitioner, demonstrates that she understands the population, expresses an acceptable value set, or is well known in the field.

Organize a meeting in which:

consumers testify about their supported employment experiences. This strategy works best if the program they come from is local or similar to your program;
family members and consumers who have experienced supported employment can speak with others;
employers share their positive experiences hiring people through supported employment programs.

Help practitioners understand by:

Introducing them to people who have similar roles at programs with established supported employment.
Educating them about studies that demonstrate how many consumers express an interest in work, how effective supported employment is in getting people to work, and what impact supported employment has on nonvocational outcomes.
Organizing retreats to predispose practitioners to implement supported employment.

Fight stigma by:

addressing the bias that adults with severe mental illness cannot work. Give information about showing that many consumers desire employment and can and do work;
having practitioners reflect on the role work plays in their lives and consider what work can do for consumers;
putting supported employment in the context of the recovery paradigm. Working is getting on with life beyond illness and is therefore a clinical concern.
presenting staff with the common arguments used against supported employment and responses to those arguments.

Making the Change
How can leader redesign program services toward supported employment?

What to consider:

Time frame. Generally, it takes about a year for staff to feel confident providing supported employment, but this can vary depending on how much structural change is needed. Programs that are not already team oriented or that have a strong protective, stress avoidance philosophy can take longer to change. Financial barriers can also slow down change.

The impact of change. Will some types of services be reduced or eliminated in order to pay for supported employment? What will be the impact of decreased group attendance when consumers go to work? Will evening hours be needed? How will the change effect other programs and staff?

Employment specialists
What to consider:

Employment specialist qualifications. Success as an employment specialist appears to have less to do with academic credentials than with personal style and philosophy. Positive, hopeful people who have a “can do” attitude tend to do well. Familiarity with the world of business and work are very helpful. See Appendix 2, 3 for more detailed description.

Part-time versus full-time employment specialists. Part time employment specialists don’t really work out well. Employment specialists need to throw themselves into the work. Conducting effective job development is difficult to do on a part time basis. When they carryout both employment specialist and case manager responsibilities they tend to lose their focus on work and are less effective.

Staff size. Employment specialists can carry caseloads of up to 25. A program will need enough employment specialists to serve the number of consumers who want to work.

Staff placement. Employment specialist can work on several multidisciplinary teams. If they work on more than two teams, they generally have to either spend too much time in meetings or don’t have the chance to adequately communicate with other team members.

Training. Employment specialist need an overview training (principles and general practices of supported employment) and then need more specific training. Training should cover general knowledge about mental illness and the impact of work on entitlements. Employment specialists need to be trained to engage consumers, elicit an employment history, seek jobs, talk to employers, help consumers keep jobs, and discuss with consumers issues regarding disclosing that they have a mental illness. Residential staff, case managers, psychiatrists and other practitioners need to be trained to see work as part of their job as well and to work together with employment specialists.

Supervision and support. Administratively, employment specialists can either report to a central employment coordinator (see Appendix 4) or to team leaders. Supported employment needs the active involvement of the team leaders. Weekly group supervision is recommended for vocational supervision. The meeting should focus on identifying difficulties employment specialists are having and working together to find solutions. Employment specialists sometimes need help in understanding more about mental illness. Some aspects of the employment specialist job are hard to understand without seeing them done by an experienced practitioner. Supported employment supervisors should take supervisees out into the field to model aspects of the job, such as job development, and directly coach them in their work. Employment specialists need a lot of support and encouragement as the program is getting off the ground. Celebrate successes.

Other meetings. Employment specialists should get together with each other for a second weekly meeting to focus on sharing and tracking job leads. Jobs are often obtained through networking. Employment specialists should keep a log of which companies they are contacting and plan ways to network in the community and build relationships.

Clinical team meetings. Supported employment works most effectively in a clinical environment where clinical teams get together to communicate at least weekly. Some teams quickly run through the list of people they serve, communicating with each other about employment and clinical issues. (See the Assertive Community Treatment implementation resource kit for more information.) Other teams just share information about crisis situations. In the latter kind of meeting, time needs to be set aside and guarded by the team leader for proactive communication about employment. Employment specialists are part of the team and attend all the team meetings. In addition, they need to actively participate and speak in them. If the employment specialist is not an employee of the mental health agency and is from another agency such as the Division of Vocational Rehabilitation or a private vendor, frequent communication with the treatment team members still needs to occur by attending team meetings and making personal contacts.

What do employment specialists need?

Office space. A place to meet with consumers and they need access to desk space, a phone, voicemail, and a computer that ideally includes internet capabilities.

Office placement. Office space should not be separate from the rest of the clinical team. Ideally, the offices are intermingled and the space is consistent with how space is allotted for other team members. Touching base in the hall and lunchroom with other team members facilitates supported employment.

