Ask a Question

Frequently Asked Questions about IPS Supported Employment

New Questions
Managing Caseloads
Competitive Employment
Helping People with Substance Use Disorders
IPS vs. Supported Employment
Rapid Job Search
Assessment
Zero Exclusion
Scope of Employment Specialist’s Duties (Vocational Generalist)
Outcomes
Job Development
Job Supports
Disclosure
Vocational Unit
Fidelity Reviews
Benefits Planning (Medicaid)
Program Implementation
Engagement
Supervision of IPS
Education
Collaboration with Vocational Rehabilitation
========================================
New Questions (Beginning April 23, 2012)

Question: How often should an employment specialist or employment support worker be mentored by someone?  Should this be their manager?  We have forms to record this, do you have any other suggestions?

Answer: Minimally, an IPS supervisor would provide monthly mentoring for job development (developing relationships with employers) to new employment specialists or those who are having difficulty in this area.  But many supervisors report that they continue to provide field mentoring monthly or quarterly because it helps them to continue to learn about employer relationships and changes in the workplace and also because they can share good strategies from one employment specialist to another.

IPS supervisors also provide other types of field mentoring, for example, if an employment specialist reports that he and a job seeker are having trouble thinking of good job matches, the supervisor would attend the next appointment with the employment specialist.  Supervisors also help employment specialists engage new clients and they demonstrate how to work on the career profile.

Working side-by-side with employment specialists is an effective teaching tool because supervisors can model the techniques they would like specialists to use.  In addition, this helps IPS supervisors meet many of the people on the IPS caseload so that they can provide better supervision.

Question: To reach the standard of at least 6 employer contacts per week, how much time is suggested for the planning, undertaking and then recording of this.

Answer:  Many employment specialists report that they schedule two to three blocks of time (90 minutes to two hours) to meet with employers each week.  Experienced employment specialists understand that they may visit 10 or 12 employers in order to have in-person contact with six people who have hiring authority.

We recommend that employment specialists document employer contacts as they occur.  While meeting with employers to learn about their businesses, employment specialists can take notes directly on employer contact logs that will become part of the client’s employment records.  Or, if an employer contact is brief, they can document what happened after they leave the business.  Employers tend to share detailed and important information, so it is best for employment specialists to write it down right away.

Question:  Recently I assisted a client who is an emerging artist to register with a variety of Christmas craft fairs in her community to sell her wares. This is in keeping with her employment goals. Is this IPS? Does it count as a regular/seasonal job?

Answer: Yes, this would count as a short-term job.  As she continues to try to earn money as an artist, you might occasionally ask her if she is getting enough work, or if she would like to revisit her goal.

Question:  We are currently conducting  the first fidelity review for 3 IPS programs that began in March 2013. At one of these sites there has been 7 jobs obtained however at the others only 1 or 2. I am seeking advice on how to score the items under the services section of the scale ‘Diversity of job types’, ‘diversity of employers’, ‘competitive jobs’, ‘individualised follow-along supports’ and ‘time unlimited follow along supports’. Do all of these items get scored a 1 until more jobs are obtained? Is there a minimum number of jobs required before these items can be scored.

 Answer:  If there is one employment specialist in the IPS program and fewer than 5 job starts, or two employment specialists and fewer than ten job starts, score the items as follows:

 Diversity of job types:  Score the item “1.”

 Diversity of employers:  Score the item “1.”

 Competitive employment:  Score the item based on the jobs that have been obtained, as well as jobs for which employment specialists have been helping clients apply.

 Individualized follow along supports:  Score based on whether job supports provided are unique to each person’s job, preferences, and needs.

 Time-unlimited follow along supports:  Score the item “1.”

 Going forward, you might consider waiting at least six months before facilitating the baseline fidelity review.  Many program staff report that they appreciate time to participate in IPS training so that they have some accomplishments to show during the first review.

Question:  How do you go about interviewing employers (talking with them about their business needs and hiring preferences)?  Are there certain questions to ask?  Do you wing it?

 Answer:  There are some questions that many employment specialists find to be effective.  You can find a list of those questions in the new practitioner manual, IPS Supported Employment: A Practical Guide (Note: the book will soon be available on our website on the Resource page).  Chapter 4 includes step-by-step instructions for building relationships with employers and includes sample questions, an example of a conversation between an employer and employment specialist, a sample thank-you note, etc.  Another resource is videos of employer meetings.  To find those, go to the Resources & Tools page of this website, select Videos, select Job Development.

 We encourage employment specialists to prepare for meetings with employers by learning a little bit about the company and selecting five or six questions to start the conversation with an employer.  Be sure to avoid asking about job openings.  The purpose of this conversation is to learn more about the employer–if you ask about openings and there are none the employer may feel that there is no point in continuing with the conversation.  Instead, focus on understanding the type of job applicant the employer would like to meet.  You can return a few days later to say, “I have had time to consider your need for workers who have good customer service skills and who are available to work on Sundays.  I think I do know someone who matches that description.  Would you like to hear a little bit about her?”

Question: I recently received some questions surrounding ethical issues and IPS supported employment.  Specifically, the employment supervisor was looking for some sort of “ethical guidelines” for Employment Specialists.  When I asked for examples of specific situations, the following are the two examples I was given:  An IPS client with a psychotic disorder and experiencing command hallucinations to harm or kill children, wanted a job in child care.  Another client of IPS was stealing from elderly patients for whom she worked as a home health care aid.  While I understand these are very extreme examples that stretch beyond ethical issues and into legal issues, I would appreciate any input you could offer.

Answer:  The person experiencing command hallucinations should not be helped with a job in child care.  Employment specialists follow the same guidelines as mental health practitioners when public safety is a concern.  We advise employment specialists to immediately seek consultation with mental health supervisors and psychiatrists who are also working with the person when there are safety concerns.

In regard to the person who is stealing from nursing home residents, because the residents are a vulnerable population, the employment specialist must report the thefts to adult protective services.  The specialist should do that immediately and discuss with her supervisor about meeting with her client, possibly with the IPS supervisor present, to explain her obligation.

Question: I work at a state psychiatric hospital which serves the adult population and also has a forensic population.  We have a work program that has been dormant for some time, but we are now in the process of expanding and re-developing the program to assist the patients in gaining on-campus (or off-campus) employment in preparation for their transition to the community.  We would like to develop this program to match the IPS model as closely as possible.  What resources or training opportunities would you suggest in order to appropriately develop this program for our institution?

Answer: To learn about the IPS approach, we suggest some of the free resources on our website (see “About IPS”).  There you will find descriptions of the practice.  Under “Resources” you can find demonstration videos.  We also offer an online course for IPS supervisors and practitioners three times each year.  The next course will be offered beginning September 23.  A description of the course is on our website.  In late June, an updated version of a practitioner’s manual will be available from our website.   Finally, program administrators may be interested in Individual Placement and Support, An Evidence-Based Approach to Supported Employment by Drake, Bond, and Becker, published by Oxford Press.

Question:  I am wondering if an IPS supported employment supervisor with four full-time employment specialists and one part-time peer could also take on the role as lead Microenterprise worker. The lead microenterprise worker would help people set up small businesses that need very little capitol (less than $500) in start-up funds.  The businesses are related to each person’s interests—often expanding someone’s hobby into a way to earn money.  I also wonder how the microenterprise fits with the IPS approach.   

Answer:  Self-employment falls under the definition of competitive employment in IPS because it is work that many people do regardless of disability status.  We encourage employment specialists and supervisors to  follow each person’s preferences, including preferences about self-employment.  We recommend that those who help with self-employment are knowledgeable about small businesses, including setting up systems for bookkeeping, paying taxes, etc.  Many IPS programs partner with Vocational Rehabilitation because of their expertise in this area.

In regards to whether the IPS supervisor will be directly responsible for helping people start microenterprises, we urge you to ensure that he or she has sufficient time for supervision.  In IPS,  the supervisor works side-by-side with employment specialists to help them develop skills for their jobs.  The supervisor also strives to know most people served by the program so that she can provide helpful suggestions to employment specialists.  IPS supervisors act as liaisons with mental health supervisors and Vocational Rehabilitation, and they review program outcomes so that they can develop program goals and strategies to help more people achieve their employment goals.  It may be difficult for a supervisor to accomplish all of this while also helping people set up microenterprises.

Question: The one area of fidelity that our IPS staff score in the lowest category is  Community Based Services with a score of ³1² – 30% time or less in the community. While job development, coaching and follow along supports take place in the community, most job search activities seem to take place in the office. More time seems to be required to complete long on-line applications that are replacing or in addition to going to the job site to meet the employer. Can you give a broad description of what a typical week for a Vocational Specialist should look like. What does an employment specialist do that is in the community 65% or more of their time?

Answer: Online job applications are time consuming.   We encourage employment specialists to meet in person with employers to learn about their business needs and the type of job candidates they would like to meet.  Employment specialists typically do this through a 20-minute scheduled appointment with a hiring manager.  If a specialist believes that her client is a good fit for the business, she returns to talk about that person and to ask the employer to meet the job seeker.  If the employer agrees, the employment specialist helps the person complete an application prior to the appointment.  Using this process of building relationships with employers reduces the number of job applications that employment specialists and clients complete together because the job seeker is competing with fewer, if any, job applicants.  For more information about this type of job development, see “Resources” on our website (http://www.dartmouth.edu/~ips) to watch a video under “Strategies That Work.”  Another source of information is a manual about IPS that will be available in June from our website, IPS Supported Employment: A Practical Guide.

Some people in the IPS program do not want their employment specialists to talk to employers on their behalf.  In this situation, the job seeker and employment specialist spend more time together completing job applications.

In IPS, employment specialists ask each person where she would like to meet for appointments.  Some people may prefer to come to the IPS offices, but others would appreciate the convenience of meeting closer to home at a library, coffee shop, or in their homes.  Employment specialists schedule four to six hours each week for meeting with employers.  They attend a vocational unit meeting and one to two mental health treatment team meetings each week.  Many employment specialists report that they spend most of their days in the community, returning at the end of the day to return phone calls and complete paperwork.

