Supported Employment: Building Your Program - SAMHSA Store ...

BuildingYour ProgramSupportedEmploymentU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services AdministrationCenter for Mental Health Serviceswww.samhsa.gov

BuildingYour ProgramSupportedEmploymentU.S. Department of Health and Human ServicesSubstance Abuse and Mental Health Services AdministrationCenter for Mental Health Services

AcknowledgmentsThis document was produced for the Substance Abuse and Mental Health Services Administration(SAMHSA), by the New Hampshire-Dartmouth Psychiatric Research Center under contract number280-00-8049 with Westat under contract number 270-03-6005, with SAMHSA, U.S. Departmentof Health and Human Services (HHS). Neal Brown, M.P.A., and Crystal Blyler, Ph.D., served asthe Government Project Officers.DisclaimerThe views, opinions, and content of this publication are those of the authors and contributors anddo not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services(CMHS), SAMHSA, or HHS.Public Domain NoticeAll material appearing in this document is in the public domain and may be reproducedor copied without permission from SAMHSA. Citation of the source is appreciated. However,this publication may not be reproduced or distributed for a fee without the specific, writtenauthorization from the Office of Communications, SAMHSA, HHS.Electronic Access and Copies of PublicationThis publication may be downloaded or ordered at www.samhsa.gov/shin. Or, please callSAMHSA’s Health Information Network at 1-877-SAMHSA-7 (1-877-726-4727) (Englishand Español).Recommended CitationSubstance Abuse and Mental Health Services Administration. Supported Employment: BuildingYour Program. DHHS Pub. No. SMA-08-4364, Rockville, MD: Center for Mental Health Services,Substance Abuse and Mental Health Services Administration, U.S. Department of Health andHuman Services, 2009.Originating OfficeCenter for Mental Health ServicesSubstance Abuse and Mental Health Services Administration1 Choke Cherry RoadRockville, MD 20857DHHS Publication No. SMA-08-4364Printed 2009

Building Your ProgramBuilding Your Program is intended to help mental health authorities,agency administrators, and Supported Employment (SE) leaders thinkthrough and develop the structure of SE programs. The first part ofthis booklet gives you background information about the SE model.This section is followed by specific information about your role inimplementing and sustaining your SE program. Although you willwork closely together to build SE programs, for ease, we separatedtips into two sections:SupportedEmployment• Tips for Mental Health Authorities; and• Tips for Agency Administrators and SE Leaders.In preparing this information, we could think of no one betterto advise you than people who have worked successfully withSE programs. Therefore, we based the information in this bookleton the experience of veteran SE leaders and administrators.For references, see the booklet The Evidence.

This KIT is part of a series of Evidence-Based Practices KITs createdby the Center for Mental Health Services, Substance Abuse andMental Health Services Administration, U.S. Department of Healthand Human Services.This booklet is part of the Supported Employment KIT that includesa DVD, CD-ROM, and seven booklets:How to Use the Evidence-Based Practices KITsGetting Started with Evidence-Based PracticesBuilding Your ProgramTraining Frontline StaffEvaluating Your ProgramThe EvidenceUsing Multimedia to Introduce Your EBP

What’s in Building Your ProgramWhat Is Supported Employment? .................3Tips for Mental Health Authorities ................9Tips for Agency Administratorsand Supported Employment Leaders ..............17SupportedEmployment

Building Your ProgramWhat Is Supported Employment?People with serious mental illnesses havemany strengths, talents, and abilities thatare often overlooked, including the abilityand motivation to work. Research hasshown the following:• About 70 percent of adults with seriousmental illnesses desire work (Mueseret al., 2001; Rogers et al., 2001).• Consumers and families consistentlyidentify finding and keeping jobs as atop priority.• Approximately 60 percent of consumerscan be successful at working when usingSE services (Bond et al., 2001).Supported Employment (SE) is anapproach to vocational rehabilitationfor people with serious mental illnessesthat emphasizes helping them obtaincompetitive work in the communityand providing the supports necessaryto ensure their success in the workplace.SE programs help consumers find jobsthat pay competitive wages in integratedsettings (i.e., with other people whodon’t necessarily have disabilities)in the community.The overriding philosophy of SE is thebelief that every person with a seriousmental illness is capable of workingcompetitively in the community if theright kind of job and work environmentcan be found. Rather than trying tosculpt consumers into becoming “perfectworkers” through extensive prevocationalassessment and training, consumers areoffered help finding and keeping jobs thatcapitalize on their personal strengths andmotivation. Thus, the primary goal of SEis not to change consumers, but to finda natural “fit” between consumers’strengths and experiences and jobsin the community.Building Your Program 3 What Is Supported Employment

In contrast to other approaches to vocationalrehabilitation, SE de-emphasizes prevocationalassessment and training and puts a premium onrapid job search and attainment. The job searchis conducted at a pace that is comfortable forconsumers and is not slowed down by anyprogramming prerequisites.Individuals with serious mental illnesses differ fromone another in terms of the types of work they prefer,the nature of the support they want, and the decisionabout whether to disclose their mental illness toemployers or coworkers. SE programs respect theseindividual preferences and tailor their vocationalservices accordingly.In addition to appreciating the importance ofconsumer preferences, SE programs recognize thatmost people with serious mental illnesses benefitfrom long-term support after successfully gettinga job. Therefore, SE programs avoid imposingunrealistic time limitations on services, whilefocusing on helping consumers become asindependent and self-reliant as possible.As consumers succeed in working in the community,their self-perceptions often change, and they viewthemselves as workers and contributors to society.Furthermore, as people in the community seeconsumers working, consumers are less stigmatizedfor their mental illnesses and they become moresocially accepted.SE programs are based on a core set of practiceprinciples. These principles form the foundationof the program.Practice Principlesof Supported Employment• Eligibility is based on consumer choice.• SE services are integrated withcomprehensive mental health treatment.• Competitive employment is the goal.• Personalized benefits counseling isimportant.• Job search starts soon after consumersexpress interest in working. Follow-along supports are continuous. Consumer preferences are important.or other problems, including substance abuse andcognitive impairment.The core philosophy of SE is that all consumers canwork at competitive jobs in the community withoutprior training, and no one should be excluded fromthis opportunity.SE does not try to bring consumers to somepreconceived standard of “work readiness” beforethey seek employment. Consumers are “work ready”when they say they want to work. Research showsthat symptoms, substance abuse, and otherconsumer factors are not strong and consistentpredictors of work when consumers receiveassistance from an SE program. Therefore, nojustification exists for excluding consumers whoare interested in working from SE programs.Principle 1: Eligibility is basedon consumer choiceAll consumers who want to participate in SEare eligible—no one is excluded. Consumerswho are interested in work are not preventedfrom participating in SE, regardless of theirpsychiatric diagnosis, symptoms, work history,Principle 2: SE services are integrated withcomprehensive mental health treatmentClosely coordinating SE services with other mentalhealth rehabilitation and clinical treatment ensuresthat all mental health practitioners (not justemployment specialists) support consumers’vocational goals. For this reason, it is important thatWhat Is Supported Employment 4 Building Your Program

SE staff participate regularly in clinical treatmentteam meetings.Participating in team meetings gives you a vehicleto discuss clinical and rehabilitation issues that arerelevant to work, including the following: Medication side effects; Persistent symptoms (e.g., hallucinations); Cognitive difficulties; or Other rehabilitation needs (e.g., skills trainingto improve ability to socialize with co-workersor self-assertion skills).Moreover, regular contact with team members(phone or face-to-face meetings) also allows youto help consumers achieve vocational goals.Principle 3: Competitive employmentis the goalSE staff help consumers obtain competitive jobs. Competitive jobs are part-time or full-time jobsthat exist in the open labor market and pay atleast a minimum wage. They are jobs that anyone could have regardlessof their disability status.Competitive jobs are not jobs that are set asidefor people with disabilities. The wage should notbe less than the wage (and level of benefits) paidfor the same work performed by people who donot have a mental illness.Competitive work is valued for several reasons: Consumers express a strong preference forcompetitive work over jobs that are set asidefor consumers. Consumers want to work incommunity settings. Competitive work promotes integratingconsumers into the community. Involvingconsumers in normal activities reduces the stigmaof mental illness. Consumers’ self-esteem often improves.As consumers see that they are able to workcompetitively, that their work is valued, and thatthey can contribute to society, some consumersexperience improvements in symptoms andself-esteem.Historically, many vocational programs have placedconsumers into noncompetitive jobs, often payingsubminimum wages, with only rare progression intocompetitive employment. Experience shows thatconsumers can successfully work at competitivejobs without previously participating in trainingprograms or noncompetitive job experiences.Principle 4: Personalized benefits counselingis importantFear of losing benefits (e.g., Social Security andhealth insurance) is a major reason that consumersmay not seek employment. For this reason, it isvital that consumers who are interested in workingobtain accurate information to guide their decisionsabout work.While employment specialists should be able tocommunicate basic information about the impactof work on consumers’ benefits, all consumersshould have access to benefits counseling whenthey start SE services and when changes occurin their work status.Principle 5: Job search starts soon afterconsumers express interest in workingEmployment specialists are directed to helpconsumers explore job opportunities within onemonth after they start the SE program. Rapid jobsearch helps engage consumers in SE services andtakes advantage of consumers’ current motivation.Studies show that fewer consumers obtainemployment when the job search is delayed byprevocational preparations and requirements.For this reason, it is against SE principles to requireBuilding Your Program 5 What Is Supported Employment