Equipment. In additions to the office supplies indicated above, access to a cell phone for outreach work can increase safety and improve communication. Marketing materials such as business cards and pamphlets may be helpful.

How can leaders redesign program services?

Keep paperwork to a minimum. Each consumer will need a vocational profile, an employment plan and a monthly note. They will also need whatever additional paperwork is required by the funding sources and local regulations.
Track outcomes. Employment specialists must keep track of who obtains or loses a job, and record weeks worked, hours/week, and wages. Some programs track reasons for job termination on a job ending check off sheet. Refer to the Supported Employment Outcomes materials that are part of the supported employment implementation resource kit.
Display outcomes. Each clinical record should have a graph that shows consumer competitive work over time. At a minimum it can show whether or not a consumer has worked in the quarter. These data are part of the core clinical outcomes as it is a measure of getting on with life beyond illness. Reporting employment outcome information at treatment team meetings also helps to keep the team focused on consumers’ goals.
Review policies and procedures. Review and revise relevant policies and procedures to be sure that they reinforce supported employment implementation.

Maintaining and Extending the Gains
Chart success

Provide all staff on the team with employment statistics for the agency and for their particular team on a regular basis. Use graphs to show the percentage of consumers that are competitively employed each quarter.
Display the number of consumers working currently, number of people working in the last year, and number of new job starts/month for each employment specialist. This clearly reinforces the consumer centered outcome goal of supported employment.

To continue successful supported employment

Complete the 15-item Supported Employment Fidelity Scale at least yearly to identify adherence to the critical components of evidence-based supported employment. See the Supported Employment Fidelity Scale in the supported employment implementation resource kit.
Conduct regular meetings with supervisory/management staff and supervisors from collaborating agencies to review program implementation and address problems.
Recognize staff members who have made supported employment a success in your program.
Find ways to tell each other employment success stories. Devote meetings to good news. This could include feedback and anecdotes from consumers, families, and employers.
Sponsor employment banquets to celebrate employment achievement. Invite consumers, family members, employers, and agency staff members. Make a big deal out of the achievement. These banquets are particularly helpful if the physicians and administrators come. Invite the state governor.
Become a supported employment training site to stay fresh and interested and help pass on your knowledge and experience to others.

Appendix 1
Website

Annotated list of readings for program leaders

Rapp, C.A. (1993). Client centered performance management and the inverted hierarchy. In (Eds.) Flexer, R. & Solomon, P., Community and social support for people with severe mental disabilities. Andover Publishing Co.

Gowdy, E., & Rapp, C.A. (1989). Managerial behavior: The common denominators of successful community based programs. Psychosocial Rehabilitation Journal, 13(2), 3151.

Supervisor’s Tool Box. (1997). Lawrence, KS: The University of Kansas School of Social Welfare.

Rapp, C. A. (1998). The Strengths Model: Case Management with People Suffering from Severe and Persistent Mental Illness. Chapter 8 – Supported Case Management Context: Creating the Conditions for Effectiveness. New York: Oxford University Press.

Batalden PB, Stoltz PK: A framework for the continual improvement of healthcare: Building and applying professional and improvement knowledge to test changes in daily work. The Joint Commission Journal on Quality Improvement. 19:10, 424445, 1993.

Nelson EC, Batalden PB, Ryer JC (Eds.): Joint Commission Clinical Improvement Action Guide. Oakbrook Terrace, Illinois, 1998.

Appendix 2
Employment Specialist sample job description

Overall Function: Carries out the services of the supported employment program by assisting consumers in obtaining and maintaining employment that is consistent with their vocational goals and recovery.

Responsibilities: Engages consumers and establishes trusting, collaborative relationships directed toward the goal of competitive employment in integrated job settings.

Assesses consumers’ vocational functioning on an ongoing basis utilizing background information and work experiences.
Assists consumers in job development and job search activities directed toward positions that are consistent with the needs and interests of consumers on his/her caseload, following the principles and procedures of supported employment.
Provides individualized, time unlimited follow along services to assist consumers in sustaining employment.
Provides education and support to employer, as agreed upon by the consumer, which may include negotiating job accommodations and follow along contact with the employer.
Provides outreach services as necessary to consumers when they appear to disengage from the service. Maintains some contact with consumers even without a vocational focus if necessary to sustain engagement.
Meets regularly with treatment team members to coordinate and integrate vocational services into mental health treatment.
Draws up the individual vocational service plan with the consumer, case manager, and other treatment team providers and updates it quarterly.
Spends at least 60% of direct service time in the community to engage and support consumers, family members, and employers.
Carries out other duties as assigned.