Question: I have implemented IPS model for adults in the mental health system. I will soon begin working on a project to develop interagency collaboration with Special Education and the Department of Rehabilitation (VR)  with day treatment programs within a school district. My  goal is to school to work transition outcomes for  students ages 14-21 for youth with psychiatric disabilities.   I want to implement the some aspects of the IPS model and would like some feedback about whether this intervention  might be a course action to take or if an alternative method/model has been researched.  I am currently conducting a literature review and would like some feedback on  studies/models that  I can implement or  research.

Answer:  IPS supported employment has been implemented in programs for people experiencing a first episode of psychosis (typically adolescents and young adults) with success in the U.S and other countries.  References for those research studies are below.  In these instances, IPS specialists helped many people with work and school.  We have limited research experience in the area of transition age youth.

Killackey, E., Jackson, H. J., & McGorry, P. D. (2008). Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual. British Journal of Psychiatry, 193, 114-120.

Nuechterlein, K.H., Subotnik, K.L., Turner, L.R., Ventura, J., Becker, D.R., & Drake, R.E. (2008).  Individual placement and support for individuals with recent-onset schizophrenia: Integrating supported education and supported employment.  Psychiatric Rehabilitation Journal, 31, 340-349.

Rinaldi, M., Killackey, E., Smith, J., Shepherd, G., Singh, S.P., & Craig, T.  (2010)    First episode psychosis and employment:  A review.  International Review of Psychiatry, 22, 148-162.

Question: My question is about counting jobs with social enterprises.  I recently referred a client to sewing business. He was paid a piece rate but his wages equaled minimum wage.  I did not count the job because I did not understand the job to be competitive as the company hires only persons who are newcomers to Canada, people living with mental illness and persons with disabilities.  However another  IPS worker, has also successfully placed a person with this business, and considered it competitive, as the positions are not reserved solely for persons with mental illness.  Person’s are required to self disclose to meet the mandate of the social enterprise.

Answer: We would not count that job as competitive because it is reserved for people who have disabilities, including mental illnesses, and those who are newcomers to Canada.  In IPS, competitive jobs are those for which any person can apply.  They are not set-aside jobs for people who have disabilities or other perceived barriers to employment.

 Question: Is there is a recommended number of hours per week that a supported employment specialist should dedicate to working with their clients?

Answer:  There is no recommended number of hours per week that specialists should work directly with their clients.  Most people who are job seeking meet with their employment specialist about once a week for support and guidance in the job search.  People who have new jobs usually meet with their employment specialist weekly, or even more often during the first weeks of employment.  For many employment specialists, managing their work schedules is complicated.  In addition to meeting  with clients, they focus on making six in-person employer contacts each week, attend the IPS team meeting and at least one mental health treatment team meeting, coordinate services with VR counselors, and stay up-to-date on documentation.  When a supervisor observes that a specialist is having difficulty managing her schedule, the supervisor should meet with her weekly to review what the specialist has planned to ensure that her time is scheduled efficiently in advance.

 Question: When was principle #7 added to the current IPS principles?

Answer:  The principle about benefits counseling was added about eight years ago.  Since then another principle has been added: Employment specialists build relationships with employers.  This principle references the multiple, in-person visits that employment specialists make to employers to learn about their businesses before asking to introduce a job seeker.  This principle was added in early 2011.   Please see our webpage for the current list of principles under the section:  What is IPS Supported Employment?

Question: Our agency contracts with nine mental health agencies to provide evidence-based IPS services. One of these agencies primarily serves Asian Pacific Islanders. Many of their clients are recent immigrants and/or possess limited English speaking abilities. This particular agency consistently receives low fidelity scores on “Job Diversity-Types”. The jobs developed tend to be in hotel food service and housekeeping. The agency reports that the clients’ limited English speaking skills and lack of familiarity with American culture limits their ability and/or willingness to pursue wider range of employment options.

Are you aware of any studies that researched the application of IPS to limited English speaking individuals and/or those that are recent immigrants? Can you put me in contact with other IPS agencies that serve these populations?

Answer: You might ask the agency to track the number and percent of people within the IPS program who do not speak English just so that you would have an idea about the degree to which diversity of job types would be affected. We also recommend that the program continues to focus on their clients’ strengths and tries to hire practitioners who speak the languages of their clients. Another suggestion is to talk to VR counselors in your area about how they help people with limited English.

The way that fidelity reviewers score the item should not be altered based upon the population they are serving. Fidelity scores should be based on the information that is available to fidelity reviewers at the time of the review. Consistency is important so that good fidelity means the same in New York as in Washington or any other state or country.

At this time, we are not aware of any studies regarding IPS for people who are recent immigrants or who have limited English language skills. We will send you contact information for other IPS agencies directly.

Question:  I am an occupational therapist working at the psychiatric hospital in Iceland. My team and I, consisting of occupational therapist, social worker, psychologist and other health staff members, are looking into the ideology of IPS. The team is working along side professionals from the state to help people in our care to seek employment. We have been exploring the role of each team member, as described in the book, but find it hard to adopt the roles to our members. We have read the book thoroughly but are still confused about the roles of: employment specialists, vocational rehabilitation counselor, case manager and supervisor. Do you have a specific prescription about the role of each of these members in order to help us see which role would be appropriate for one to take?

Answer:  Job titles of team members in mental health services vary across different agencies and countries.  The employment specialist, as described in our IPS manuals, is the person on the team who focuses on helping individuals who want to gain regular employment in their community.  The employment specialist partners with the individual in gathering career profile information that will help lead to job choices and potential job settings.  The employment specialist connects with employers to learn about potential job openings and provides job support to the individual and sometimes to the employer at the request of the individual.  Additionally the employment specialist regularly attends meetings of the mental health treatment team (i.e., the practitioners who provide mental health services and are serving the same group of clients) and communicates client progress regarding employment.  The team members convey information and provide services that may assist clients in their work lives (e.g. change in medication due to symptoms at work, stress tolerance skills, etc.).  The treatment team often includes a psychiatrist or medication provider and a case manager or social worker who assists with housing needs, social skills, money management, hospitalization plans, etc.  Other team members are substance use disorder specialist, housing specialist, nurse.  Teams are organized differently, but a common structure is a group of practitioners that serves 60-80 clients, for example.  The team meets weekly to discuss their shared caseload.
The vocational rehabilitation counselor is a role in the United States in a separate system from the mental health system.  The Vocational Rehabilitation Department serves people with physical and mental disabilities who meet eligibility and want to return to work.   Often IPS employment specialists connect with vocational rehabilitation counselors to access additional information and resources for clients.  Some countries have a similar system but some do not.

Question: It is common for IPS clients to move on from the program once working steadily and successfully, having good support and no further service wanted. However due to the episodic nature of serious mental illness, some of these clients are re-referred to IPS by the clinical team. i.e job lost, laid off, return to work plan required. Does the fidelity consider this a “new” referral and can the practitioner count a “new “ job as a new stat?

Answer:  If you are attempting to look at data in a similar way to the Johnson & Johnson –Dartmouth program so that you can use those benchmarks, then a person re-referred to the program would count as a new referral.  If the person had a lost a job and IPS helped the person find a new job, that would count as a new job start.  If the person was referred for help  keeping a job, then that would not count as a new job start, but the person would count in the percent of people who are working.

Question: Hi there, is there a quantified minimum hours/weeks/months under IPS fidelity where we “count” or not count the client’s job as competitive? Practitioners across the 3 provinces in Canada recently reported that they used different thresholds, although many were not IPS supported employment model. So, if we have a client that starts a competitive job, stays for a few hours, or only a few days, we do not count that as a stat on our data base collection. On the other hand, if we have a client that works at our local, annual 2 week summer exhibition (seasonal), we do count it.  From the client’s point of view, they have held a job even if only very briefly.

Answer:  In IPS, the number of hours worked per week does not determine whether or not the job is considered to be competitive.  Some people choose to begin with very few hours and gradually increase the amount they work as they become acclimated to working.  To be considered a competitive job, it must be a position that is not reserved for people who have disabilities, but instead, be a job that anyone can apply for regardless of disability status.  In addition, the worker should be paid at least minimum wage and the same wages as his co-workers who are doing similar jobs.  Finally, the job should not have artificial time limits imposed by the rehabilitation program.  The type of seasonal job that you described would be considered to be competitive, though a job that is designed by a social service agency to be short-term in order to provide someone with a “work experience” would not be considered to be competitive.

In the Johnson & Johnson-Dartmouth Community Mental Health Program, 130+ IPS programs report employment outcomes quarterly.  They report each person who has had competitive employment whether the job was held for one day or for the entire quarter.

Question: What approach does IPS suggest for people who have mental illness but also have below average IQ?  Specifically, clients that will likely need intensive job coaching because of their cognitive impairment.  We have a few clients that fall in this category at our agency who want to work and we’re trying to utilize the zero exclusion principle in all cases but these clients need their employment specialists to perform all facets of the job search, including setup and managing email, completing the application because of limited reading ability, etc.

Answer: We understand that intensive job coaching can make it difficult to continue serving everyone on the caseload.  Some programs in this situation have contracted with people to provide job coaching when it looks like a client might need those services for more than a week or two.  For example, they would draw up a contract for someone to provide a short-term service (coaching).  You might find a retired teacher or other person who is interested in working off and on.  Since VR pays an hourly rate for job coaching in many states, you would likely be able to pay the contract coach from the money you bill VR.  The employment specialist should work closely with the coach and continue to make some visits to the worksite to talk to the employer and ensure that the coaching is effective.

If a person will only need coaching for a week or two, others on the team might help out so that the employment specialist can continue to serve the rest of his caseload.  For example, one or two other specialists on the team might agree to each take one or two shifts each week.

Question: Our employment specialists are wondering about offering groups to instruct a number of clients at one time on topics such as interview skills. Can this fit with the IPS model of providing individualized services?

Answer:  We encourage your team to help each person with job search skills, as needed.  This is for two reasons.  First, because groups usually take a fair amount of practitioner time.  For example, they have to prepare for the group, it usually requires two people to facilitate a group, and then the practitioners need to complete multiple progress notes after the group.  They may even need to provide transportation for some group participants.  In order to maximize employment outcomes, we would recommend that they spend their time helping people apply for jobs, working with employers, and so forth.  The second reason that we would not recommend groups is that each person likely has different job search skills to learn.  For example, one person may need help completing a job application that he can copy when applying for jobs.  Another may need help describing his justice system involvement and efforts to move his life forward since his last conviction.  We recommend working on these skills with people while conducting the job search.

