“66% of people with mental health issues want to work, less than 20% are employed.”1
“Few things are worse for people’s physical and mental health than unemployment.”2
“I don’t know anybody who wants to be poor.”3
“Everybody gets a tickey mark when agencies collaborate and clients are successful.”4
“The overall unemployment rate is low and the time is right, seize the moment.”5
Over 150 individuals from more than 30 Behavioral Health Agencies, the Division of Vocational Rehabilitation and other state agencies, tribal programs, behavioral health and managed care organizations and community rehabilitation programs came together in Lacey Washington on August 9 and 10 to celebrate, network, and learn about effective supported employment services for people with behavioral health challenges. The 2016 Washington State “Great Minds @ Work Supported Employment Conference” featured nationally known keynote and breakout speakers and was designed to help prepare for the upcoming Healthier Washington 1115 Demonstration Medicaid Waiver by building capacity within the community behavioral health agencies to provide supported employment services. Sponsors included Washington’s Department of Social and Health Service’s Divisions of Behavioral Health and Recovery and Vocational Rehabilitation, Washington State Health Care Authority, University of Washington’s Department of Rehabilitation Medicine, King County Behavioral Health Organization, Grant County Mental Health, Washington Business Alliance, and the Becoming Employed Starts Today (BEST) project funded by the Substance Abuse Mental Health Services Administration (SAMHSA).
Three content strands wove throughout the conference presentations. Keynotes by LaVerne Miller and Danita Diamata as well as panels on the peer role, WRAP for work, and Peer Employment Support Groups offered personal stories of lived experience with mental illness as well as stories of empowerment, hope, and encouragement. Presentations on topics like the IPS model, consultative job development, managing supported employment programs and work incentives provided practical strategies; and discussions of the new Medicaid Waiver, DVR’s role, collaboration with the Job Service Centers, and resources from other agencies such as the Employment Pipeline highlighted partnerships and systems issues.
The following summary provides highlights from the four keynotes and some of the fifteen breakout sessions offered over the two days of the conference. For more complete information, please visit www.ccer.org to access handouts and presentation materials.
Hope, Encouragement, Personal Stories
LaVerne Miller advocates for the inclusion of peers in the planning, implementation, service delivery, and evaluation of SAMHSA funded programs at the National GAINS Center. Her message focused on the fundamental role of hope in recovery, and the role of work in helping people take advantage of community life. Fear is a natural
consequence of what people hear about their future, often from the people providing services. Professionals need to see hope too – having peers on the team can help. There is a tendency to assume every barrier is related to the diagnosis; often people are referred back to more intensive treatment if they are struggling, but difficulties are typical when people start careers and many barriers result from living in poverty.
LaVerne also facilitated a discussion about the role of peers on the Supported Employment team during which Denise Sumpter, Wanda Johns, and Erika Ritchie shared their powerful personal stories about living with mental health challenges and how these stories can be motivational to people accessing services.
“I like to hear people’s dreams and keep them alive.”6 In another approach, Peer Employment Support Groups (developed by the Integrated Employment Institute at Rutgers University) are being offered by two agencies in King County. The intention of the Peer Employment Support Group is to offer a place for discussion and exploration about employment for consumers unsure about seeking employment. It is intended to be a low barrier point of entry to employment services. Participants can work through their ambivalence without pressure and talk about whatever concerns they may have about employment in a supportive atmosphere. 31 modules cover topics like Identifying Interests, Building your Resume, Disclosure, and Managing Symptoms While Working.
Donita Diamata reminded us that people with mental health challenges have a life expectancy 25 years shorter than the average, with poverty and unemployment contributing to this statistic. Why don’t more people work? They were told they couldn’t or placed into jobs that don’t support recovery. They had negative experiences with coworkers or ran into employer stigma. They lack needed education and skills or are fearful of losing benefits. Donita is a strong advocate for consumer-run services, and offered these suggestions about bringing in and supporting peer support providers:
- Peer support values are different than traditional counseling, e.g. around self-disclosure or physical contact. Ensure that staff training supports this.
- Be clear about the peer role in the agency.