extensive pre-employment assessment and trainingor intermediate work experiences (like prevocationalwork units, transitional employment positions,or sheltered workshops).How do we know thatSupported Employmentis effective?Principle 6: Follow-along supportsare continuousSome consumers struggle with symptoms thatchange or persist over time, so their optimaltreatment and rehabilitation require a long-termcommitment. For this reason, despite theirvocational success, consumers who receive SEservices are never terminated unless they directlyrequest it. Follow-along supports are providedto consumers on a time-unlimited basis.While follow-along supports are continuous,for many consumers the extent of supportgradually decreases over time. In fact, the goalfor employment specialists is to provide supportand assistance while helping consumersbecome independent.Principle 7: Consumer preferencesare importantConsumers who obtain work that they findinteresting tend to have higher levels of satisfactionwith their jobs and longer job tenures. For thisreason, consumers’ preferences guide all phases ofSE services. Honoring consumers’ preferences iscritical in helping them pursue their vocational goals.The SE model has been the most extensivelystudied model of vocational rehabilitation forpeople with serious mental illnesses. Ampleevidence supports its effectiveness. A recent reviewof 17 studies involving employment programsconsistently demonstrated that SE programsshowed significant advantages over traditionalapproaches. Across these studies, 58 percent ofconsumers who were in SE obtained competitiveemployment compared to 21 percent in traditionalprograms (Bond et al., 2001).The SE model has been found to produce bettervocational outcomes than the comparison programs,such as prevocational programming, sheltered work,and transitional employment. Specifically,consumers in SE programs were more successfulin achieving these goals: Obtaining competitive work; Working more hours; and Earning higher wages (Bond et al., 2001).Some research shows that when consumers succeedin finding competitive work, improvements mayoccur in symptoms, self-esteem, and satisfactionwith finances (Bond et al, 2001; Mueser et al.,1997). Most consumers in SE programs who obtainemployment work part-time and are able to keeptheir benefits (i.e., Social Security payments, healthinsurance). Work often becomes a meaningful partof their lives.What Is Supported Employment 6 Building Your Program

No evidence of negative effectsPractitioners, consumers, and family members aresometimes concerned that competitive work will bea stressful experience that may increase the chancesof relapses and rehospitalizations. However, theresearch on SE has consistently found that nonegative effects relate to participating in an SEprogram. Specifically, consumers who participatein SE programs do not experience more severesymptoms or higher levels of distress, nor do theyrequire more intensive psychiatric treatment suchas emergency room visits or psychiatrichospitalizations (Bond et al., 2001).Who benefits most fromSupported Employment?Research shows that consumer factors do notpredict better employment outcomes. Specifically,employment success has not been linked to any ofthe following: Diagnosis; Symptomatology; Age; Gender; Disability status; Prior hospitalization; Education; or Co-occurring condition of substance use(Bond et al, 2001).Although work history predicts better employmentoutcomes, SE remains more effective thantraditional vocational services for consumers withboth good and poor work histories. Consequently,we speculate that the professional assistance thatSE programs provide at every stage of theemployment process compensates for consumerdeficits in a way that less assertive vocationalrehabilitation approaches do not.Some consumer factors have not beensystematically examined in the literature.For example, few studies research the effectof employment services for people with seriousmental illnesses who are homeless. However, Workas a Priority (Shaheen, Williams, & Dennis, 2003)addresses the need for employment services to becoordinated with housing and other services forthis population.The majority of studies were conducted in settingswith significant numbers of Caucasian, AfricanAmerican, and Latino consumers (Bond et al.,2001). Although more replications are needed, allthe evidence to date suggests that the effectivenessof SE compared to traditional vocational servicesgeneralizes to both the African American andLatino populations.Further research is needed to determine whetherSE is equally effective across all ethnic groups.However, anecdotally, we know that culture andlanguage pose significant barriers to providing SEin some populations.Where should Supported Employmentbe provided?Community characteristics do not appear to imposea major barrier to implementing an SE program.SE has been successfully implemented in both veryurban and very rural settings as well as in mid-sizedcities in many different states.Nearly all research on the effectiveness of SE hasbeen conducted in community mental healthcenters. The extent to which SE can be successfullyadapted to other types of agencies is the subject ofcurrent research, but no strong conclusions can bedrawn now.Building Your Program 7 What Is Supported Employment

Is Supported Employment cost-effective?Only limited research has examined the cost ofproviding SE services. This research shows thatwhen an SE program is added to an existingpsychiatric rehabilitation program, overall costsof services (that is, the combined treatment andemployment program costs) increase. However,when an SE program replaces another rehabilitationprogram—such as a day treatment program—the overall treatment costs remain the same.Assuming a caseload of about 18 consumers peremployment specialist, the cost of SE servicestypically ranges between $2,000 and $3,000 perconsumer per year (Clark, 1998; Kregel et al., 2000).SE programs may either increase overall treatmentcosts or not affect treatment costs, depending onwhether the services are added or substituted foranother service in a rehabilitation program.In summary, many mental health systems andagencies are confronted with the challenge ofmeeting the needs of consumers in an environmentof limited resources. The SE model, an evidencebasedpractice, is one of the most effective servicestrategies available, demonstrating consistent,positive outcomes for consumers.What Is Supported Employment 8 Building Your Program

Building Your ProgramTips for Mental Health AuthoritiesSuccessfully implementing evidence-based practices requires the leadershipand involvement of mental health authorities. This section discusses whyyou should be involved in SE implementation and the types of activities thatmental health authorities typically undertake.Why should you beinterested in SupportedEmployment?The SE KIT makes it possible to giveyou this evidence-based practice in acomprehensive and easy-to-use format.The Supported Employment (SE) KITpresents public mental health authoritieswith a unique opportunity to improveclinical services for adults with seriousmental illnesses. Research about servicesystems has evolved to a point where it canidentify a cluster of practices thatdemonstrate a consistent, positive impact onthe lives of consumers. This KIT representsone of those evidence-based practices.Can SE make a difference?Whenever new programs come along,administrators have to ask whether it isworth it to reorganize: Is the new programreally going to make a difference?When it comes to SE, extensive researchshows that the answer is, “Yes.” MostBuilding Your Program 9 Tips for Mental Health Authorities

impressive is the extent to which SE has beensubjected to rigorous research and the consistencyof favorable findings.Briefly stated, extensive research shows thatconsumers in SE programs were more successfulthan consumers in other vocational programs in thefollowing areas: Obtaining competitive work; Working more hours; and Earning higher wages (Bond et al., 2001).Some research shows that when consumers succeedin finding competitive work, improvements mayoccur in symptoms, self-esteem, and satisfaction withfinances (Bond et al., 2001; Mueser et al., 1997).For more information, see The Evidence in this KIT. Follow-along supports are continuous; and Consumer preferences are important.Will SE work in your mentalhealth system?The SE model has been adapted in communitymental health agencies in many states. Studiesshowing the effectiveness of SE were conducted insettings that included primarily Caucasian, AfricanAmerican, and Latino consumers. However, noevidence suggests that race, gender, geographicsetting, age, education, diagnosis, symptomatology,disability status, prior hospitalization, or cooccurringcondition of substance abuse are relatedto consumers’ ability to benefit from SE services.Aren’t we already doing this?Your mental health system may already providevocational programs. While these services share somecharacteristics of SE, important distinctions exist.SE helps consumers obtain competitive work in thecommunity and provides the supports necessary toensure success at the workplace. SE programs helpconsumers find jobs that pay competitive wages inintegrated settings (i.e., with others who don’tnecessarily have a disability) in the community.SE is based on the following principles: Eligibility is based on consumer choice; SE services are integrated with comprehensivemental health treatment; Competitive employment is the goal;How can mental healthauthorities support SE?As you read about Supported Employment, youmay think that it sounds great but unaffordable.We want to challenge that notion because othermental health systems with limited resourcesare in the process of implementing SE programssystem-wide. These systems have visionarieswho recognized the benefits of providing thisevidence-based practice and who persistedin overcoming challenges.Implementing SE must be a consolidated effort byagency staff, mental health authorities, consumers,and families. However, for this initiative to besuccessful, mental health authorities must leadand be involved in developing SE programs inlocal communities. Personalized benefits counseling is important; Job search starts soon after consumers expressinterest in working;Tips for Mental Health Authorities 10 Building Your Program