Question: I understand that the max caseload for each employment specialist should be 20 – 25 people at any one time. I am interested however in understanding how many people they would be expected to support over 12 months e.g. what the through put is in terms of an effective service as some people would find employment within 12 months, some people may for a variety of reasons disengage from the service and others may then come onto the caseload. I appreciate that this will obviously vary by service but wondered if there is an established benchmark or any research that covers this?

Answer:  To date, there is limited information from studies to establish benchmarks regarding the number of different people an employment specialist might work with over the course of a year. You are right that this would likely vary from agency to agency and even state to state.  For example, one employment specialist we know is very good at engaging people and so would likely work with fewer people during a year.  At a different agency, the case managers are eager for people to work and are referring some people who haven’t quite decided that they want to get a job.  At that agency, the employment specialists would probably see more people during the course of a year.  Time on the caseload of course is influenced by the client and in particular time after obtaining a secure job.  In addition, different funding provides variation across programs and states.

Managing caseloads

Question: I’m interested in cases/examples of IPS teams providing 1:1 support for clients to keep their jobs, and how that support is provided/maintained. I know IPS includes “ongoing” support, but what if the support is too resource-intensive for programs to proivde? Given the cost, it seems IPS programs couldn’t sustain such a level of service, even if it were necessary to the individual keeping his position. Do you have any examples of how IPS programs provide 1:1 supports, if at all, over long periods of time?

Answer: The job supports provided by IPS programs vary from person to person based upon need and desire. Generally, employment specialists are encouraged to provide intensive supports, including face-to-face contact, on a weekly basis for at least the first month of employment. Other supports might include phone calls, meetings with employers to obtain extra feedback, help managing anxiety before going to work in the morning, wake –up calls, on-the-job coaching to learn new duties, etc. The type of supports provided can vary considerably from person to person. If a person needs very intensive job supports for a long period of time, for example, months of on-site job coaching, then the IPS supervisor should question whether that job is actually a good job fit for the person. The supervisor might advise the specialist to help the person find employment that matched his or her skills and abilities so that long-term coaching was not required. Over time, most clients want and require fewer supports and eventually transition off the IPS caseload. On average, clients remain in the IPS program for about a year. This allows new clients to enter the program.

Question: As a supervisor, I am encouraging my team to spend at least 65% of their time in the field, but we are having trouble reaching that goal. Can you give me some ideas regarding ways that we can improve?

Answer: You could first explain the rationale for spending time in the community. For example, you could tell them that this has been linked with better client outcomes, and also that it may help them keep people engaged in the program if they don’t need to come into the office for appointments. You could point out that people are more likely to find jobs if employment specialists are out in the community talking to employers, helping their clients apply for jobs, and helping their clients follow up on job applications in person.

But the most effective strategy is often for supervisors to model spending time in the community. For example, you could go out with your staff to conduct job development, to meet new clients, to help them engage clients who have stopped meeting them, to meet with VR counselors… Going out with them to client homes, employers, etc. will not only show them how to provide services in the community, it will demonstrate that you are serious about the need to spend time in the community.

Finally, during individual supervision, you can review schedules with team members who are having the most difficulty getting into the community. “What are you scheduled to do tomorrow? And where are you meeting Tim? Why are you meeting him in the office instead of taking him out to look at jobs?…”

Question: How do you determine if an individual is inactive? Often we find that some individuals are active and then do not meet for 3 weeks or 2 months etc. They remain on our data sheets and we don’t know if we should still be making contacts for them or when to cease making those contacts. Having individuals on our data who aren’t active effect the outcomes of the data in a negative way.

Answer: We recommend that employment specialists focus on learning what is getting in the person’s way of continuing with the employment plan. They can do that by talking to members of the mental health team, family members (with permission), trying to call the person, making home visits, sending letters, etc. The focus is not to inform the person that she must attend appointments in order to get a job or to stay in the program. Rather, the focus is to understand, from the person’s point of view, why she has not been available to work on her employment goal. For example, if she has been missing appointments because of childcare issues, the employment specialist might ask team members to help her with that problem. If she has been missing appointments because it is hard to remember, the employment specialist could offer to call on the morning of appointments or provide other types of reminders. If the person reports that she no longer wants to work, the employment specialist would close her case for the time being.

Employment specialists should not keep “active” and “inactive” caseloads. We recommend that they have contact with each person on their caseload, or at least make outreach attempts, monthly. If contacts or monthly outreach attempts are not made (for example, if a person has a long-term medical issue to deal with before pursuing employment) the person’s case should be closed.

Question: I was reviewing the Fidelity Review Manual regarding caseload size. My understanding is that the 20 or fewer clients on the caseload only refers to active clients. However, there doesn’t seem to be a specification for how many inactive clients one can have on their caseload. For example, I often have inactive clients one month, who become active the next month. From reading the fidelity scale, it appears that the number of inactive clients you have is not a fidelity issue. It is essentially a judgment call by the supervisor and IPS worker. Am I interpreting this correctly?

Answer: A revised version of the fidelity manual is now available and includes further clarification about caseload size. The second edition addresses your issue in the following way:

Many employment specialists keep a list of inactive clients because they are not sure when a person is considered to be on their caseload. The following guidelines will help programs define caseloads in a consistent manner:

If a person is receiving outreach attempts on at least a monthly basis, that person is considered to be on the employment specialist’s caseload. This is true, even if the outreach attempts are not successful.

If the person is receiving monthly services from the employment specialist, that person is considered to be on the specialist’s caseload.

If a working person calls the employment specialist occasionally (less than monthly) to say hello and update the specialist on his or her job, that person would not be on the caseload.

If three months go by without monthly outreach attempts or other monthly employment services, the employment specialist should close the case. An example might be someone who is trying to resolve a medical issue before pursuing a job.

Competitive Employment

Question: I was reading in the IPS material that a Peer Specialist is considered competitive employment. As these jobs are reserved for people with mental illness, our agency had interpreted peer specialists as non-competitive employment. In addition the money earned by our peer specialists is exempt earnings, meaning it doesn’t affect their disability benefits. As a team, we have often discussed whether peer support work should be considered competitive employment as these roles seem like somewhat sheltered jobs. What employment conditions would make a peer specialist position competitive employment?

Answer: Because it is a job requirement of peer specialists to have first-hand experience recovering from mental illness, we would not discount these positions out of hand. Instead, we encourage you to think carefully about the peer specialist positions at your agency or in your local area. In order for these positions to be considered competitive, we would expect them to meet the following criteria:
* Peer specialists should be treated like other practitioners at the agency. They should be included in meetings and have access to the same information and records that other practitioners use.

* Peer specialists should be compensated in a similar manner as other practitioners with the same training and education. Further, agencies might consider experience with mental illness to replace some educational requirements.

* Peer specialists should not be part-time positions only. Agencies should offer the same full-time positions and benefits to peers as to other practitioners. (Agencies might also have one or two part-time peer positions, just as they often have a few part-time case managers or counselors positions for people who prefer to work part-time.)

Question: Is twenty plus clients placed with one medium size employer in temporary positions considered transitional employment? It is my opinion that this work is not competitive employment under the fidelity scale, even though any person can apply for the job.

Answer: Transitional employment usually refers to employment that has an artificial time limit. For example, a six-month position that is intended for a person with a disability. The purpose of the position might be to help a person gain work experience so that he or she could eventually pursue a competitive job.

Twenty or more clients working for the same medium size employer on a temporary basis does sound like transitional employment, though it is difficult to know this without more information. It does not sound like something an IPS supported employment program would promote since we encourage employment specialists to help clients seek out employment based upon their preferences. It seems unlikely that one company would have the perfect job for that many people in the program. Further, although temporary work (such as seasonal positions) can be competitive, if these jobs are time limited because they are for people who have disabilities, then they would not be considered competitive positions. Finally, I think there might be reason to worry that such a large group of people from a supported employment program would have difficulty blending into the work environment. For example, other workers might easily identify them as part of a group and treat them differently.

Question: Is twenty plus clients placed with one medium size employer in temporary positions considered transitional employment? It is my opinion that this work is not competitive employment under the fidelity scale, even though any person can apply for the job.

Answer: Transitional employment usually refers to employment that has an artificial time limit. For example, a six-month position that is intended for a person with a disability. The purpose of the position might be to help a person gain work experience so that he or she could eventually pursue a competitive job.

Twenty or more clients working for the same medium size employer on a temporary basis does sound like transitional employment, though it is difficult to know this without more information. It does not sound like something an IPS supported employment program would promote since we encourage employment specialists to help clients seek out employment based upon their preferences. It seems unlikely that one company would have the perfect job for that many people in the program. Further, although temporary work (such as seasonal positions) can be competitive, if these jobs are time limited because they are for people who have disabilities, then they would not be considered competitive positions. Finally, I think there might be reason to worry that such a large group of people from a supported employment program would have difficulty blending into the work environment. For example, other workers might easily identify them as part of a group and treat them differently.

Question: I was reading in the IPS material that a Peer Specialist is considered competitive employment. As these jobs are reserved for people with mental illness, our agency had interpreted peer specialists as non-competitive employment. In addition the money earned by our peer specialists is exempt earnings, meaning it doesn’t affect their disability benefits. As a team, we have often discussed whether peer support work should be considered competitive employment as these roles seem like somewhat sheltered jobs. What employment conditions would make a peer specialist position competitive employment?

Answer: Because it is a job requirement of peer specialists to have first-hand experience recovering from mental illness, we would not discount these positions out of hand. Instead, we encourage you to think carefully about the peer specialist positions at your agency or in your local area. In order for these positions to be considered competitive, we would expect them to meet the following criteria:
* Peer specialists should be treated like other practitioners at the agency. They should be included in meetings and have access to the same information and records that other practitioners use.

* Peer specialists should be compensated in a similar manner as other practitioners with the same training and education. Further, agencies might consider experience with mental illness to replace some educational requirements.