- Treat peers as full members of the team.
- Ideally have a peer supervisor as well, one who has been through the peer support training.
In her presentation on “What I’ve Learned So Far,” Mindy Oppenheim reminded us that so many changes have happened over the past 30 years – for example, supported employment, the ADA, self-determination, customized employment. Yet the unemployment rate for people with disabilities hasn’t improved – 60.7% in 2008, 65.8% in 2013. Discussing her San Francisco experience serving people with multiple barriers relating to mental illness, poverty, criminal, substance abuse, homelessness, etc., Mindy shared seven lessons relating to employment services and support:
- What you believe will happen will happen – have high expectations of success for the people you serve. “Every time we promoted someone, they rose up.”
- Do not poke, prod, or mess with other people’s belief systems. You won’t change a belief system in a sales call.
- Changes happens from within – peers change peers, CEOs change CEOs. Employer concerns come from a lack of education, exposure, & ignorance about mental illness
- It’s who you know. You want to relate to business as the technical expert, not the salesman. Right now we’re getting people jobs but not infiltrating business.
- “Up your ask.” Don’t be afraid to ask for something – tours, job analysis, job club speaker, interviews, resume review, job shadowing, etc.
- Be the change you want to see (e.g. hire consumers, and not just in “peer” positions)
- There is no such thing as failure, only feedback. Redefine success – 90 days isn’t the only positive outcome. What about reducing substance use, homelessness, mental health emergencies, hospitalizations, incarcerations; increasing self-worth, integration, housing stability?
Several presentations provided information on practical strategies for assisting people in obtaining and maintaining employment. An overview of the principles underlying the Individualized Placement and Support (IPS) model provided research evidence (in studies comparing IPS services to other services provided to individuals exiting the state hospital, 60% of the IPS participants became employed vs. 23% of the other group); and information about the eight key IPS practice principles. Additional approaches are useful for job seekers with criminal backgrounds, who often have a high level of self-awareness by the time they are involved in employment services. Employment specialists can’t change what happened, but can help people prepare to talk to employers. “I did it, I own it, I’m past it.” Tell the truth and move on to what you have to offer to a business. Another crucial area of focus is helping people get accurate information about the impact of work on Social Security benefits. Earnings and benefits are not an either-or choice as many assume – it’s helpful to think in terms of progression. “People don’t make bad decisions; they make decisions based on bad information.”7
Other presentations focused on building relationships with business on behalf of job seekers. A consultative approach involving partnering with the business and using their supports for training may be a more holistic way of connecting consumers with the workplace. This takes time up front but works best in the long run; before you can convince a business you can meet their needs, you need to understand what those needs are. Often this means starting at the top rather than in the HR department – as Mindy Oppenheim reminded us, “HR is paid to put square pegs in square holes.” The “Great Minds @ Work” campaign developed by the Washington Business Alliance has resources including brochures and fact sheets that can be used in business outreach efforts. Section 503 of the Rehabilitation Act now requires federal contractors and sub-contractors (which represent 82% of Washington businesses with at least 50 employees) to actively recruit applicants with disabilities and shoot for at least 7% employees with disabilities at each level in the company; supported employment programs representing applicants with mental health disabilities can be an attractive partner and resource to such businesses.
Three Washington State programs offer resources for behavioral health consumers considering employment. The Alternative Solutions program works with parents to remove child support barriers while helping make connections to services and employment opportunities. Many of these parents are struggling very limited financial resources ($797 average gross monthly income), did not graduate from high school, could be defined as homeless, have insufficient transportation, have a history and/or unresolved issues with criminal justice system, lack a stable employment history, and may have mental illness. The integrated, cooperative caseload approach can help with modifications to child support orders, conference boards, license releases, reasonable payment plans, coordination with employment services
etc. The Employment Pipeline connects job seekers who are DSHS clients with potential employment opportunities, and provides barrier removal and support service resources through Employment Navigators. The Basic Food Employment and Training Program (BFET) provides employment, education, and training services to Basic Food recipients. BFET’s goal is to help people obtain a livable wage leading towards self-sufficiency through a 3rd party reimbursement model in partnership with community-based organizations (CBOs) and state colleges. Services include job search, job search training, job retention, basic and vocational education. BFET can also provide funds for transportation, permits, safety clothing, housing and utility assistance, child care subsidy, personal hygiene, school supplies, tools and equipment for employment.