Be involved in implementingSupported EmploymentStep 1 Create a vision by clearly articulating SEprinciples and goals. Designate a staffperson to oversee your SE initiative.Step 2 Form advisory groups to build support,plan, and provide feedback for your SEinitiative.Step 3 Establish program standards thatsupport implementation. Makeadherence to those standards partof licensing criteria.Step 4 Address financial issues and alignincentives to support implementation.Step 5 Develop a training structure tailoredto the needs of different stakeholders.Step 6 Monitor SE fidelity and outcomesto maintain and sustain programeffectiveness.Create a visionAgencies commonly set out to implement oneprogram, but end up with something entirelydifferent. Sometimes these variations areintentional, but often they occur for thefollowing reasons: One administration starts an initiative andanother with a different vision and prioritiessubsequently assumes leadership; The model wasn’t clearly understood to beginwith; or The staff drifted back to doing things in a waythat was more familiar and comfortable.Articulating the vision that people with mentalillnesses can work and experience competitiveemployment is essential to successfullyimplementing an SE program. Place the SEinitiative in the context of the larger recoveryparadigm. Articulate how SE programs will helpagencies fulfill their mission—assisting consumersin their recovery process.To ensure that your vision is clearly articulated,designate a staff person who has experiencewith the SE model to oversee your SE initiative.Form advisory groupsYou can ensure that the SE model is implementedappropriately if you contractually mandate thatstakeholder advisory groups guide theimplementation initiative. The development of yourSE program can benefit in many ways from formingan advisory group including these: Building internal and external support; Generating referrals; Increasing program visibility; and Advising with ongoing planning efforts.Consider forming local and state-level advisorygroups and a Business Advisory Council. State-leveladvisory groups may include the following: Representatives from different state agencies(department of labor, rehabilitation servicesadministration or vocational rehabilitation,Medicaid, and the Social Security Administration)that would be invested in the initiative; Stakeholders from the Chamber of Commerceor other business associations; Leadership from implementing agencies; and Representatives from consumer and family stateadvocacy organizations.Involving stakeholders from the Department ofLabor, for example, can lead to collaborating withOne-Stop Career Centers, which seek to provideintegrated employment and training services so thatBuilding Your Program 11 Tips for Mental Health Authorities

consumers do not need to go from one placeto another to receive information and services.Involving stakeholders from vocationalrehabilitation can help streamline procedures thathelp generate additional revenue for SE programs.Furthermore, representatives from the SocialSecurity Administration can help you identifyresources for benefits counseling and routinetraining on the impact of work on benefits.Local advisory groups can serve as liaisonsbetween the community and participatingmental health agencies. Community stakeholderswith an interest in the success of SE programsinclude representatives of the following: Local consumer organizations; Local family organizations; Agency administrators; and Local vocational rehabilitation agencies.Additionally, many communities have found ithelpful to establish a Business Advisory Councilat the local level.“It has often been said that the employment of peoplewith disabilities is mostly a matter of opportunity andsupport. The quantity and quality of opportunity,however, depends on how available, interested, andinformed employers are. Furthermore, as studies onemployer views of disability illustrate, the target of thesupport should be as much the employer as the jobseeker.” (Luecking, Fabian, & Tilson, 2004).Forming a Business Advisory Council will allowyou to engage and elicit feedback from localemployers. Use the forum to educate employersabout the benefits of hiring people with mentalillnesses. Inform them of the benefits of acollaborative working relationship includingthe following components: A pool of interested and qualified applicants; Prescreening of potential applicants to assesstheir skills and strengths for available positions; Short-term, onsite job coaching to help newemployees become situated; Guidance about reasonable accommodations; and Information about the Work Opportunities TaxCredit that reduces employers’ federal incometax liability.From the beginning, you need to lead youradvisory groups in understanding and articulatingwhat SE is and how it is going to be developed inyour mental health service system. For trainingmaterials that you can use to help stakeholdersdevelop a basic understanding of SupportedEmployment, see Using Multimedia to IntroduceYour EBP in this KIT.Advisory groups should continue to meet well afteryour SE program has been established. We suggestthat they meet about once a month for the firstyear, once every 2 months for the second year, andquarterly for the third year. By the second and thirdyears, advisory groups may help SE programssustain high fidelity by assisting with fidelityevaluations, outcomes monitoring, or translatingevaluation data into steps for continuous qualityimprovement. For more information on the role ofadvisory groups, see Getting Started with EBPs inthis KIT.Planning your SE initiativeWith a vision firmly in place, the process ofunfolding SE programs across the service systemcan begin. Carefully planning this process will helpensure a successful outcome.Implementing SE programs first in pilot ordemonstration sites may be useful. Working withpilot sites can help you manage problems as theyarise and give constituents the opportunity to seethat SE works.Multiple pilot sites are preferable to just one.When only one site is used, idiosyncratic thingsTips for Mental Health Authorities 12 Building Your Program

can happen that misrepresent the model. On theother hand, when systems do a system-wide“rollout,” it is difficult to adequately train all SEstaff. In that case, system problems that may havebeen resolved easily on a smaller scale with a fewSE programs can cause havoc.Establish program standardsStudies of agencies that have tried to replicateevidence-based models have found that if agenciesdid not achieve positive outcomes, it was oftenbecause they failed to implement all of model’scomponents (Becker et al., 2001; Bond & Salyers,2004). As a mental health authority, you have thecapacity to ensure that the system has incentives toimplement SE. Attention to aligning theseincentives in a positive way (such as attachingfinancial incentives to achieving higher competitiveemployment rates) is vital to successfullyimplementing SE.States have the authority to adopt regulations thatgovern services to consumers. These regulations setstandards for the quality and adequacy of programs,including criteria that govern these areas: Admission and discharge; Staffing; Service components; Assessment and treatment planning; Consumer medical records; Consumer rights; and Supervision and program evaluation.Support the implementation of SE by explicitlyreferencing SE in licensing standards and otherprogram review documents (for example, grantapplications, contracts, requests for proposals, andso forth). It is also important to review currentadministrative rules and regulations to identify anybarriers to implementing SE. Work closely withagency administrators to ensure that mental healthauthority policies support high-fidelity SE practice.Address financial issuesEach state is different. In many cases, while yourSE initiative can be mounted with little or noadditional appropriations, it is important to reviewfunding streams to ensure that they support SEimplementation.What does SE cost?The cost of providing SE services varies from stateto state, ranging from $2,000 to $4,000 perconsumer per year (Clark, 1998; Kregel et al.,2000). The cost figures vary according to manyfactors, including the following: Severity of disability for consumers served; Local wage scales for employment specialists; Indirect costs; and Costs of clinical services.How is SE funded?Funding mechanisms vary from state to state. Forthe most part, funds are used from these sources: Rehabilitation services administration (orvocational rehabilitation); Division of mental health; and Medicaid.Work with leaders from these state agencies todevelop a mechanism to pool monies that can beused to reimburse the services of SE programs.State Medicaid rules may allow reimbursement forselected SE services. Consider contactingadministrators from other states who havesuccessfully worked out a plan to gather usefulideas and strategies.Building Your Program 13 Tips for Mental Health Authorities

If you determine that additional appropriationsare necessary to fund SE services, consider shiftingresources from services that have not beenscientifically demonstrated to be effective or thatconsumers desire less.Develop a training structureAgencies who implement evidence-based practices(EBPs) are often stymied in their efforts becausepeople misunderstand the model or lackinformation. It is important that key stakeholders(consumers, families, and other essentialcommunity members) and agency-wide staffdevelop a basic understanding of SE.We encourage you to support agency administratorsin their efforts to develop a training structure forimplementing SE. The training plan should include basic trainingfor key community stakeholders, including thesepeople: Consumers; Families; Employers; Mental health authorities; and Staff from key community organizations. The training plan should also include basictraining for staff at all levels across the agencyand intensive training for employment specialists.Choose your trainerYou may design an intensive training plan foremployment specialists in several different ways,but you must first decide who will conduct thetraining. SE leaders may facilitate the initialtraining for employment specialists by using thetraining tools in Training Frontline Staff in this KIT.Some choose to hire external trainers.One successful strategy in training employmentspecialists entails having new employmentspecialists visit an existing, well-functioning,high‐fidelity SE program to observe how theprogram works. New employment specialists willbenefit most from this visit if they have a basicunderstanding of the SE model.Once trained, SE leaders and employmentspecialists will be able to use the tools in UsingMultimedia to Introduce Your EBP in this KITto provide basic training to key stakeholders.Offer ongoing training and consultationThroughout the first year of your SE program, weencourage you to offer SE staff intermittent boostertraining sessions. After the first year, considerestablishing an annual state-wide conference on SE.Routine onsite and telephone consultation is alsoimportant, particularly for SE leaders. Leading anSE team requires a complex set of administrativeand clinical skills. SE leaders provide direct servicesand supervision, which may require a shift inthinking about consumers’ potentials and abouthow colleagues work together.SE leaders also have administrative responsibilitiessuch as hiring, preparing administrative reports,and developing policies and procedures. Perhapsmore important, SE leaders are responsible forensuring that the SE program operates with fidelityto the SE model, including ensuring the quality andcontent of staff-consumer interactions.Only through day-to-day leadership will the SEmodel be faithfully carried out. For this reason,it is very difficult for anyone to grasp everythingthat has to be learned in a brief time. Also,understanding what needs to be done andtranslating that understanding into action aredifferent and equally difficult.Tips for Mental Health Authorities 14 Building Your Program