* Peer specialists should not be part-time positions only. Agencies should offer the same full-time positions and benefits to peers as to other practitioners. (Agencies might also have one or two part-time peer positions, just as they often have a few part-time case managers or counselors positions for people who prefer to work part-time.)

Question: I have some funding that is earmarked for internships to help people train for and take steps towards competitive employment. Other than ensuring that the internships structured like regular work (with a job description, supervision and clear schedule), do you have recommendations for how they should be set up to be most aligned with Supported Employment principles?

Answer: Congratulations on your acquisition of funds to help people with their working lives. Our answer about the internships, however, is that we would recommend that you use those resources to help people find competitive jobs. We define competitive jobs as jobs that aren’t set-aside for people with disabilities, jobs in which people are paid at least minimum wage (and at the wage of others who are doing the same work), jobs in which people are paid directly by their employer (e.g., the paycheck comes from the employer, not from a social service agency) and time limits are not imposed by the rehabilitation/mental health agency.
The reasons that we urge you to help people with competitive jobs include the following:

  • People who have serious mental illness say that they want help with regular jobs. For many, getting a job is not just about earning money, but also about re-joining the community and getting on with their lives. As one counselor said, “When I see people get jobs, the difference is striking. They go from feeling ‘out’ to feeling like they are part of the world again.”
  • Many people report that it is stressful to be asked to transition through multiple jobs, learning the job and the culture of a specific work setting. People like having the option to choose whether they leave a job because of a poor job match, for example, rather than from an imposed time limit.
  • Helping people to prepare for the workforce in a stepwise approach is not effective. Research demonstrates that people are most likely to be successful at work if they are not asked to engage in short-term job tryouts or sheltered employment. Perhaps this is because people have higher levels of motivation to succeed in regular jobs or perhaps this is because when we help people find competitive work, we are demonstrating our confidence in their skills and abilities, thereby building their confidence.

We’ve seen numerous programs that tried to make internships and job tryouts seem as much as possible like regular work. However, it has been our observation that the people working in those jobs always know the difference, and the message they hear is that they don’t have what it takes to succeed in the competitive workplace. On the other hand, we’ve also met numerous people with serious mental illness who have worked successfully (in competitive jobs) in spite of ongoing psychosis, serious social problems, substance use issues and other complications. Those people told us that a regular job helped them “feel equal with other people”, helped them “gain back self-respect”, and helped them “feel independent again”.
In order to practice the IPS supported employment principle, rapid job search, we advise you to skip the internships and help people find regular jobs related to their preferences.

Question: Do you have any information on providing supported self employment services for individuals with a psychiatric disability?

Answer: Helping people with self-employment can be part of IPS supported employment. When helping clients with self-employment, practitioners should carefully discuss the person’s preferences for hours, work environment, wages, etc. to ensure that self-employment will satisfy the person’s needs. Further, in order to self-employment to be considered a competitive job, wages should be recorded and reported to all sources of entitlements (e.g., Social Security Administration) and the IRS.
For resources about how to help people with self-employment, we recommend connecting with your local VR office. In addition, you may be interested in:

  • Making Self-Employment Work for People with Disabilities by Griffin and Hammis, published by Brookes, 2003.
  • Diversity World A website by Denise Bissonette that includes some information about self-employment

Helping People Who Have Substance Use Disorders

Question: Have there been any studies completed with substance abuse counseling centers, not just mental health / behavioral health centers?

Answer: The research for IPS supported employment has focused on people who have severe mental illness but who may also have a substance use disorder.

Question: How do we work with an individual who has substance abuse issues and repeatedly does not show up or will not engage with us? How much time do you put in outreach and how long would you keep working with someone?

Answer: Rather than focusing on the length of time spent on providing outreach, try to focus on finding out the reason that the person is not engaging. If you find out that the person has changed his mind about employment, then go ahead and close the person’s case. You can always re-open it later on. If the person is encountering other obstacles, such as trouble remembering the appointments, try new strategies to help the person succeed in IPS. For example, you might try calling before appointments, making appointments at the same day and time each week, or helping the person use a calendar for appointments.

Question: Since many employers require drug testing, how do you get around drug screening when trying to help a person get employment who may still be actively using?

Answer: As an employment specialist, you would let your client know that an employer may screen for drug use. If the person doesn’t get the job because of the drug test, then the person has more information about how drugs and/or alcohol are affecting his goals. Some people will decide to cut down on substance use while looking for work, and others may decide to look into treatment options. Still others will decide to try to find employers who don’t use drug screening.

Question: Can you recommend any materials available through the web that address issues of disclosure / non disclosure and other job development issues for persons who are actively abusing substances (with co-occurring mental illness)?

Answer: There are a number of resources on our website that you may find helpful. The website address is: www.dartmouth.edu/~ips
Go to Resources. Select “IPS Forms & Docs.” Select “Disclosure.” This is a worksheet that helps employment specialists talk about disclosure with their clients.
Go to Resources. Select “Recommended Readings.” See description of Supported Employment: A Practical Guide for Practitioners and Supervisors. This manual includes information about disclosure, as well as guidelines for helping people with substance use disorders.
Go to Resources. Select “Vocational Publications.” Scroll down to 2005 to see a reference to an article by Becker, Drake and Naughton titled Supported Employment for People with Co-Occurring Disorders.
Go to Resources. Select “Posters.” Select “Employment Supports for Clients with Co-Occurring Mental Illness and Substance Abuse: Myths and Facts.”
Go to Resources. Select “Videos.” Select “Strategies That Work.” Select “Co-Occurring Disorders”

IPS Versus Supported Employment

Question: Please clarify the difference between IPS and Supported Employment. Are the names considered interchangeable?

Answer: Supported employment is a widely used term that does not necessarily refer to the evidence-based practice. Consequently, some states and countries are choosing to use the term Individual Placement and Support (IPS), which refers to the evidence-based approach to supported employment for people with serious mental illness. At this time, the Dartmouth Psychiatric Research Center is using “IPS supported employment” to differentiate the evidence-based approach from other vocational models.

Question: What’s the difference between IPS and Supported Employment?

Answer: IPS (Individual Placement and Support) is synonymous with evidence-based supported employment. However the term “supported employment” is sometimes used to describe programs and funding streams that are for people with any type of disability who need long-term job supports. In contrast, evidence-based supported employment, or IPS, is a carefully defined employment service based on a 25-item fidelity scale. The evidence base includes studies with participants who have serious mental illness.

Individualized Job Search

Question: I was wondering if your experience and research could recommend supportive or ideal work environments with individuals who suffer from depression and mild schizophrenia. Specifically, I am hoping to assist a young male find employment.
Answer: We don’t have recommendations based upon diagnosis. In fact, we recommend individualized job search based upon each person. So, if a person had disorganized thoughts, you might suggest work environments that were quiet or had routine duties to help the person focus on his job. If a person felt good about interacting with others, a job with the public might help lift the person’s depression. If a person had problems with paranoia, it is possible that the person would be more successful in a job that did not include dealing with the public. We recommend the following approaches:
* Spend time talking to the person about his or her work history. Ask questions to find out what parts of the job the person liked and didn’t like. Ask about the reasons that the job ended or the reasons that the job lasted a long time. You may begin to see some trends. If you think that trends are developing as you talk to the person, check it out. “It seems like you didn’t work as long at the jobs that required you to do more than one thing at a time. Is that right?”
* With permission, talk to family members or mental health practitioners who may have seen the person try working in the past. You may find out that the person blossomed in ways that others did not expect, or that a particular type of supervision works well for the person. Even if the person does not have a work history, you may find out that he is at his best at a certain time of day or that he enjoys activities that you didn’t know about.
* Ask the person about his or her preferences. Some people have preferences about the type of work, others have preferences about how long the commute will be, and still others prefer to work with men or women… Spend some time trying to understand what is most important to your client.
* If your client hasn’t worked much in the past, you could offer to take him to visit some different types of work sites to find out which ones appeal most to him.

Remember, personal preferences and a desire to work can help some people overcome all sorts of obstacles. So don’t discourage your client if he wants to try a type of work that you aren’t sure about.

Question: I work with young adults with psychiatric challenges, assisting them with vocational and educational planning and implementation and am wondering what is in the forefront currently for career assessment tools, skills assessments, etc.

Answer: In IPS supported employment, employment specialists attempt to help people make good job matches by learning as much as possible about each individual. The employment specialist talks to the person’s mental health workers, and with permission, family members. The specialist also has a series of conversations with the job seeker about his work history (jobs he liked, strategies that worked, etc.), his job preferences, work skills, interests, current symptoms and coping strategies, etc. Employment specialists also spend time in the community talking to employers about the types of jobs that they have available, job requirements and hiring preferences. This information about local jobs is invaluable as the specialist can combine this information with client preferences to suggest jobs to the job seeker. Information is collected into a Career Profile which can be found athttp://www.dartmouth.edu/~charky1/page40/page3/page3.html
In addition, if a person hasn’t had much work experience or is not sure what he would like to do, the employment specialist might take him out to look at different worksites and observe people working. For example, if the person thought he might like to work in a factory, the employment specialist could call a factory or two to make plans to come in and take a tour and observe people working at their jobs. They might also prepare some questions to ask the manager, such as “What qualities make a person a good assembler?” If someone was thinking about working in retail, they might simply visit a few stores and talk together about the tasks they saw the retail workers performing.
The employment specialist might also arrange a family meeting, with client permission, to talk about job ideas. It is possible that family members have seen the person work in the past and have information about his strengths and strategies that worked to help him succeed.
IPS supported employment does not use skill assessments or vocational evaluations because these have not been demonstrated to predict employment for people with severe mental illnesses. Also, because most people with mental illnesses have said that they prefer not to go through testing. Instead, employment specialists help people learn about their skills by helping them find real jobs, just like everyone else. This makes sense if you think about it. Since the factors that lead to job success are often not related to specific job skills but are factors such as a supportive supervisor, a quiet environment for a person with disorganized thoughts, a job working alone for a person who has symptoms of paranoia, or a job helping others for a person who wants to feel that he is contributing to his community.
After a person begins a job, ends a job, or starts a school program, the employment specialist updates the career profile with information learned from each of these experiences. Examples of updates for the profile can be found at the website listed above.