Staff at Grant County Mental Healthcare have been developing their collaboration with the local WorkSource Center (WS)for over 20 years. They started by collaborating on mini-job fairs and offering occasional training to WS staff, but this had no impact on MH clients. Eventually they established Grant County Mental Healthcare a location within the WS Center, and that made all the difference. There were more referrals, it was possible to do real-time education and coordinate job developing with Veterans’ services and other business services. Many WS clients have mental health issues and even those that don’t face many of the same barriers. The panel pointed out that collaboration is about relationships & sometimes developing them can take a while.
Joe Marrone’s presentation on “Writing Medically Necessary Employment Service Notes” began with advice about developing and documenting the treatment plan that should underlie and justify the services that are provided. Joe said treatment, as we know it, is too often something that is done to or for the person rather than with the person. Most plans speak to the goals of the clinician but rarely address the desires of the person in recovery. Housing & employment should be included as part of the recovery plan.
The words “Medical Necessity” scare people but Who? What? Where? When? And Why? covers almost all of what’s needed if you have a properly developed plan. Medically necessary = medical items and services that are “reasonable and necessary” for the diagnosis or treatment of illness or injury or to improve the functioning of the person.” Documentation provides a written, legal record of treatment and services; provides a mechanism for submission of payment, and creates a road map of services for consumers, staff, supervisors, payers. Progress notes should clearly state activities and interventions that are directly related to the goals and interventions described in the treatment plan.
A panel on Supervising a Supported Employment Program within the IPS model offered many strategies for creating a culture of employment in the agency
- Address client ambivalence: ensure easy access to supported employment staff; encourage clinicians to address employment barriers including negative self-image from long-term unemployment, unrealistic expectations, past professionals warning against work, and experience with less than adequate employment programs; provide basic benefits information; support and provide access to successful role models.
- Expect a recovery mindset – e.g., include questions about employment goals on the intake form. Train all staff in IPS. Feature pictures of employed consumers in the lobby. Expect the Employment Specialist to be the cheerleader within the treatment team.
- Focus on employment competencies when hiring – it’s easier to teach MH stuff to people with business skills than vice versa. Supervisors should have not only clinical experience but experience providing and supervising SE services. Use working interviews, role plays, second interviews to ensure both sides understand what they’re getting into.
Mike Donegan shared the “Preparation for Employment Checklist” used at DESC. The list includes:
- Discuss interests, skills, possible employment goals during Intake and Case Management Engagement process
- Consider referral to Peer Employment Support Group or Job Club
- Help consumers get prepared for DVR referral and job applications by obtaining copy of Driver’s License or State ID card, copy of Social Security card, voice mail, email address, goal and service plan including work as treatment domain, documentation of disability, info about veterans’ status.
- As appropriate, help people develop list of activities/interests, identify hygiene issues, identify long-term employment goal and steps needed, encourage volunteer work, identify references, money management classes, benefits planning.
- While consumer is working with Employment Team (or seeking work on their own), communicate regularly with Employment Specialist and include her in Housing Service and other planning; accept ambivalence as natural aspect of change; encourage work as a motivator for treatment compliance and decreasing substance usage; talk with consumers about their experiences in working, use Motivational Interviewing techniques, and most importantly, believe that everyone can work.
As the new Medicaid Waiver becomes reality in Washington, employment funding and collaboration roles will continue to shift; relationships with DVR, housing programs, and the Employment Security Department/WorkSource Washington will be more important than ever. In his overview of the 1115 Waiver, Jon Brumbach from the Health Care Authority shared these goals for the initiative: reduce the avoidable use of intensive services and settings, improve population health, accelerate the transition to value-based payment, and ensure the per-capita cost growth is below national trends. These changes have the potential to impact 2 million Medicaid beneficiaries in Washington state once the agreement is finalized this fall, and will allow Medicaid resources to be used for Supportive Housing and Supported Employment services. Echoing the symbiosis between housing and employment, Pat Tucker’s presentation illustrated the interaction between work and housing by reminding us that work is an integral part of recovery for homeless people, and earned income from work gives people more housing choices.