For at least the first year a new program is inoperation, SE leaders need someone who isexperienced in SE to provide ongoing consultationon organizational and clinical issues. Consultationranges from integrating SE principles into theagency’s policies and procedures to case consultation.Some states develop EBP programs in stages sothat the first employment specialists can help trainthose in newly developed programs. Generally, ittakes about a year for staff to feel confidentproviding SE, but this can vary depending on howmuch structural change is needed. Programs thatare not already team oriented or are reluctant toaccept new models can take longer to change.It may take 2 to 3 years for an agency to becomesufficiently proficient in the SE model to assumethe added responsibility of training other agencies’employment specialists. Agencies that havebecome SE training sites indicate that involvingtheir staff in training staff from new SE programsreinforces SE principles and knowledge of the SEmodel. A state- or county-wide coordinator who isexperienced with the SE model can also help newSE programs through ongoing contact, assessment,and troubleshooting.Monitor SE fidelity and outcomesProviding SE involves incorporating a new programinto the service delivery system. The best way toprotect your investment is to make certain thatagencies actually provide SE services that positivelyaffect the lives of consumers.Programs that adhere more closely to theevidence-based model are more effective.Adhering to the model is called SE fidelity. The SEFidelity Scale measures how well programs followkey elements of the SE model (Bond et al., 1997).Studies of evidence-based models tell us that thehigher an agency scores on a fidelity scale, thegreater the likelihood that the agency will achievefavorable consumer outcomes (Bond & Salyers,2004). For this reason, it is important to monitorboth SE fidelity and SE outcomes.As a central part of the initial planning process, youmust address how you will monitor the fidelity andoutcomes of SE programs. Too many excellentinitiatives had positive beginnings and enthusiasticsupport but floundered at the end of a year becausethey did not plan how they would maintain the SEprogram. Monitoring SE fidelity and outcomes onan ongoing basis is a good way to ensure that yourSE programs will continue to grow and develop.Consider developing routine supervision andevaluations of your SE programs. If it is notpossible, use strategies (e.g., rules, contracts,financial incentives, etc.) to support fidelity andoutcomes monitoring on the local level or withinindividual agencies.The characteristics of an SE program that wouldhave a perfect score on the SE Fidelity Scale areshown on the next page. For the entire SE FidelityScale, see Evaluating Your Program in this KIT.Building Your Program 15 Tips for Mental Health Authorities

Characteristics of an SE program that would have a perfect score on the SE Fidelity ScaleCaseloadVocational services staffVocational generalistsIntegration of rehabilitationwith mental health treatmentVocational unitZero-exclusion criteriaOngoing, work-based assessmentRapid search for competitive jobsIndividualized job searchDiversity of jobs developedPermanence of jobs developedJobs as transitionsFollow-along supportsCommunity-based servicesAssertive engagementand outreachEmployment specialists manage caseloads of up to 25 consumers.Employment specialists provide only vocational services.Each employment specialist carries out all phases of vocational service.Employment specialists are part of the mental health treatment teamswith shared decisionmaking.Employment specialists function as a unit.There are no eligibility requirements to enter the SE program.Vocational assessment is an ongoing process.The search for competitive jobs occurs rapidly after program entry.Employer contacts are based on consumers’ job preferences.Employment specialists provide job options that are in different settings.Employment specialists provide competitive job options that havepermanent status.Employment specialists help consumers end jobs when appropriate andthen find new jobs.Individualized, follow-along supports are provided to employers andconsumers on a time-unlimited basis.Vocational services are provided in community settings.Employment specialists make multiple contacts with consumers as partof initial engagement and at least monthly on a time-unlimited basiswhen consumers stop attending vocational services.Tips for Mental Health Authorities 16 Building Your Program

Building Your ProgramTips for Agency Administrators and SupportedEmployment LeadersWhether your agency is interested in enhancing an existing program or developinga new program, you will need a broad range of activities to successfully implementSupported Employment (SE). This section outlines the range of implementationactivities in which agency administrators and SE leaders are often involved.Recruit your SE staffSE programs consist of an SE leader,two or more employment specialists, anda benefits counselor, depending on thenumber of consumers that the agency plansto serve.SE leader and employment specialistpositions are typically full time. Part-timepositions generally do not work out well.As part of their jobs, both employmentspecialists and SE leaders juggle a varietyof tasks and must be dedicated to the work,which is difficult to do on a part-time basis.In the SE model, SE leaders andemployment specialists provide onlyvocational services. They do not superviseor act as case managers. When they carryout dual responsibilities, they tend tolose their focus on employment and areless effective. Therefore, staff should bededicated completely to SE.Building Your Program 17 Tips for Agency Administrators and SE Leaders

Choose an SE leaderIt is important to hire or designate a leader foryour SE program. We suggest that SE leaders arefull-time employees whose time is 100 percentdedicated to the SE program.SE leaders are often mid-level managers who havethe authority to make or suggest administrativechanges within the agency. Successful SE leadershave both administrative and clinical skills. As partof their administrative responsibilities, SE leadersundertake the following: Hire and train employment specialists; Develop SE policies and procedures; Act as a liaison with other agency coordinators; Manage SE referrals; Monitor the program’s fidelity to the SE model;and Oversee various other quality control andfinancial responsibilities.As part of their clinical responsibilities, SE leadersundertake the following: Provide SE services; Provide weekly group supervision; Provide individual supervision as needed; and Give program feedback to the SE team.Below is an example of the SE leader’s jobdescription. Since SE leaders must have an activerole in setting up the structures and processesneeded to support the SE team, we encourage youto make the KIT available to candidates during thehiring process so that they will understand whatthey must do.Select the best employment specialistsThe most important characteristic of a goodemployment specialist is the belief that people withserious mental illnesses who are interested inSample job description for Supported Employment leadersOverall functionResponsibilitiesQualificationsOversees the SE program by supervising employment specialists and being the administrativeliaison to other coordinators within the mental health agency Accepts SE referrals and assigns employment specialists to work one-on-one with consumers Supervises SE team weekly using case examples and following SE principles and procedures Individually supervises employment specialists as needed Acts as liaison to other department coordinators in the mental health agency Monitors and ensures the integration of the employment specialists with treatment teams Provides SE services to small caseload (e.g., fewer than 15 people)Master’s degree in rehabilitation counseling or related fieldPrevious experience as an employment specialist helping people with serious mental illnessesobtain and sustain competitive employment is desiredPrevious supervisory experience is desiredTips for Agency Administrators and SE Leaders 18 Building Your Program