Rapid Job Search

Question: I have a question regarding the fidelity review. Item T4 (Rapid job search for competitive job) – it shows our average is 29.71 days from first meeting to employer contact. To clarify, does this mean from the first time we meet our client to the first time we meet an employer specifically for that client?

Answer: Yes, “Rapid Job Search for Competitive Job” refers to the time between meeting with a client to first face-to-face contact with an employer. The following scenarios would constitute an employer contact:

*An employment specialist meets with an employer whom she believes has the type of jobs in which her client is interested. She asks the employer to schedule an appointment with her so that she can learn more about his business.
*An employment specialist accompanies a client to apply for a job. As the client is turning in her application, they ask to speak to a manager and spend a few minutes talking to the manager about the job or about the client’s work experience.
*A client has a job interview and the employment specialist participates in the interview.

The scenarios below would NOT constitute an employer contact:

* An employment specialist helps a client complete an online application.
* An employment specialist calls an employer to ask about job openings.

Question: We are working on improving our fidelity, but are questioning the criteria for #4- Rapid Job Search for Competitive Employment. It reads that “first face to face employer contact occurs with employment specialist or by individual within first 30 days after program entry.” With the economy and technology we have a lot of individuals applying on line for jobs. Would that meet standards?

Answer: We realize that many employers are now using online applications, however, the standard for rapid job search is still face-to-face contact with employers. As you know, when clients are applying for jobs online, they are competing with a large number of applicants. We encourage employment specialists and clients to go into the community and ask to speak directly to hiring managers and human resource departments. If an online application is required, the job applicant might consider submitting the application before going to meet with the employer.

Recently we heard a couple of tips for working with managers in regards to the online applications. First, employment specialists should spend time getting to know employers. For example, asking about the employer’s needs: “Can you tell me about someone who has been successful here–why are they successful?”, “What are some of your headaches as a manager?”, “What type of person does well in these positions?”, “What is a typical day like for a clerk in your office?”. As you are doing that, you may begin asking about the hiring process as well. If an employer says that applicants must submit an online application along with everyone else, try something like this: “You mentioned that you need people who are energetic and friendly. If you had a friend who had just that type of personality, how would you go about helping that person get hired?”

  • As it turns out, many managers are able to ask their human resources department to pull certain applications. Some will do that because of their relationship with the employment specialist or because they have had contact with a client whom they believe to be a good candidate. We encourage employment specialists not to undervalue the importance of face-to-face relationship building with employers.

Question: When receiving a new referral and the engagement process with the client is taking longer than the suggested rapid 30-day engagement, what are some suggestions as to how other people are handling this issue in meeting their fidelity outcomes?

Answer: Actually, the 30 days refers to the rapid job search. In other words, after the first meeting between the employment specialist and client, face-to-face contact with employers should occur within 30 days. Some people aren’t always interested in applying for a job within 30 days so they might make employer contacts to find out more information about different types of jobs and work settings. Investigating job types and employers (rather than submitting applications right away) may facilitate the engagement process.

Question: How do you keep from “burning” an employer when you are putting clients out there so quickly?

Answer: Employment specialists take time to learn about each employer’s needs before introducing a job seeker, and this work helps to ensure a good job match. Furthermore, specialists stay in close contact with employers after their clients start work. If someone doesn’t work out, employers are often willing to work with the specialist again if they feel that the employment specialist was there to provide support along the way. For example, if the employment specialist had been calling or stopping by regularly.

Assessment

Question: Could you please clarify or point me in the direction re:  Dartmouth’s view re: job shadowing. I was just in a meeting with an employment specialist who suggested a job shadow.

Answer: If a person is not sure what type of work she would like to do, or would like to find out more about a particular company, going to visit a workplace for a few hours is definitely in keeping with the IPS approach. Some examples might be:
A person who hadn’t worked much in her life and didn’t know much about jobs. In this case, an employment specialist might ask her if she would be interested in visiting a few businesses to observe workers. They might talk for awhile first so that the employment specialist had a sense of the types of jobs that might interest the person, and then visit a few places that had those types of jobs.
A person who thought that she might be interested in working as an assistant in an optometrist’s office but didn’t know much about that type of work. The employment specialist could offer to set up an appointment to meet with an optometrist or an assistant to ask questions about the job and, if possible, observe the assistant at work for a few hours.
If the job shadowing is actually an assessment (e.g., to see if the person will arrive on time, will conduct herself appropriately for that environment, and so on) that would not be in keeping with the IPS approach. Further, all job shadowing should be something that the client wants to do, not an activity required by the employment specialist.

Question: I work with young adults with psychiatric challenges, assisting them with vocational and educational planning and implementation and am wondering what is in the forefront currently for career assessment tools, skills assessments, etc.

Answer: In IPS supported employment, employment specialists attempt to help people make good job matches by learning as much as possible about each individual. The employment specialist talks to the person’s mental health workers, and with permission, family members. The specialist also has a series of conversations with the job seeker about his work history (jobs he liked, strategies that worked, etc.), his job preferences, work skills, interests, current symptoms and coping strategies, etc. Employment specialists also spend time in the community talking to employers about the types of jobs that they have available, job requirements and hiring preferences. This information about local jobs is invaluable as the specialist can combine this information with client preferences to suggest jobs to the job seeker. Information is collected into a Career Profile which can be found athttp://www.dartmouth.edu/~charky1/page40/page3/page3.html
In addition, if a person hasn’t had much work experience or is not sure what he would like to do, the employment specialist might take him out to look at different worksites and observe people working. For example, if the person thought he might like to work in a factory, the employment specialist could call a factory or two to make plans to come in and take a tour and observe people working at their jobs. They might also prepare some questions to ask the manager, such as “What qualities make a person a good assembler?” If someone was thinking about working in retail, they might simply visit a few stores and talk together about the tasks they saw the retail workers performing.
The employment specialist might also arrange a family meeting, with client permission, to talk about job ideas. It is possible that family members have seen the person work in the past and have information about his strengths and strategies that worked to help him succeed.
IPS supported employment does not use skill assessments or vocational evaluations because these have not been demonstrated to predict employment for people with severe mental illnesses. Also, because most people with mental illnesses have said that they prefer not to go through testing. Instead, employment specialists help people learn about their skills by helping them find real jobs, just like everyone else. This makes sense if you think about it. Since the factors that lead to job success are often not related to specific job skills but are factors such as a supportive supervisor, a quiet environment for a person with disorganized thoughts, a job working alone for a person who has symptoms of paranoia, or a job helping others for a person who wants to feel that he is contributing to his community.
After a person begins a job, ends a job, or starts a school program, the employment specialist updates the career profile with information learned from each of these experiences. Examples of updates for the profile can be found at the website listed above.

Question: I am wondering if the Center has done any work on developing tools around positive risk assessments, to assist in supporting people to access employment. I am thinking about people with complex forensic/risk histories and a specific pro forma which would support the individual and employment specialist to look at how risks can be managed, and could also be used to encourage our own organization to take people on if there are any risk issues, i.e., it would help us building a case to support the individual. It would be something we would want to do with the employment specialist and clinical team.

Answer: We have not developed a tool, such as you have described. During multidisciplinary treatment team meetings, employment specialists and the clinical team discuss possible risks and strategies to reduce risk. Discussions are documented in the client’s record. We appreciate your interest in serving this population of people.

Question: I have a question about the item called, “On-going work-based assessment”. I was interested in knowing why it is necessary to update the vocational profile with each new job experience since the employment specialists are writing progress notes along the way.

Answer: Employment specialists are encouraged to update the vocational profile with each new job experience for the same reason that mental health practitioners update the mental health assessment on a regular basis. It is important to store lessons learned about the person’s strengths, needs and preferences in a location that is easy to find. Further, a practitioner might have to wade through numerous progress notes in order to gain an understanding of what was learned from each job experience. Also, at many agencies, progress notes focus on the interaction between the client and employment specialist and may leave out important information such as job duties. If an employment specialist leaves his or her job, the next specialist will benefit from all of this information. Finally, a good job update form does more than document history. It also leads practitioners and clients to think about key issues. An example of job update forms are on this website under “program tools”.

Question: Why doesn’t supported employment use vocational evaluations? Wouldn’t it be helpful for people to know more about the type of job that would be a good fit?

Answer: Traditional approaches to assessment and evaluation, such as standardized pencil and paper tests, work samples and situational assessments are not a good source of information. Research has shown us that in regards to adults with serious mental illness, these tests do not predict who will succeed in the workforce. One reason may be that work environments and supervisors are so often the key to success. For example, a data entry job with an approachable supervisor who gives feedback in a friendly manner is entirely different than a data entry job with a critical boss who does not provide training. No matter how good the test, it can’t anticipate these types of factors.

Further, the testing process can be discouraging to some people who want to move towards employment right away. Finally, vocational evaluation can feel demeaning to some people who want to go about finding a job just like everyone else–by going out to meet employers and put in applications.

Instead, supported employment (IPS) attempts to help people make good job matches by learning as much as possible about each individual. The employment specialist talks to the person’s mental health workers, and with permission, family members. The specialist also has a series of conversations with the job seeker about his work history (jobs he liked, strategies that worked, etc.), his job preferences, work skills, interests, current symptoms and coping strategies, etc. Employment specialists also spend time in the community talking to employers about the types of jobs that they have available, job requirements and hiring preferences. This information about local jobs is invaluable as the specialist can combine this information with client preferences to suggest jobs to the job seeker.

Of course, not every job works out, but this is also true for workers without disabilities. If a job doesn’t go well, the employment specialist, client, VR counselor, mental health practitioners, and with permission, family members, talk about the things that went well, as well as those things that didn’t go well. Practitioners try to look for lessons learned and help the person develop a new job plan. They offer to help with a new job search without delay.

Zero Exclusion

Question: I am wondering if the Center has done any work on developing tools around positive risk assessments, to assist in supporting people to access employment. I am thinking about people with complex forensic/risk histories and a specific pro forma which would support the individual and employment specialist to look at how risks can be managed, and could also be used to encourage our own organization to take people on if there are any risk issues, i.e., it would help us building a case to support the individual. It would be something we would want to do with the employment specialist and clinical team.