The Division of Vocational Rehabilitation (DVR) will continue to have a significant role in assisting behavioral health consumer to go to work via IPS services and possible 1115 Waiver support. DVR helps people get and keep jobs to their maximum potential, focusing on careers & pathways to “middle income” wages. Many behavioral health agencies are also “Community Rehabilitation Programs or CRP” for DVR, providing job placement, intensive training, and psychosocial job support services via DVR funds. Probably the most common partnership will involve individuals being served through Medicaid initially, because IPS standards require employment activity within 30 days of request and it may not be possible to accomplish the DVR application and eligibility process that quickly. Job development and placement activities might then be provided in partnership with the DVR counselor, followed by long-term support through Medicaid. There may be other services available from DVR as the newly-released regulations for the Workforce Innovation and Opportunity Act (WIOA) are analyzed and applied.
Wrapping it up
Jim Vollendroff, (King County Mental Health Chemical Abuse and Dependency Services Division) shared both his personal story about recovery, employment, and increased acceptance of lived experience; and his agency’s vision for behavioral health and recovery services. In their move toward whole person care, their goals include providing services at an earlier age; providing treatment services on demand; addressing critical housing issues, and diverting from the justice system whenever possible. Mental Health and Substance Use Disorder services are being integrated into Behavioral Health Organizations; by 2020 they will be integrated with healthcare. The demand for services exceeds the supply of providers – peers can help. King
Co has lots of resources but also 24,000 people to serve in behavioral health services. How do we get leaders involved? 20% will buy in right away, 20% will never buy in, the 60% in the middle is your target. What does leadership need? Data? Stories? Both?
Final thoughts from Joe Marrone –
- Collaboration should be judged by results, not just the relationship
- Have to say “yes” to the first thing your new partner asks for – find a way.
- We have some better employment programs but they’re still not an integral part of recovery services
- We’re missing the boat if we’re only focusing on employment & housing staff; everyone working at the agency needs to be on board.
- Change requires 1) hope, 2) concrete help, 3) hassling people (e.g. make people uncomfortable with the state they’re in.)
- Focus on discrimination by employers (behavior) rather than stigma (attitude).
- Don’t equate hiring peers into the system with having an employment program.
- Employment is a broad part of citizenship; SE is a strategy, not the goal.
- All change is difficult no matter how long you put it off.
Thanks to all our presenters – LaVerne Miller, Donita Diamata, Denise Sumpter, Wanda Johns, Erika Ritchie, Amabel Narvaez, Mindy Shoemaker, Jody Brown, Rodney Goin, Lisa Bennett-Perry, Sandy Reese, Pat Tucker, Rich Coleman, Lisa Floyd, Vicki Gilleg, Don Kay, Jon Brumbach, Mindy Oppenheim, Brian Mark, Kassandra Watson, Keresa Wright, Dawn Miller, Patrick Whalin, Mike Donegan, Laura Fleagle, Mandi Ucab, Kaily Fiedler-Gohlke, Jim Vollendroff, Joe Marrone, Calvin Greer, Kevin Semler, Lisa Pan, Mike Hudson, Rick Kugler, Melodie Pazolt, Karen Miceli, Quanda Evans, and Katie Mirkovich – for sharing both your expertise and your lived experience.
Thanks also to the conference committee (Lisa Floyd, Lisa Bennett-Perry, Mike Hudson, Dawn Miller, Don Kay, Vicki Gilleg, John McClure, Tammi Olson, Susan Bonnell, and Laurie Ford) for development and coordination efforts. And a very special thank you to Melodie Pazolt, Supported Employment and Supported Housing Administrator at DBHR, for her consistent dedication to the importance of employment for all people, including people in recovery from behavioral health challenges.
1 Mindy Oppenheim
2 Joe Marrone
3 LaVerne Miller
4 Dawn Miller
5 Jim Vollendroff