working can obtain competitive jobs and sustainthem, if the job is a good match and the rightsupports are put in place. Some agencies hireemployment specialists who go for months withouthelping consumers find work.The SE leader may hear the employment specialistsay that consumers are not motivated, employerswill not hire people with mental illnesses, or highunemployment is the problem. In such cases,employment specialists’ doubts may impedeconsumers’ success. To effectively supportconsumers in obtaining and sustaining employment,employment specialists must wholeheartedlybelieve that consumers can work.Success as an employment specialist appears tohave less to do with academic credentials and moreto do with personal style and philosophy. Positive,high-energy, and enthusiastic people who have a“can do” attitude tend to do well.As you can see from the sample job descriptionon the next page, the employment specialists’ tasksare as varied as the skills needed to complete them.Employment specialists must have these skills: Counseling skills; Skills to engage consumers and employers; Business skills to conduct job searches; and Strong interpersonal skills.Good candidates generally come either from thebusiness community or from positions in vocationalrehabilitation services where they have workedvery closely with employers. Applicants who havetraining and experience in vocational programsthat use a step-wise approach may not be goodcandidates since they may reject SE principlessuch as rapid job search.Desired qualifications are as follows: Knowledge of serious mental illnesses (includingtreatment, medication, and the impact of mentalillnesses on vocational functioning); Ability to identify consumers’ interests, strengths,skills, abilities, and unique set of challenges andmatch them with jobs; Ability to identify and arrange long-term supportsto help consumers keep jobs; Ability to advocate effectively for consumerswith team members and employers; General knowledge and experiencein job development and marketing; Demonstrated ability to relate positivelywith employers in the community; and Working knowledge of a broad rangeof occupations and jobs.Successful employment specialists are typicallytask-oriented people who are outgoing and assertiveand who have the ability to engage all differenttypes of people, including consumers, familymembers, team members, and employers.Employment specialists must also be able to workboth independently and as team members—providing cross-coverage for SE team membersand participating in group supervision.Employment specialists must also enjoy workingin the community. Employment specialists spendmore than 60 percent of the time in the communitydeveloping jobs and providing support to consumersand employers. For this reason, employmentspecialists should enjoy knocking on doors, talkingto people in their community, putting people andideas together, and doing whatever it takes to helpconsumers reach their vocational goals.Hiring employment specialists who have livedin the community and are familiar with the localbusinesses is helpful for conducting successfuljob searches.People who become good employment specialistsdo not necessarily come to the job with all theabove qualifications. Some people can acquireknowledge and skills on the job as long as theyare smart and eager to learn. Training and goodsupervision — along with the lessons learnedBuilding Your Program 19 Tips for Agency Administrators and SE Leaders

Sample job description for employment specialistsOverall functionResponsibilitiesQualificationsCarries out SE services by helping consumers obtain and sustain employment that is consistentwith their vocational goals and recovery Engages consumers and establishes trusting, collaborative relationships directed toward thegoal of competitive employment in integrated job settings Assesses consumers’ vocational functioning on ongoing basis Following SE principles and procedures, helps consumers in job development and job searchactivities directed toward positions that are consistent with consumers’ needs and interests Provides individualized, time-unlimited, follow-along services to help consumers sustainemployment Based on agreement with consumers, provides education and support to employers, whichmay include negotiating job accommodations and follow-along contact with employers Provides outreach services to consumers, as necessary, when they appear to disengage from SEservices. If necessary, maintains some contact with consumers even without a vocational focusto sustain engagement Meets regularly with treatment team members to coordinate and integrate vocational servicesinto mental health treatment Draws up individual employment plans with consumers, case managers, and other treatmentteam providers and updates the plans quarterly Spends at least 60 percent of direct service time in the community to engage and supportconsumers, family members, and employers Carries out other duties as assignedEducation and experience equivalent to undergraduate degree in mental health or social services,business, personnel management, or vocational servicesExperience working with people with serious mental illnesses, experience with vocational services,and knowledge of the work world are preferredAbility to work as an effective team player is essentialthrough day-to-day experience — help mostemployment specialists develop the skills andconfidence to do a good job.Consider hiring a benefits counselorHistorically, practitioners encouraged consumers tolimit working to protect their benefits. However, formost consumers a life spent on benefits means a lifespent in poverty. In most cases, consumers arebetter off financially if they work and takeadvantage of available work incentives. For thisreason, it is important that consumers have accurateinformation to make informed choices.In general, employment specialists and otherpractitioners may know that rules govern benefitsand earned income. But in most cases, theirinformation is not comprehensive. The rules arecomplicated and periodically adjusted, making itdifficult to keep up to date with the information.This is why many agencies create benefits specialistpositions. Benefits specialists have comprehensiveinformation about benefits and work incentives.They meet with consumers who are consideringgoing to work to review their benefits and projecthow work will affect them. They also providepersonalized benefits planning to help consumersmanage their benefits and health care coverageas they work more and increase their earnings.Tips for Agency Administrators and SE Leaders 20 Building Your Program

Some evidence shows that consumers who receivedbenefits counseling tend to earn more money thanconsumers who did not.If your agency is unable to hire a benefits specialist,look for other ways that consumers can accessbenefits counseling. For example, the SocialSecurity Administration funds benefits counselingservices in all 50 states through the Work IncentivesPlanning and Assistane (WIPA) projects. Contactyour state WIPA project for more information.Visit DisabilityInfo.gov or ask your mental healthauthority for other resources in your area.Reflect your community’s cultural diversitySE teams should reflect the cultural diversityof the communities in which they operate. Moreimportant, employment specialists must be awareof and sensitive to cultural differences andconsumer preferences. SE teams should reflect thecultural diversity of the communities in which theyprovide services, and they should include bilingualemployment specialists as needed.Having a balance of male and female employmentspecialists may also be helpful. Your SE programmust also have resources available to allowemployment specialists to work with consumerswho have hearing and visual impairments.Consider these hiring tipsYou should thoroughly check references for jobcandidates. The best predictor of work performanceis likely to be candidates’ performance in previousjobs, particularly jobs that required some of thesame skills and personal qualities that are desirablefor employment specialists. The SE leader shouldtalk to previous supervisors, ask in detail aboutcandidates’ previous work responsibilities andperformance, and seek opinions about theircapabilities. If candidates have had little experiencein the mental health field or have just finishedschool, you can gather valuable information fromfield supervisors, training mentors, and teachers.Invite all candidates who are being seriouslyconsidered for employment to spend half a dayor more in your SE program so that they can seeemployment specialists at work firsthand.Candidates can then better evaluate how well theymight fit in and be able to make a more informeddecision about taking the job. This visit will alsogive employment specialists a chance to talk withand observe candidates. Ask them to offer theirfeedback during the hiring process. This type ofscreening may help you weed out people who maybe too authoritarian or patronizing to beappropriate for an SE program.Build support for yourSE programDeveloping successful SE services depends onthe support and collaboration of a number ofstakeholders. Internally, it is important that yourdirector and staff across the agency understandand support the implementation of SE. Your SEprogram is more likely to achieve high fidelity ifyour agency director is informed and involvedin the implementation process from the start.It is important that your agency director take thelead in promoting the SE program and addressingany misconceptions that consumers cannot work.Your agency director should articulate internal andpublic support for your SE program by telling keystakeholders that people with mental illnesses cansucceed in competitive employment and that SEservices are linked to positive consumer outcomes.Emphasize the importance of your SE services bydemonstrating how work helps consumers get onwith life beyond illness to achieve their personalrecovery goals.Building Your Program 21 Tips for Agency Administrators and SE Leaders

Once your agency director has articulated a clearvision for implementing SE, bolster internalsupport for your SE program by providing basicinformation to all agency staff. For moreinformation, see Develop a Training Plan laterin this booklet.Form advisory committeesForming an SE advisory committee is an effectiveway to gain the support of key stakeholders for yourSE program. Identify community stakeholders withan interest in the success of your SE program toserve on your committee. Committees ofteninclude the following personnel: Representatives from your local consumerorganizations; Members of your local family organizations; Designated vocational rehabilitation counselors; Representatives from your local mental healthauthority; Key agency staff; and SE staff.Consider also establishing a Business AdvisoryCouncil to engage and elicit feedback from localemployers. Use the forum to educate employersabout the benefits of hiring people with disabilities.Inform them that SE services can providethe following: A pool of interested and qualified applicants; Prescreening of potential applicants to assesstheir skills and strengths for available positions; Short-term, onsite job coaching to help newemployees become situated; Guidance about reasonable accommodations; and Information about the Work Opportunities TaxCredit that reduces their federal income taxliability.To start, your mental health authorityrepresentative or agency director should voicesupport for the SE initiative. Next, basic trainingshould be provided to help advisory groupmembers understand the SE model. Onceestablished, advisory groups may help implementSE in a variety of ways. For more information,see Getting Started with Evidence-Based Practicesin this KIT.Sustain support for your SE programBuilding support for your SE program shouldbe an ongoing effort. Once your SE program isoperational, find ways to recognize and rewardthe achievements of SE staff and consumers. Forexample, organize meetings with key stakeholderswhere consumers share employment success storiesand administrators highlight staff achievements.Another option is to sponsor an employmentbanquet to celebrate the program’saccomplishments with consumers, family members,employers, and agency staff members. Banquetsare particularly helpful if a wide array ofstakeholders (such as physicians, administrators,and key public officials) attend.Your agency director and SE leader should meetregularly to review program evaluation data,discuss roadblocks, and plan ways to improve yourSE program.Tips for Agency Administrators and SE Leaders 22 Building Your Program