Answer: We have not developed a tool, such as you have described. During multidisciplinary treatment team meetings, employment specialists and the clinical team discuss possible risks and strategies to reduce risk. Discussions are documented in the client’s record. We appreciate your interest in serving this population of people.

Question: Regarding Individual Placement and Support (Evidence-Based Supported Employment), would the only entrance criteria to be listed on our service definition be “An Individual that has a Serious and Persistent Mental Illness or a Severe Mental Illness diagnosis or a Dual Diagnosis with Substance Abuse” and “The Individual is experiencing barriers to employment” AND “The individual has a desire to work”?

Answer: Most programs have an entry statement similar to this one: “Evidence-Based Supported employment (Individual Placement and Support) is available to any person served by the agency who has a serious mental illness and a desire to work at a competitive job.”
Ideally, clients can self-refer to supported employment, so any person who believes that he or she would benefit from supported employment would be eligible if s/he has a serious mental illness and a desire to work at a competitive job. We encourage agencies to share information about self-referrals to all clients and any family members who are involved in the person’s treatment.

You raise an interesting point that some people with serious mental illness are able to find and keep jobs on their own. Therefore, we also encourage agencies to spend time talking to case managers about ways that they can promote employment and help individuals problem-solve job related issues. For example, at some agencies case managers will help clients think of ways to answer interview questions and might also help clients fill out applications that they bring to appointments. When case managers and counselors focus on employment, they often find that some people will return to work independently.

Question: The Supported Employment Fidelity Scale also indicates there should be Zero Exclusion Criteria – how would this work for clients that are currently exhibiting evidence of or high risk factors for violence?

Answer: Mental health teams work with people who have the potential for violence from time to time. When helping people with housing in the community, teams work together with supervisors and psychiatrists to determine an acceptable level of risk for the person and community. We see employment in a similar light.

It is important for the mental health team, employment specialist, psychiatrist and IPS supervisor to meet and discuss the person’s employment goal. They should also consider the person’s history of violence. For example, many people have a history of one aggressive incident that took place in a particular situation and may never recur. Others tend to be aggressive only in specific situations, for instance, when drinking and not taking medication. The group should consider any history of violence, current treatment, substance use, stressors, etc. Further, the team should discuss the type of job and work environment that might be best for that person and can offer extra follow-along supports from the mental health team and employment specialist.

Finally until the team is very clear about the type and level of risk, it is critical that they take precautions in their own work. Safety should come first for everyone as none of us can do well in our jobs unless we are feeling safe.

Scope of Employment Specialist’s Duties (Vocational Generalists)

Question:  I’ve read findings that SE participants assigned to a single vocational worker had more positive outcomes than participants served by a team of workers. Vocational programs that use a team-based approach with multiple workers seeing each client may present challenges to clients with SMI because many of them have difficulty forming interpersonal relationships. I’m working on the evaluation of a pilot program where the client will have regular meetings with 3 workers at once-a job coach, job developer, and a peer. Prior findings suggest that 3-on-1 meetings aren’t a good idea but how do you avoid that when you have 3 types of workers? Do they coordinate prior to seeing the client and then one handles the client interaction? Or do you recommend that a single worker handle all the vocational tasks instead of a team approach?

Answer:  In IPS programs, we recommend that one person provide the full-range of employment services to the people on his or her caseload. This helps in a few different ways.  First, because the person who wants to work is able to establish a relationship with one worker who helps them throughout the return to work.  In research trials when people were asked to work with one person for job development and another for job supports, clients often dropped out of employment services when they needed to switch to a new worker.  We can imagine that it would be difficult to try to get to know someone new at a stressful time.   In addition, the employment specialist and worker learn together as the person tries employment.   For example, they may discover that the person is most successful when the supervisor is promoted to give frequent feedback.  If the client is switching back and forth between workers as she tries different jobs, these lessons may be lost. Finally, it helps to have one employment specialist so that the person returning to work does not hear conflicting messages from several different people.
In the situation that you describe, all three workers will meet with the client at once.  Although that might prevent the person from hearing different messages, it could be overwhelming.  We also wondered what you meant by “job coach.”  Is that someone who would provide training on-the-job?  If so, we don’t believe that most people in IPS use, or need, job coaches.  We would suggest that instead of the current plan, that each worker would provide the full-range of employment services, to their own caseload of clients.   We believe that this will be a more successful approach than the team approach that you described.

Question: We have two MH SE providers in our county. One is a clubhouse with transitional employment and the other facilitates individual employment. The individual employment team is located within a mental health agency. This IPS program has been providing services for 15 plus years. It is currently a team of 2.5 individuals. One full time and one part-time function primarily as job developers. (the part-time primarily DVR and the other RSN funded services). The developers also do some job coaching (i.e.: the first week or so on the job). The other FTE team member provides intake, ongoing benefits analysis and reporting, customized on-going coaching support, vocational group facilitation, and WRAP plans (as part of long term support strategies). All three participate in treatment team meetings with case managers and therapists and are flexible at covering for each other as needed.

This vocational program is looking at becoming an EBP. They believe that because of their small size and their approach that every staff member is part of each individual clients employment journey at all stages of the employment process that it is ok to delegate roles in the team. Client drop out is low and outcomes are high. Two members of this team have worked together for 13 years and feel like their system is structured on the strength based rather than generalist approach (one excels at working with employers and the other has great coaching and WRAP facilitation skills.)

Is it necessary for this program to restructure itself from Employment Specialists to Employment Generalists to be an EBP?

Answer: Programs that have good fidelity to the supported employment (IPS) model have better outcomes. Even when the economy is troubled, good fidelity is something programs can focus on in order to help more people with employment. During research trials for supported employment (IPS), clients were most likely to drop out of services when asked to transfer from one employment specialist to another. Many clients value the relationships that they form with employment specialists and do not wish to give these up in order to work with someone new. It has also been observed by some supported employment teams that most employers prefer to work with only one employment specialist throughout the employment process.

To follow good fidelity, each employment specialist carries out all phases of employment service, including intake, engagement, assessment, job placement, job coaching, and follow-along supports before step down to less intensive employment support from another mental health practitioner. (It is not expected that each employment specialist will provide benefits counseling to their clients. Referrals to a highly trained benefits counselor are in keeping with good fidelity.)
Some programs attempt to divide job duties between employment specialists because they believe that only a certain type of person will be able to be effective at job development. However, we have worked with numerous supported employment programs and it is our observation that most people can master job development if they have access to good training and ongoing mentoring. A key seems to be field mentoring by the supported employment supervisor. For example, when a new employment specialist is hired, the supervisor might go out with that person weekly to help him make employer contacts. The supervisor would continue this practice for couple months until s/he determined that the specialist was skilled at job development, and then might drop back and provide field mentoring for job development on a less frequent basis. Experienced co-workers and VR counselors can also help the employment specialist develop this skill.

We have one final suggestion regarding the WRAP plans that you mentioned. As part of “Employment Services Staff” (another fidelity item), we would suggest that case managers or counselors help clients with WRAP plans, rather than the employment specialist. Although many people might include employment in their WRAP plans, we would suggest that employment specialists focus on helping people with jobs, rather than facilitating WRAP activities. Ideally, mental health practitioners provide services that support the employment plan. For example, mental health practitioners might help a person manage his paycheck, work on social skills that could be used on the job, help with clean clothing for work, etc. The WRAP plan is another way to involve mental health staff in the employment process without distracting employment specialists from their essential duties.

Thanks for your question. Grappling with issues such as these will help your program achieve good fidelity and better outcomes for clients.

Outcomes

Question: Is there any statistical information about success rates of IPS supported employment during the current economic downturn?

Answer: In a 13-state project coordinated through Dartmouth Psychiatric Research Center, the percent of people in IPS programs who are employed dropped from 50 percent to 42 percent during the economic downturn. However, some programs continue to achieve rates of employment that are above 50 percent.

Question: As an IPS supervisor, how would I know if my program was performing well?

Answer: A benchmark is something that a program can be measured by; however, benchmarks must be achievable and must also indicate high standards. Additionally, it is helpful to have a benchmark that shows minimal achievement.
Using data from a 13-state learning collaborative that included 8 years of program data, we determined that an IPS program with 33% employment could be considered to be meeting the minimal standard, a program with 45% employment would have achieved average performance, and a program with 57% employment would have demonstrated excellent performance. The mean average across the 8 years was 47% employment.

Job Development

Question:  How do you go about interviewing employers (talking with them about their business needs and hiring preferences)?  Are there certain questions to ask?  Do you wing it?

 Answer:  There are some questions that many employment specialists find to be effective.  You can find a list of those questions in the new practitioner manual, IPS Supported Employment: A Practical Guide (Note: the book will soon be available on our website on the Resource page).  Chapter 4 includes step-by-step instructions for building relationships with employers and includes sample questions, an example of a conversation between an employer and employment specialist, a sample thank-you note, etc.  Another resource is videos of employer meetings.  To find those, go to the Resources & Tools page of this website, select Videos, select Job Development.

 We encourage employment specialists to prepare for meetings with employers by learning a little bit about the company and selecting five or six questions to start the conversation with an employer.  Be sure to avoid asking about job openings.  The purpose of this conversation is to learn more about the employer–if you ask about openings and there are none the employer may feel that there is no point in continuing with the conversation.  Instead, focus on understanding the type of job applicant the employer would like to meet.  You can return a few days later to say, “I have had time to consider your need for workers who have good customer service skills and who are available to work on Sundays.  I think I do know someone who matches that description.  Would you like to hear a little bit about her?”

Question: I recently received some questions surrounding ethical issues and IPS supported employment.  Specifically, the employment supervisor was looking for some sort of “ethical guidelines” for Employment Specialists.  When I asked for examples of specific situations, the following are the two examples I was given:  An IPS client with a psychotic disorder and experiencing command hallucinations to harm or kill children, wanted a job in child care.  Another client of IPS was stealing from elderly patients for whom she worked as a home health care aid.  While I understand these are very extreme examples that stretch beyond ethical issues and into legal issues, I would appreciate any input you could offer.

