Is Supported Employment the Future of Psychiatric Rehabilitation Services?

It likely comes as no surprise that the age of onset for disabling psychiatric conditions most commonly occurs between the ages of 18 and 24, and employment is likely to be one of the highest priorities.  Young people with mental health conditions are most likely to be actively engaged in the workforce, and researchers hypothesize that “early intervention services will change the course of serious mental illness, and divert young adults from the disability system”.   Recently, some early intervention studies that have included Individual Placement and Support (IPS) Supported Employment have reduced those going on disability rolls.     Use of IPS not only results in significantly better employment outcomes than other approaches to services, but has shown to reduce hospitalizations for SE participants, and to decrease long-term services use for those achieving steady employment.     Finally, the return on Investment has been estimated to be 54 cents per dollar for IPS, compared to 18 cents per dollar for other vocational services. 
    
Vinfen's rehabilitation services provide an ideal setting for integrating key elements of fidelity:  multidisciplinary team integration meeting 3 or more times per week; competitive employment (jobs paying at least minimum wage, in socially integrated community settings); jobs tailored to personal career preferences;  job search process beginning immediately after SE entry; and ongoing job supports available throughout Services.  In doing so, VInfen has been able to achieve significant advantages over Statewide employment rate of about 12%, with an average employment rate in March 2017 of 39% for those working with a CBFS Employment Specialist.

Integration of IPS has been fundamental to both efficient delivery and culture of the service team.  The mental health research literature often reports on staff pessimism about the prospects of their clients' abilities to go back to work, which hinders both demand for SE and progress of people trying to go back to work.  In settings where the Employment Specialist is integrated into the teams, clinical staff have regular employment-related discussions in team meetings, see progress being made, and come to believe that work is possible for many they previously did not hold the belief for.

Beginning in 2014, Vinfen and the UMass Medical School  Work Without Limits Administrative Employment Network (WWL AEN) began partnering to provide enhanced benefit counseling to individuals served by Vinfen who are working or actively seeing employment.  The WWL AEN provides enhanced long-term benefit counseling to persons receiving Social Security, health care and other public benefits who participate in Social Security’s Ticket to Work program.  The goal of the Vinfen and WWL AEN is to support individuals’ efforts to improve their financial well-being through employment and, when possible, become economically self-sufficient.  In this partnership, Vinfen provides employment placement and on-going supports.  The WWL AEN provides detailed information and long-term follow along services regarding the impact of employment on the individual’s Social Security, health care, food assistance, housing and other benefits. The WWL AEN also serves as a resource to Vinfen staff providing information regarding employment and public benefits.

The WWL AEN not only provides long-term enhanced benefits counseling for Social Security Beneficiaries, it also manages all of the administrative operations of the Ticket to Work program. Milestone payment revenues through the Ticket program are shared with partner organizations..  This currently results in approximately $40,000 in revenue to Vinfen each year, all of which goes to provide additional training or work related resources for individuals served by Vinfen.  Revenues made available to future job seekers provide a way for individuals to use their employment success to pay forward to people who are using Vinfen Employment Services.

Bob has been seeking employment in musical sound engineering. Bob began working with a CBFS Employment Specialist, and quickly learned that he required updated knowledge of the software in his industry. Through the Vinfen Ticket to Work fund, he purchased a $600 software program to adapt his skills to the current technology. Since this time, Bob has been actively interviewing in his field. One of Bob’s ultimate goals is to become financially self-sufficient, and move to the west coast. Bob has an interview set up in May in Los Angeles for a position in his field. 

Upon being deemed ineligible for services by the state VR agency due to use of drugs and a recent criminal history, Gail began working on employment with Vinfen's IPS services. The team's Employment Specialist helped her to acquire a job at a local fast food restaurant doing entry level service, and through 2 years of her own determination, combined with Vinfen’s employment services and WWL benefits counseling, she now works as general manager of the restaurant, and is fully off of benefits.  It's unlikely that neither she, nor many other people served by the public mental health system would have access to this kind of opportunity without an integrated approach to employment support and the benefits counseling.
    
Despite these promising stories, Employment rates for people with disabling psychiatric conditions have actually dropped Nationwide, from 23% in 2003 to 17.8 in 2012.     A recent NAMI report on employment for people with disabling psychiatric conditions, reported that while "some states are doing better than others in making supported employment available to people served by public mental health systems...it is deplorable that nationwide, only 1.7 percent of people served in state mental health systems received supported employment services in 2012."      As our field continues to mature and change, it is critical that practitioners seize opportunities to use information about our most effective practices, shaping the direction of future service systems so that greater numbers of people can effectively move through services, rather than facing a lifetime of extreme poverty and dependence within them.

^[1] Liebman JB, Smalligan JA. An evidenced-based path to disability insurance reform. Washington (DC): Hamilton Project, Brookings Institution; 2013 Feb 26.
[2] Liebman JB, Smalligan JA. An evidenced-based path to disability insurance reform. Washington (DC): Hamilton Project, Brookings Institution; 2013 Feb 26.
[3] Cullberg J, Mattsson M, Levander S, Holmqvist R, Tomsmark L, Elingfors
C, et al. Treatment costs and clinical outcome for first episode schizophrenia patients: a 3-year follow-up of the Swedish “Parachute Project” and two comparison groups. Acta Psychiatr Scand. 2006;114(4):274–81.
^[4] Hoffmann H, Jäckel D, Glauser S, Mueser KT, Kupper Z. Long-term effectiveness of supported employment: 5-year follow-up of a randomized controlled trial. Am J Psychiatry. 2014;171(11):1183–90. (herein 2014 HOF)
^[5] Bush PW, Drake RE, Xie H, McHugo GJ, Haslett WR. The long-term impact of employment on mental health service use and costs for persons with severe mental illness. Psychiatr Serv. 2009;60(8):1024–31.
^[6] 2014 HOF supra note 5
[7] Bureau of Labor Statistics (2003 -2012) Employment-Population Ratio. http://data.bls.gov/pdq/SurveyOutputServlet
[8] Lutterman, T; (Aug. 2013) 2012 Uniform Reporting System Results and National Outcome Measures (NOMs) Trends. NRI.
http://www.nasmhpd.org/docs/Webinars%20ppts/2012%20URS%20National%20Resu...
[9] Road to Recovery: Employment and Mental Illness
(2014), the National Alliance on Mental Illness. https://www.nami.org/About-NAMI/Publications-Reports/Public-Policy-Reports/RoadtoRecovery.pdf
[10] Lutterman, T. (Aug. 2013) 2012 Uniform Reporting System Results and National Outcome Measures (NOMs) Trends. NASMHPD/NRI
http://www.nasmhpd.org/docs/Webinars%20ppts/2012%20URS%20National%20Resu...