Develop a collaborative relationship withyour local vocational rehabilitation agencyMany agencies collaborate with the rehabilitationservices administration (also known as vocationalrehabilitation) to provide SE services. Vocationalrehabilitation and mental health agencies share thegoal of helping people with disabilities return towork and increase their independence.Historically, the two state systems have not alwayscollaborated in a way that provides seamless andcoordinated services for consumers. If this is thecase in your state, your SE initiative presentsa new opportunity to build an effective workingrelationship with your local vocationalrehabilitation agency.Collaborations may bring added resources andservices. For example, vocational rehabilitationcounselors may provide the following: Training; Additional job shadowing; Job-related equipment and supplies; School tuition; Planning assistance; or Assistance with placement and support.Work with your agency director and mental healthauthority representative to engage local and statevocational rehabilitation representatives early in theimplementation process. Share information aboutSE and invite them to participate in your SEadvisory group.Understanding the guidelines and practices of eachother’s systems will close the gaps that have formedbarriers and create new ways of working togetherto provide more effective services for consumers.Agencies with effective relationships withtheir local vocational rehabilitation agencycommunicate regularly with designated vocationalrehabilitation counselors. Often counselors areincluded on consumers’ treatment teams. OtherSE programs also arrange for counselors to meetweekly or biweekly with consumers at the mentalhealth agency.In summary, building support from internal staffand key community stakeholders for your SEinitiative is essential to implementing effectiveSE services.Agency directors can lead this effort• Articulating clear support for the SEprogram to internal staff and keycommunity stakeholders• Attending some SE trainings, supervision,and advisory group meetings• Meeting monthly with the SE leaderto address roadblocks to providing SE• Facilitating ongoing planning and programimprovement efforts• Engaging local and state vocationalrehabilitation agency representativesBuilding Your Program 23 Tips for Agency Administrators and SE Leaders

Develop effective policiesand proceduresStarting a new SE program means developingpolicies and procedures that support the activitiesof the SE model.What policies and proceduresshould cover• Admission criteria• Discharge criteria• Staffing criteria• Program organization and communication• Assessment and treatment planning criteria• Consumer records requirements• Consumers’ rights• Program and team memberperformance evaluationDevelop admission criteriaWhen you develop your SE admission criteria,integrate the principles of the SE model. The SEmodel includes specific criteria that you shouldintegrate into your admissions and dischargecriteria. The SE model indicates that servicesshould be accessible to as many consumers aspossible. Consumers should not be excluded fromSE services because of substance abuse or cognitiveimpairments or because they are not “ready towork.” According to SE principles, all consumerswho want to work are eligible—no one is excluded.Develop a simple referral process using minimaleligibility criteria. Typically, SE leaders receive allreferrals, review them, and pair consumers withemployment specialists. This process should occurrapidly. In the SE model, employment specialistsand consumers meet within one week after thereferral. Engaging consumers in SE services quicklyhas been found to be a key component in providingeffective SE services.Once you have developed your referral process,integrate it into your intake procedures so thatconsumers who are new to your agency know thatSE services are available. SE staff and intakespecialists should review how to explain the SEprogram to consumers in a way that helps themmake informed decisions about accepting services.Generating referrals takes some planning andeffort at first. All of the activities designed tobuild support for your program (described inthis booklet) can also help you generate referrals.Acquaint a variety of stakeholders with yourreferral process including these individuals: All staff in your agency; SE advisory committee members; and Consumers in your agency.The key to generating referrals is to get the wordout. Elicit ideas from your SE advisory groupand staff for engaging consumers and increasingreferrals. On the next page is an example of anSE referral form that you may use as a basis forcreating your own.Tips for Agency Administrators and SE Leaders 24 Building Your Program

Sample Supported Employment Program Referral FormConsumer’s nameConsumer’s I.D.numberTelephone (______) ______ --__________ Date of referral ____/___/_____Referral sourceDate referralwas received____/___/_____Assigned toDate of first meeting withemployment specialist ___/___/______ Date Employment Plan was completed ____/___/_____Job suggestions andrecommendations forwork environmentsMedications and sideeffects, if any, thatmight interfere withwork such as shaking,memory impairment,drowsiness, etc.Substance use(substances, current use)Criminal history (if any)Any information youfeel would help thisperson reach his or heremployment goalsBuilding Your Program 25 Tips for Agency Administrators and SE Leaders

Develop discharge criteriaWhen you develop your SE discharge criteria,integrate the principles from the SE model. Someconsumers struggle with symptoms that persist overtime, so their optimal treatment and rehabilitationrequire a long-term commitment. For this reason,despite their vocational success, consumers whoreceive SE services are never terminated unlessthey directly request it. In your SE dischargepolicies and procedures specify that follow-alongsupports should be provided to consumers on atime-unlimited basis.Establish staffing criteriaYour SE policies and procedures should also specifythe staffing criteria for your program. Generally, SEteams should plan on having an employmentspecialist-to-consumer ratio of no more than 25consumers per employment specialist.Once your program is fully operational, continueto monitor the staff-to-consumer ratio. If youexceed the maximum number of consumers,work effectiveness will break down andemployment specialists will react to crises(or the imminent threat of crises) rather than helpconsumers take proactive steps towards achievingtheir vocational goals.Create useful job descriptionsInclude clear and useful job descriptions withinthe staffing criteria of your SE policies. For jobapplicants, a good position description clarifieswhether a particular position matches their skillsand expectations. Develop task-specific positiondescriptions, outline the main task categories, anddetail specific duties.Clear job descriptions allow SE leaders to effectivelysupervise new employees and also allow employeesto focus on the basic elements of their jobs.To figure your program capacity:Total number of employment specialists= 2 FTEMaximum number of consumers per practitioner = 25:12 FTEX 25 consumers per employment specialists50 maximum program capacityYou may consider decreasing this ratio in the firstyear of implementation. Make sure your staff-toconsumerratio is small enough to ensure that allemployment specialists learn how to practice highfidelitySE. No matter how well a team is organizedor how competent employment specialists may be,the team will be unable to achieve high-fidelitypractice if its caseload is too large during thefirst year.Discuss program organization andcommunicationSE policies and procedures should include criteriafor how the SE program is organized and howemployment specialists relate to one another. To beeffective, employment specialists must be able towork both independently and as team members.As members of the SE team, employmentspecialists should communicate regularly andprovide cross-coverage for consumers.Employment specialists should also attend weeklySE group supervisory meetings. These meetingsgive employment specialists the opportunity todiscuss and problem-solve consumer cases.Tips for Agency Administrators and SE Leaders 26 Building Your Program

In addition to group supervision, employmentspecialists should meet weekly to share job leads,which are often obtained through networking.Instruct employment specialists to keep anemployer log to track the businesses they contact.In this meeting, SE staff can review the employer logand plan ways to build more employer relationships.Your SE policies should also outline clearprocedures for how SE staff will communicatewith other treatment team members. SE servicesare most effective in an environment whereemployment specialists are part of a clinicaltreatment team that communicates frequentlyand meets weekly. Close coordination of SEservices with other mental health rehabilitationand treatment ensures that everyone involved(not just employment specialists) provides servicesthat support consumers’ vocational goals.Employment specialists can work on severalmultidisciplinary treatment teams. However, if theywork on more than two teams, they generally haveto spend too much time in meetings or don’t havethe chance to adequately communicate with otherteam members.Treatment teams are organized differently from oneagency to the next. Some teams quickly run throughthe list of consumers they serve, communicatingwith team members about employment and clinicalissues. Other treatment teams just shareinformation about crisis situations. In the latter kindof meeting, time must be set aside and guarded bythe team leader for proactive communication aboutemployment. Additionally, employment specialistsmust actively participate and speak duringtreatment team meetings.Integrating SE services with mental healthtreatment may be more challenging if employmentspecialists and other team members work fordifferent agencies. Seek creative solutions to ensurethat employment specialists are able to meet weeklyand communicate frequently with consumers’clinical treatment teams.Involve significant othersSE policies and procedures should encourage andfacilitate involving family and other supporters tohelp consumers increase their natural supports.Instruct employment specialists to ask consumersto identify a family member or other supporterwhom they would like to involve in SE services.Involving family or other supporters helpsemployment specialists to do the following: Clarify consumer interests, strengths, skills,and abilities; Identify job leads; Determine whether a potential job is a goodmatch; Identify challenges consumers are facing on thejob; and Provide ongoing support to working consumers.With consumers’ permission, family or othersupporters may join meetings with the consumerand employment specialist, meet or talk with theemployment specialist alone, or attend treatmentteam meetings.Building Your Program 27 Tips for Agency Administrators and SE Leaders