Answer:  The person experiencing command hallucinations should not be helped with a job in child care.  Employment specialists follow the same guidelines as mental health practitioners when public safety is a concern.  We advise employment specialists to immediately seek consultation with mental health supervisors and psychiatrists who are also working with the person when there are safety concerns.

In regard to the person who is stealing from nursing home residents, because the residents are a vulnerable population, the employment specialist must report the thefts to adult protective services.  The specialist should do that immediately and discuss with her supervisor about meeting with her client, possibly with the IPS supervisor present, to explain her obligation.

Question: We are in the process of creating an Employment Center within our behavioral health facility and are struggling with how we present ourselves to employers. We are of the impression that is best to be open about our affiliation with Creative Health Services and gain consent from employees if we would like to discuss a specific information for employment (non medical information only). It is being strongly suggested, however by our training staff that we should instead create an alternate business cards that has no association with Creative Health and present ourselves as merely a career center. I have attempted to research this issue but have found very little information on the subject. I am hoping you might have some additional resources/insights on this matter as I feel there may be a backlash with an employer relationship if the association is not initially disclosed. Your input would be greatly appreciated.

Answer: We agree with you that it is best to be honest with employers from the start. If you are job developing with the idea that you are building long-term relationships with employers, then you must also treat those employers as your customer. Further, even if you attempt to hide the fact that you work in mental health, employers may find out at some point that you are from a behavioral health facility, so you really cannot guarantee to your clients that this information will remain private.

Our suggestion is to explain to employers (without hesitation) that you work with people who have had mental health problems but have the treatment they need and are ready to work. You could also give some examples, “It is difficult to describe the people I work with because each person has different interests and skills. For example, one person I am working with is a bookkeeper, another is a dishwasher, and another is an aide at a childcare center. Each of these people is performing his job as well as his co-workers.”

Finally, we suggest that you tell your clients that if they do not wish to disclose mental health issues, that you can help with job applications, resumes, finding job leads, following up on applications, and so on. You could also ask if they would like to make their decision about disclosure on an employer-by-employer basis. For example, if you meet with an employer who seems interested in meeting someone from the supported employment program and has the jobs your client is interested in, your client may feel comfortable using disclosure in that situation.

Question: With IPS Supported Employment, what is the benefit to employers?

Answer: The benefit to employers is finding a person who is a good match for the job. Because employment specialists take time to understand the needs of employers before introducing a job candidate, they are able to help employers find candidates who have the skills and attributes each employer is seeking. For example, one manager might want someone who “walks in with a smile on his face” while another manager needs a person who is very reliable. Employers may also be eligible for tax credits such as the Work Opportunities Tax Credit (WOTC). To find out more about this tax credit, go to www.doleta.gov/business/incentives/opptax.

Question: Does the employment specialist talk about the client being in a program for disabled or the like? Do clients sign a waiver or consent form for sharing information with possible employers? Can the employment specialist just talk in generalities about the type of clients they represent?

Answer: We recommend that specialists be upfront about who they are and where they work. For instance, the specialist could say, “I’m an employment specialist, and I work for Community Mental Health Agency.” The employment specialist should view the employer as a customer, so honesty is important. If a client does not wish to disclose information about his or her disability to employers, then the employment specialist can offer to help from “behind the scenes” with job applications, finding job leads, etc. When an employment specialist begins to develop a relationship with an employer who seems to have the types of jobs that would be a good match for one of her clients, then she must obtain a signed release from the client allowing her to share information about the client with the employer.

Question: Since many employers require drug testing, how do you get around drug screening when trying to help a person get employment who may still be actively using?

Answer: As an employment specialist, you would let your client know that an employer may screen for drug use. If the person doesn’t get the job because of the drug test, then the person has more information about how drugs and/or alcohol are affecting his goals. Some people will decide to cut down on substance use while looking for work, and others may decide to look into treatment options. Still others will decide to try to find employers who don’t use drug screening.

Question: Some of our clients have limited income…With that in mind, is there funding to help clients get ready [for job interviews], such as [programs helping people with their] appearance, clothes, hair, makeup, etc.?

Answer: Many areas have programs called “Dress for Success” or other resources to provide clothing for a return to work. You could do an Internet search for Dress for Success in your area and also call social service agencies that might know about other options. For example, your state’s department of Vocational Rehabilitation, Easter Seals, and Career OneStop Centers may have information about where to obtain clothing for people who are returning to work

Question: How is this program implemented in rural districts where employment is limited and places where what the client wants to do is not offered? How would we try to match their wants and needs to what is available?

Answer: If a person wants to drive a bus but there is no public transportation in the area, the employment specialist might begin to talk to others at the mental health agency or at Vocational Rehabilitation to find out whether there are jobs that are similar to driving a bus. She might find out that a program for older adults hires van drivers and that Meals on Wheels hires people to deliver meals. She could take these ideas back to her client for his consideration. Employment specialists can also engage in the job search with their clients. So, if a person wants to work at a hardware store and there is only one in the area, the employment specialist would help him apply at the store (according to his preferences for disclosure) and then ask if he would like to think of other related jobs, such as building supply companies, or wait a bit to find out how things go with the hardware store application.

Question: Is any job development done? Where employment specialists talk to employers in placing the person in the competitive job?

Answer: Employment specialists spend a significant amount of time on job development each week. In fact, specialists in IPS make at least six face-to-face contacts with hiring managers or business owners each week. They make contacts with businesses that have the types of jobs that their clients are interested in obtaining.

Job Supports


Question: I’m interested in cases/examples of IPS teams providing 1:1 support for clients to keep their jobs, and how that support is provided/maintained. I know IPS includes “ongoing” support, but what if the support is too resource-intensive for programs to proivde? Given the cost, it seems IPS programs couldn’t sustain such a level of service, even if it were necessary to the individual keeping his position. Do you have any examples of how IPS programs provide 1:1 supports, if at all, over long periods of time?
Answer: The job supports provided by IPS programs vary from person to person based upon need and desire. Generally, employment specialists are encouraged to provide intensive supports, including face-to-face contact, on a weekly basis for at least the first month of employment. Other supports might include phone calls, meetings with employers to obtain extra feedback, help managing anxiety before going to work in the morning, wake –up calls, on-the-job coaching to learn new duties, etc. The type of supports provided can vary considerably from person to person. If a person needs very intensive job supports for a long period of time, for example, months of on-site job coaching, then the IPS supervisor should question whether that job is actually a good job fit for the person. The supervisor might advise the specialist to help the person find employment that matched his or her skills and abilities so that long-term coaching was not required. Over time, most clients want and require fewer supports and eventually transition off the IPS caseload. On average, clients remain in the IPS program for about a year. This allows new clients to enter the program.

Disclosure


Question: Can you recommend any materials available through the web that address issues of disclosure/non-disclosure and other job development issues for persons who are actively abusing substances (with co-occurring mental illness)?

Answer: There is a worksheet on our website that you may find helpful. The website address is: www.dartmouth.edu/~ips
Go to Resources. Select “IPS Forms & Docs.” Select “Disclosure.” This is a worksheet that helps employment specialists talk about disclosure with their clients. For more information, go to Resources. Select “Recommended Readings.” See description of Supported Employment: A Practical Guide for Practitioners and Supervisors. This manual includes information about disclosure..

Vocational Unit

Question: Why do you have to have two employment specialists for supported employment?

Answer: Forming a unit of at least 2 employment specialists provides the organizational structure for sharing information and resources with each other for better client outcomes. A single employment specialist at an agency typically has no one to help him learn skills such as job development and to share job leads. Further, it is often difficult for a single employment specialist to promote the importance of work and supported employment services with practitioners who may not have similar values.

Some agencies report that it is not possible to hire more than one employment specialist because the mental health program is very small. However, even mental health programs serving as few as 60 people will eventually find that more than one employment specialist is necessary. As mental health practitioners begin to value employment, and clients spread the word about their jobs, it is not uncommon to find that 50-70% of adults served by the mental health program are interested in getting a job.

Rural programs or new supported employment (IPS) programs may find that it is necessary to begin with just one employment specialist. We recommend that these programs try to hire another employment specialist as soon as possible. In the meantime, try to help the employment specialist to connect with other job development programs in the area. For example, VR may be able to make introductions to other programs doing similar work.

Fidelity Reviews

Question:  We are currently conducting  the first fidelity review for 3 IPS programs that began in March 2013. At one of these sites there has been 7 jobs obtained however at the others only 1 or 2. I am seeking advice on how to score the items under the services section of the scale ‘Diversity of job types’, ‘diversity of employers’, ‘competitive jobs’, ‘individualised follow-along supports’ and ‘time unlimited follow along supports’. Do all of these items get scored a 1 until more jobs are obtained? Is there a minimum number of jobs required before these items can be scored.

 Answer:  If there is one employment specialist in the IPS program and fewer than 5 job starts, or two employment specialists and fewer than ten job starts, score the items as follows:

 Diversity of job types:  Score the item “1.”

 Diversity of employers:  Score the item “1.”

 Competitive employment:  Score the item based on the jobs that have been obtained, as well as jobs for which employment specialists have been helping clients apply.

 Individualized follow along supports:  Score based on whether job supports provided are unique to each person’s job, preferences, and needs.

 Time-unlimited follow along supports:  Score the item “1.”

 Going forward, you might consider waiting at least six months before facilitating the baseline fidelity review.  Many program staff report that they appreciate time to participate in IPS training so that they have some accomplishments to show during the first review.

Question: The one area of fidelity that our IPS staff score in the lowest category is  Community Based Services with a score of ³1² – 30% time or less in the community. While job development, coaching and follow along supports take place in the community, most job search activities seem to take place in the office. More time seems to be required to complete long on-line applications that are replacing or in addition to going to the job site to meet the employer. Can you give a broad description of what a typical week for a Vocational Specialist should look like. What does an employment specialist do that is in the community 65% or more of their time?