Qualifications: Education and experience equivalent to undergraduate degree in mental health or social services, business, personnel management, or vocational services. Experience with people with severe mental illness, experience with vocational services, and knowledge of the work world are preferred. Ability to work as an effective team player is essential.

Appendix 3
Description of the personal qualifications that appear to be associated with success as an employment specialist

The job description for the position of employment specialist could read, simply, “Help people find jobs appropriate for their skills, interests, and individual challenges as soon as possible, and give them the help they need to continue working as long as they can.” The most important aspect of a good employment specialist is the belief that most people with severe mental illness who have some interest in working can work if the right situation is found and the right supports are put in place.

The tasks of the employment specialist are varied as are the skills needed to complete them. Employment specialists must have counseling skills, skills to engage consumers, business skills to conduct job searches, and excellent overall interpersonal skills to work effectively with team members, employers, consumers, and family members. People who enjoy working in the community may be more successful at engaging consumers and other stakeholders. Employment specialists spend more than 60% of the time in the community engaging with clients, developing jobs, and providing support to the client and employer around keeping the job. He or she should be the kind of person who enjoys knocking on doors, talking to people in their community, putting people and ideas together, and doing whatever it takes to make it work. This will most likely be entirely new for those people who have worked as rehabilitative day treatment counselors.

The employment specialists provide only vocational services. They do not serve as case managers or carryout case management tasks. Employment specialists have only vocational responsibilities in order to prevent diluting the emphasis on work when case management tasks take priority.

Good candidates for the employment specialist position generally come either from the business community or from positions in vocational or rehabilitation services where they have worked very closely with employers. Applicants who come from another kind of vocational program may not be good candidates for employment specialist positions. If they have training and experience in vocational programs that use a stepwise approach, they may resist the rapid job search approach to supported employment. Desired qualifications include:

general knowledge and experience in job development, job marketing and job securing;
demonstrated ability to relate positively with employers in the community;
working knowledge of a broad range of occupations and jobs;
ability to identify consumers’ interests, strengths, skills, abilities, and unique set of challenges and match them with jobs;
ability to identify and arrange long term supports to help consumers keep jobs;
knowledge of long term mental illness, including treatment and medication, and the impact of illness on vocational functioning;
ability to advocate effectively for clients with other team members and employers.

People who become good employment specialists do not necessarily come to the job with all the above qualifications. Some of the knowledge about mental illness and occupations can be learned on the job as long as the person is smart and eager to learn.

Successful employment specialists tend to be high energy, positive and enthusiastic people who see the bright side of situations—people who see challenges where other people see problems. Oftentimes they have sales person like personality in that they are outgoing, assertive and have the ability to engage all different types of employers. They typically are task oriented people. Above all, each individual hired as an employment specialist will have to develop his own style of working in what is a complex position where personality and the quality of interpersonal relationships can contribute greatly to success with employers and clients. The people chosen for the job should seem to fit well with the other members of the treatment team as well as with the other employment specialists and the consumers served. It is helpful to have a balance of male and female workers. If clients speak a language other than English, hiring someone who can speak that language is necessary. Hiring employment specialists who live in the community where they will be conducting job searches is important. Candidates who have lived in the area for awhile will be familiar with the local businesses and employers and have lots of contacts that can be used for networking in job searches.

When hiring, the supported employment program leader makes very clear that the employment specialist’s performance will be evaluated on whether he or she is helping people obtain jobs. The employment specialist who goes for months without helping a consumer obtain work is not doing his or her job. The supervisor may hear the employment specialist say that consumers whom she is working with are not motivated, or that employers will not hire people with mental illness, or high unemployment is the problem. The reality is that good employment specialists are able to help people with severe mental illnesses secure employment that is based on the consumer’s preferences, strengths, and unique set of challenges. Training and good supervision along with the lessons learned through day to day experience help most employment specialists develop the skills and confidence to do a good job.

Appendix 4
Employment Specialist Program Leader sample job description

Overall Function: Oversees the supported employment program by supervising employment specialists and providing administrative liaison to other coordinators within the mental health center.

Responsibilities: Accepts referrals for supported employment services and assigns employment specialists to work one to one with consumers.

Conducts weekly vocational supervision to the employment specialist team using case examples and following principles and procedures of supported employment.
Provides individual supervision to employment specialists as needed.
Acts as liaison to other department coordinators in the mental health center.
Monitors and ensures the integration of the employment specialists with treatment teams.
Provides supported employment services to small caseload (e.g., fewer than 15 people).

Qualifications: Master’s degree in rehabilitation counseling or related field. Previous experience as an employment specialist assisting clients with severe mental disorders in obtaining and maintaining competitive employment is desired. Previous supervisory experience is desired.

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