Develop assessment and treatmentplanning criteriaOutline procedures for assessment and treatmentplanning in your SE policies and procedures.In general, SE staff use two tools to assess andtrack consumers’ goals and progress: Vocational Profile; and Individual Employment Plan.Employment specialists and consumers completethe Vocational Profile within a few weeks afterconsumers are referred to the SE program.Information collected on the Vocational Profilehelps employment specialists begin the jobsearch rapidly.Starting the job search within one month has beenfound to be a key component of providing effectiveSE services. Procedures for completing theVocational Profile should specify that the formdoes not need to be fully completed for the jobsearch to begin. In others words, the job searchshould not be delayed in order to completethe form. Employment specialists should addinformation to the form as it becomes available.Procedures should also instruct employmentspecialists to collect information from a varietyof sources: The consumer; The treatment team; The consumer’s record; and With permission, the consumer’s family membersand previous employers.On the next several pages are examples ofa Vocational Profile form and an IndividualEmployment Plan.Tips for Agency Administrators and SE Leaders 28 Building Your Program

Sample: Vocational ProfileVocational ProfileConsumer’s nameConsumer’s I.D. numberCompleted by Date completed __/___/___Work goalConsumer’s work goaland life dream for workWhat would you say is yourdream job? What kindof work have you alwayswanted to do?Consumer’s short-termwork goalWhat job would you liketo have now?Dream job:Job you’d like to have now:BackgroundEducationWhat school did youattend last?What was the highestgrade you completed?Last school attended:Highest grade completed:Work historyMost recent jobWhat was your mostrecent job?What were the job duties?Reason for leaving jobMost recent job: _________________________ Job title: __________________Job started: ____/___/_____ Job ended: ____/___/_____Number of hours worked per week: _________Job duties:Why did the job end?Positive experiencesWhat did you like bestabout the job?Problems on jobWhat did you not likeabout the job?Building Your Program 29 Tips for Agency Administrators and SE Leaders

Vocational ProfileWork history continuedNext most recent jobWhat did you like bestabout the job??What were the job duties?Reason for leavingthe jobPrevious job: _________________________ Job title: __________________Job started: ____/___/_____ Job ended: ____/___/_____Number of hours worked per week: _________Job duties:Why did the job end?Note: Attach resume tocapture additionalwork history.Current adjustmentDiagnosisProdromal symptomsWhat are the first signs thatyou may be experiencing asymptom flare-up?How would I be able to tellif you are having a bad dayor not feeling well?Coping strategiesWhat do you do to makeyourself feel better?Medication managementWhat medication do youtake and when do youtake it?Physical healthHow would you rate yourphysical health?Do you have any physicallimitations that mightinfluence your work? Whatare they?EnduranceHow many days per weekwould you like to work?How many hours a day?First signs of a flare-up:Signs of a bad day:Medication: ______________________________ When you take it: _____________Medication: ______________________________ When you take it: _____________Medication: ______________________________ When you take it: _____________ExcellentGoodFairPoorPhysical limitations:Most number of days per week: _________Most number of hours per day: _________Tips for Agency Administrators and SE Leaders 30 Building Your Program

Vocational ProfileCurrent adjustment continuedGroomingDo you have a place tobathe or shower?Do you have the clothesyou will need for work?Interpersonal skillsHow well do you get alongwith people?YesNoYesNoExcellentGoodFairPoorWork skillsJob-seeking skillsHow have you looked forwork in the past?Specific vocational skillsWhat skills have youlearned either on the jobor in school?AptitudeWhat kind of work are youparticularly good at?Interests and dailyroutineWhat kinds of things doyou like to do?What is a typical day likefor you?Motivation andexpectationsWhat appeals to you aboutwork?What do you not like aboutwork?Are there things that youworry about regardinggoing back to work?What do you think workwill do for you personally,financially, and socially?Building Your Program 31 Tips for Agency Administrators and SE Leaders

Vocational ProfileWork skills continuedWork habitsHow was your attendancein previous jobs?What kinds of situationsand tasks cause you tofeel stress?Support networkWhom do you spendtime with?How often do you seeor talk to them?What do they thinkabout work?How could they supportyour work goals?Current living situationWhere do you live andwith whom do you live?TransportationHow would you getto work?Substance useHave you ever used streetdrugs or alcohol?Have other people in yourlife been concerned aboutyour substance use?Criminal recordHave you ever beenarrested?Disclosure of mentalillnessWill you be willing to tellpossible employers aboutyour illness?Income and benefitsWhere does your moneycome from?Person you spend time with: ________________________ How often: __________Person you spend time with: ________________________ How often: __________Person you spend time with: ________________________ How often: __________Where you live: ____________________________________________________________________________________________________________________With whom? ____________________________________________________________________________________________________________________YesNoYesNoYesNoYesNoWhere your money comes from: __________________________________________________________________________________________Tips for Agency Administrators and SE Leaders 32 Building Your Program

Vocational ProfileWork skills continuedWhat medical benefits doyou get?Do you manage your ownmoney?Do you know how earningsfrom work will affect othersources of income andmedical benefits?Have you spoken with abenefits counselor? If not,would you like to?What medical benefits?YesNoYesNo Yes No Would you like to? Yes No____________________________________________________________________________________________________________________________________________________________________________________The second tool is the Individual EmploymentPlan; an example of it is on the next page.Similar to the Vocational Profile, this form shouldbe completed in the first few weeks afterconsumers are referred to the SE program.Completing the form should not slow down thejob search. Instead, you may add informationto the Individual Employment Plan as itbecomes available.Building Your Program 33 Tips for Agency Administrators and SE Leaders

Sample Individual Employment PlanIndividualEmploymentPlanConsumer name ______________________Completed byI.D. numberDate: __/___/___Overall vocational goal:Objective 1InterventionPeople responsibleTarget dateDate objective achieved__/___/_____/___/___Objective 2InterventionPeople responsibleTarget dateDate objective achieved__/___/_____/___/___Date job search began__/___/___Employers contacted Employer Date contacted__/___/_____/___/_____/___/_____/___/_____/___/___Tips for Agency Administrators and SE Leaders 34 Building Your Program

We strongly encourage you to adapt these formsand incorporate them into your routine paperwork.For printable copies, see the CD-ROM for thisKIT. For a more detailed discussion of theassessment and treatment planning process,see Training Frontline Staff in this KIT.Describe how to maintainconsumer recordsIn your SE policies and procedures, describehow you will maintain consumer records.You must maintain records for each consumerand safeguard them against loss, tampering,and unauthorized use. The records should beconsistent with the Joint Commission (formerlyknown as the Joint Commission on Accreditationof Healthcare Organizations) and Centers forMedicaid and Medicare Services requirements.If you are creating a new recordkeeping system,you will need materials to create records (forexample, binders and forms) and to store themappropriately. You also need written policies andprocedures for documenting and maintainingrecords. Educate your SE team and supervisethem in completing the required documentation.Discuss how to ensure consumers’ rightsIn your SE policies and procedures, discuss howyou will ensure that consumers’ rights are upheld.Employment specialists should be aware of thestate and federal consumer rights requirements,especially the Americans with Disabilities Act (ADA).For more information, visit DisabilityInfo.gov.Furthermore, your SE policies and proceduresshould reflect the model’s recovery orientation.Traditional services were developed with abiomedical approach to mental health treatment;they focus on reducing symptoms and preventingrelapse. In contrast, the SE model is based on theconcept of recovery. In the recovery framework,the expectation is that consumers can live a lifein which mental illness is not the driving factorfor their lives. Recovery means more than“maintaining” people with mental illnesses in thecommunity. Recovery-oriented services encourageconsumers to define and fulfill their personal goals,such as a goal to work.Employment specialists must believe in and betrue to the recovery principles within the SEmodel. SE teams should be careful not to replicatethose elements of traditional services that simplyemphasize containing symptoms and complyingwith medication.The value of consumer choice in service deliveryand the importance of consumer perceptions mustbe infused in how you provide SE services. Mostpractitioners have never examined their ownattitudes and behaviors about consumer recoveryand, therefore, uncritically accept many clinicaltraditions without paying attention to howdisempowering these practices are for consumers.In recovery-based SE services, establishinga trusting relationship is critical. Interactionswith consumers should be based on mutualityand respect. Employment specialists should be challenged tolisten to, believe in, and understand consumers’perspectives and take into account consumers’reasons for “noncompliance.” Employment specialists should also focuson consumer-defined needs and preferencesand accept consumer choice in service delivery.SE services provided with a recovery orientationmean that employment specialists put more effortinto supporting and empowering consumers toachieve their individual goals.Building Your Program 35 Tips for Agency Administrators and SE Leaders

How administrators and SE leaderscan help provide recovery-orientedSE services• Clearly explain consumer rights in SE policiesand procedures• Offer training on recovery principles andconsumer rights• Hold community forums using themultimedia tools in this KIT• Involve consumers in local advisory groupsDevelop procedures to evaluate programand team member performanceWhen properly implemented, SE services areassociated with a variety of positive outcomes.For example, consumers in SE programs weremore likely to achieve these goals: Obtain competitive work; Earn higher wages; Work more hours; Show improved symptoms; Show improved self-esteem; and Express satisfaction with their finances.Evaluating the performance of your SE programwill help you provide high-quality services toconsumers and assure stakeholders of the effectiveperformance of your SE program. We recommendthat you develop procedures to evaluate your SEprogram early using the guidelines in EvaluatingYour Program in this KIT.Additionally, you should develop procedures for howyou will supervise and evaluate the performance ofyour SE team. To a large extent, clinical supervisionis the process that will determine whether your SEteam will simply be a group of mental healthprofessionals doing what they’ve always done orwhether they will truly change and provide servicesin an evidence-based way.We recommend that SE leaders supervise the SEstaff weekly. Group supervision should review allconsumers involved in the SE program andproblem-solve ways to help them better meettheir individual goals.Because SE leaders dedicate some time to directservices, they will be familiar with all of the partsof providing SE services. SE leaders will not justreview “cases” that employment specialists present,but will also be able to actively problem-solve usingSE principles and techniques. SE leaders alsoprovide individual, side-by-side supervision,as follows: To assess performance; To give feedback; and To model interventions.SE leaders may schedule regular meetings withemployment specialists to review specific cases.They should be regularly available to consult withemployment specialists, as needed.Some aspects of the employment specialist’s jobare hard to understand without seeing them doneby an experienced practitioner. Once SE leadersthoroughly understand the SE model, they shouldtake employment specialists out into the fieldto model aspects of the job—such as jobdevelopment—and directly coach them in theirwork. For training tools and recommendations,see Training Frontline Staff in this KIT.If the SE team is working with a consultant, theSE leader should involve the consultant in groupsupervision, treatment team meetings, and jobdevelopment meetings. In many new SE programs,it has been found that feedback from an externalconsultant is a crucial component for improvingstaff performance and the quality of the programas a whole.Tips for Agency Administrators and SE Leaders 36 Building Your Program

Develop a training planDeveloping an SE team is a complex undertaking.Recruiting and retaining employment specialistswho know the SE model or who know how to treatconsumers can be difficult. Agencies that havesuccessfully implemented an SE program indicatethat offering one-time training for employmentspecialists is not enough. Instead, you shouldassess the knowledge level of key stakeholders(See Evaluating Your Program) and developa training plan.What should your trainingplan include?• Basic training for key stakeholders, includingconsumers, families, mental health authorities,and members of key community organizations• Basic training for staff at all levels acrossthe agency• Intensive training for employment specialists• Basic training on benefits and work incentivesPractitioners who implement evidence-basedpractices (EBPs) are often stymied in their effortsbecause people misunderstand the model or lackinformation. It is important that key stakeholders(consumers, families, and other essentialcommunity members) and agency-wide staffdevelop a basic understanding of SE.This training will build support for your SEprogram. Your SE staff will find that they are betterable to generate referrals for their SE program,develop job leads, and provide job supports. Sinceeffective SE services depend on integrating SE andclinical services, it is important for all members ofthe treatment team to have a basic understandingof the SE model.Additionally, consumers, families, and other keystakeholders may hold misconceptions aboutconsumers’ ability and desire to work or how workmay affect their benefits. It is important to correctfalse beliefs before they impede implementing yourSE program. Consider organizing routineeducational meetings for consumers, families, orother key stakeholders in which consumers whohave received SE services or employers who havehired consumers through an SE program sharetheir experiences. For materials to support thisbasic training, see Using Multimedia to IntroduceYour EBP. You will find these resources: An introductory PowerPoint presentation; A sample brochure in both English and Spanish;and The introductory video.Once trained, SE leaders and employmentspecialists will be able to use these materials toconduct routine community workshops and inserviceseminars. Furthermore, the SE KITincludes Training Frontline Staff, which givesemployment specialists in-depth information aboutthe SE model and skills for providing SE services.SE leaders may facilitate a structured grouptraining using these materials.Once employment specialists have a basicunderstanding of the model, we recommend thatthey visit an existing, well-functioning, high-fidelitySE team to observe how employment specialistswork with consumers and how they interact withone another.In addition to in-depth training on the SE model, wealso suggest that you offer basic training on benefitsand work incentives to employment specialists andother practitioners. Employment specialists shouldbe able to define the following terms: Medicaid and 1619B Medicaid; Medicaid for the Working Disabled; Medicare;Building Your Program 37 Tips for Agency Administrators and SE Leaders

Supplemental Security Income (SSI); Social Security Disability Insurance (SSDI); Plan for Achieving Self-Support (PASS); Impairment-Related Work Expense; Substantial Gainful Employment (SGA); Ticket to Work; Expedited reinstatement for benefits; and The Department of Housing and UrbanDevelopment (HUD) mandatory earned incomeinclusion.Rules about benefits are complicated and areperiodically adjusted, which makes it hard to stay upto date. Resources are available to help you developand maintain your staff’s knowledge about benefits.Consider regularly offering training on benefitsto help SE staff stay as current as possible. Contactthe Social Security Administration to find trainingresources. The Social Security Administrationhas Area Work Incentive Coordinators (AWICS)in every state, and many local Social SecurityAdministration offices also have Work IncentiveLiaisons who can provide training and consultationto agencies and staff. Visit DisabilityInfo.gov formore information.Another resource is the Social SecurityAdministration’s Redbook. Use it as a referenceguide for SSDI and SSI. To see the Redbook online,go to www.ssa.gov/work.Hire an external consultant and trainerEstablishing the initial processes that must bein place to provide quality services requires greatattention to detail. Consequently, during the first1 to 2 years after forming a new SE team, manyagencies have found it helpful to work with anexperienced external consultant and trainer.Consultants and SE leaders often work togetherover the 2 years to ensure that the SE programis structured appropriately. They integrate SEprinciples into the agency’s policies and tailorSE program procedures to meet local needs.Once the program has been launched, it isimportant that you do not allow employmentspecialists to revert to older and more familiar waysof doing things. External consultants and trainerswho are experienced in running SE programs canprovide ongoing technical assistance, side-by-sidesupervision, and periodic booster training sessions.This type of assistance, along with ongoingevaluation of fidelity and outcomes, has beenfound to be critical in maintaining adherenceto SE practices.Select a location for yourSE programAlthough employment specialists will spend 60percent or more time in the community, sometimesthey will meet with consumers in your agency.For this reason, it is important for employmentspecialists to have a place to meet with consumersand to have access to a desk, a phone, voice mail,and a computer that includes Internet capabilities.Voices of Experience 38 Building Your Program

Office space should not be separate from the restof the clinical treatment team. Ideally, the officesare intermingled and the space is consistent withhow space is allotted for other team members.Touching base in the hall and lunchroom withother treatment team members providing SEservices facilitates ongoing communication thatsupports the goals of SE.Additionally, access to a cell phone for outreachwork can increase safety and improvecommunication. Marketing materials such asbusiness cards and a SE brochure also facilitatejob development activities. See Using Multimediato Introduce Your EBP in this KIT for a sampleSE brochure.Review your SE program budgetand revenue sourcesIt is important for you to understand your SEprogram budget and revenue sources so that youcan actively participate in the budgeting process,make informed management decisions, andunderstand where collateral revenue sources aremost needed.In some mental health systems, SE programsreceive a fixed rate for each consumer who receivesservices. In other systems, SE programs are onlyreimbursed based on the specific services provided.In that case, you should be familiar with howservices must be tracked to capture billing fromvarious funding streams. You will also need to knowthe billing process and billing codes.Financing mechanisms for SE vary from agencyto agency. The leaders of numerous agenciesand systems have successfully established waysto fund SE services using Medicaid, vocationalrehabilitation funding, and other sources.In some states, mental health authorities haveworked out a mechanism to pool funds that canbe used to reimburse the services of SE programs.Also, state Medicaid rules may allowreimbursement for selected SE activities.Financial barriers can slow implementation.Consulting with agencies and system administratorswho have been successful in this area can give youuseful ideas and strategies.Consider how implementing SE will affectthe agency. Will some types of services be reduced oreliminated in order to pay for your SE program? What will the impact of decreased groupattendance be when consumers go to work? Will evening hours be needed?Be aware that over time the mission and activitiesof programs can become defined by the fundingthat supports them. Know the principles of SEand be vigilant that funding opportunities supportthe model rather than shape and corrode it.In summary, building an effective, well-functioningSE team is a developmental process. We encourageyou to periodically revisit the information in thisKIT throughout the first year after starting yournew program. We believe that these materialswill take on a new meaning as the process ofimplementing an SE program evolves.Building Your Program 39 Voices of Experience

DHHS Publication No. SMA-08-4364Printed 200924771.0409.7765020404