Answer: Online job applications are time consuming.   We encourage employment specialists to meet in person with employers to learn about their business needs and the type of job candidates they would like to meet.  Employment specialists typically do this through a 20-minute scheduled appointment with a hiring manager.  If a specialist believes that her client is a good fit for the business, she returns to talk about that person and to ask the employer to meet the job seeker.  If the employer agrees, the employment specialist helps the person complete an application prior to the appointment.  Using this process of building relationships with employers reduces the number of job applications that employment specialists and clients complete together because the job seeker is competing with fewer, if any, job applicants.  For more information about this type of job development, see “Resources” on our website (http://www.dartmouth.edu/~ips) to watch a video under “Strategies That Work.”  Another source of information is a manual about IPS that will be available in June from our website, IPS Supported Employment: A Practical Guide.

Some people in the IPS program do not want their employment specialists to talk to employers on their behalf.  In this situation, the job seeker and employment specialist spend more time together completing job applications.

In IPS, employment specialists ask each person where she would like to meet for appointments.  Some people may prefer to come to the IPS offices, but others would appreciate the convenience of meeting closer to home at a library, coffee shop, or in their homes.  Employment specialists schedule four to six hours each week for meeting with employers.  They attend a vocational unit meeting and one to two mental health treatment team meetings each week.  Many employment specialists report that they spend most of their days in the community, returning at the end of the day to return phone calls and complete paperwork.

Question: I want to ask why fidelity in this site has 125 score in total and in some literature authors are using fidelity scale has 75 score in total (Bond GR, Becker DR, Drake RE, et al: A fidelity scale for the Individual Placement and Support model of supported employment. Rehabilitation Counseling Bulletin 40:265-284, 1997.) Is it because it is newer?
Answer: Your conjecture is right.  We revised the fidelity scale, expanding it to 25 items, as attached.  See the last page for the scoring details. A scoring manual is available on this website under the Fidelity tab.

Question: I’m interested in the trajectory of IPS fidelity scores over time. I was recently involved in the fidelity reviews of three Denver-area IPS programs. Two of the programs are in the first year of implementation, and the third program has implemented IPS for a number of years. Not surprisingly, the third established program scored much higher on the fidelity scale than the programs that started more recently. Can you tell me (or point me to resources that could tell me) what fidelity scores typically look like in the first years of IPS implementation versus later years?

Answer: In the National Evidence-Based Practice Project, 9 newly-established IPS supported employment programs all reached good fidelity within the first year of implementation. Eight of the 9 sites maintained good fidelity over the following 12 months. In another study (the Mental Health Treatment Study), we provided technical assistance and fidelity monitoring to 23 sites across the U.S. and found that about 80% of the sites attained high fidelity within the first year of the project and remained at high fidelity over a three-year period. We also know that in states with established IPS technical assistance centers, programs attaining high IPS fidelity typically maintain that level for many years thereafter.

These research findings are based on programs assessed using the original IPS fidelity scale. We have less information about long-term outcomes for the 2008 IPS Fidelity Scale, though we are confident that IPS programs will achieve similar results with the revised scale.

To summarize: Most programs can achieve high fidelity to the IPS model within one year and can maintain that level for many years thereafter, provided funding remains at appropriate levels, the leadership remains committed maintaining standards, and appropriate supervision and monitoring continues.

Question: I want to ask why fidelity in this site has 125 score in total and in some literature authors are using fidelity scale has 75 score in total (Bond GR, Becker DR, Drake RE, et al: A fidelity scale for the Individual Placement and Support model of supported employment. Rehabilitation Counseling Bulletin 40:265-284, 1997.) Is it because it is newer?

Answer: Your conjecture is right.  We revised the fidelity scale, expanding it to 25 items, as attached.  See the last page for the scoring details. A scoring manual is available on this website under the Fidelity tab.

Question: Who conducts a fidelity review and who sponsors the review?

Answer: In some states, state supported employment trainers are available to conduct supported employment fidelity reviews. These trainers usually work for either Vocational Rehabilitation, a department of mental health or a state-supported center of excellence for supported employment. Some states have hired people (other than trainers) specifically to conduct supported employment fidelity reviews. If your state is not one of the states participating in the Johnson & Johnson-Dartmouth Community Mental Health Program (CT, KY, KS, IL, MD, MN, MO, OH, OR, SC, VT, WI, District of Columbia) then it is possible that a state fidelity reviewer is not available.

External fidelity reviewers who have been trained in supported employment are the ideal candidates for conducting fidelity reviews. However, if such a person is not available, agencies can still benefit by using the fidelity scale. Dartmouth Psychiatric Research Center (PRC) has Supported Employment Fidelity Kits (available through this website) that include the fidelity scale, fidelity manual, demonstration DVD and sample fidelity reports. Two to three people from the agency who are not closely connected to the SE program (for example, people who work in the QA department) might spend time becoming familiar with the fidelity materials and then conduct a review for the agency. The fidelity manual provides detailed information about conducting reviews, scoring items and writing reports.

New fidelity reviewers who have questions about the scale or scoring items should also feel free to submit their questions to this website.

Benefits Planning/ Medicaid

Question: Does competitive employment affect Medicaid status and continued enrollment and support from community mental health service providers?

Answer: Paid employment can affect Medicaid status depending upon the amount earned and each person’s individual situation. We recommend that people meet with a trained benefits specialist, such as a representative from WIPA (Work Incentives Planning Assistance). To find out more about WIPA, go to http://www.ssa.gov/work/wipafactsheet.html. Counselors at Vocational Rehabilitation and One Stop Centers may know of other trained benefits planners.

Question: How is IPS and Supported Employment viewed by Medicaid?  We have a waiver in our state and Supported Employment is considered B 3 services. Do you have any tools that crosswalk IPS with Medicaid standards?

Answer: Medicaid plans vary from state to state. We recommend that you speak with someone from your state Medicaid office.

Program Implementation

Question: I work at a state psychiatric hospital which serves the adult population and also has a forensic population.  We have a work program that has been dormant for some time, but we are now in the process of expanding and re-developing the program to assist the patients in gaining on-campus (or off-campus) employment in preparation for their transition to the community.  We would like to develop this program to match the IPS model as closely as possible.  What resources or training opportunities would you suggest in order to appropriately develop this program for our institution?

Answer: To learn about the IPS approach, we suggest some of the free resources on our website (see “About IPS”).  There you will find descriptions of the practice.  Under “Resources” you can find demonstration videos.  We also offer an online course for IPS supervisors and practitioners three times each year.  The next course will be offered beginning September 23.  A description of the course is on our website.  In late June, an updated version of a practitioner’s manual will be available from our website.   Finally, program administrators may be interested in Individual Placement and Support, An Evidence-Based Approach to Supported Employment by Drake, Bond, and Becker, published by Oxford Press.

Question: What type of training and support do employment specialists receive?

Answer: Because very few people come to the job with related experience, we recommend that IPS supervisors develop an orientation program for each employment specialist that includes a long period of training. Examples of some activities might include:
1. Reading about IPS supported employment. Many materials can be found at this website. Another source of information about IPS is the online course which is also described at this website.
2. Shadowing another employment specialist while he or she conducts job development and client contacts.
3. Going out with the IPS supervisor to conduct job development weekly for at least the first month, and then 1-2x/month for the next couple of months at least.
4. Shadowing a case manager or other mental health practitioner.
5. Attending some mental health treatment team meetings with the IPS supervisor who can model how to be a member of the team.
6. Observing the IPS supervisor as she or he works on the career profile with a client new to the program.
7. Weekly individual supervision for the first six months.

Question: I’m interested in the trajectory of IPS fidelity scores over time. I was recently involved in the fidelity reviews of three Denver-area IPS programs. Two of the programs are in the first year of implementation, and the third program has implemented IPS for a number of years. Not surprisingly, the third established program scored much higher on the fidelity scale than the programs that started more recently. Can you tell me (or point me to resources that could tell me) what fidelity scores typically look like in the first years of IPS implementation versus later years? Thank you!

Answer: In the National Evidence-Based Practice Project, 9 newly-established IPS supported employment programs all reached good fidelity within the first year of implementation. Eight of the 9 sites maintained good fidelity over the following 12 months. In another study (the Mental Health Treatment Study), we provided technical assistance and fidelity monitoring to 23 sites across the U.S. and found that about 80% of the sites attained high fidelity within the first year of the project and remained at high fidelity over a three-year period. We also know that in states with established IPS technical assistance centers, programs attaining high IPS fidelity typically maintain that level for many years thereafter.

These research findings are based on programs assessed using the original IPS fidelity scale. We have less information about long-term outcomes for the 2008 IPS Fidelity Scale, though we are confident that IPS programs will achieve similar results with the revised scale.

To summarize: Most programs can achieve high fidelity to the IPS model within one year and can maintain that level for many years thereafter, provided funding remains at appropriate levels, the leadership remains committed maintaining standards, and appropriate supervision and monitoring continues.

Question: We are in the process of creating an Employment Center within our behavioral health facility and are struggling with how we present ourselves to employers. We are of the impression that is best to be open about our affiliation with Creative Health Services and gain consent from employees if we would like to discuss a specific information for employment (non medical information only). It is being strongly suggested, however by our training staff that we should instead create an alternate business cards that has no association with Creative Health and present ourselves as merely a career center. I have attempted to research this issue but have found very little information on the subject. I am hoping you might have some additional resources/insights on this matter as I feel there may be a backlash with an employer relationship if the association is not initially disclosed. Your input would be greatly appreciated.

Answer: We agree with you that it is best to be honest with employers from the start. If you are job developing with the idea that you are building long-term relationships with employers, then you must also treat those employers as your customer. Further, even if you attempt to hide the fact that you work in mental health, employers may find out at some point that you are from a behavioral health facility, so you really cannot guarantee to your clients that this information will remain private.

Our suggestion is to explain to employers (without hesitation) that you work with people who have had mental health problems but have the treatment they need and are ready to work. You could also give some examples, “It is difficult to describe the people I work with because each person has different interests and skills. For example, one person I am working with is a bookkeeper, another is a dishwasher, and another is an aide at a childcare center. Each of these people is performing his job as well as his co-workers.”

Finally, we suggest that you tell your clients that if they do not wish to disclose mental health issues, that you can help with job applications, resumes, finding job leads, following up on applications, and so on. You could also ask if they would like to make their decision about disclosure on an employer-by-employer basis. For example, if you meet with an employer who seems interested in meeting someone from the supported employment program and has the jobs your client is interested in, your client may feel comfortable using disclosure in that situation.

Question: What tools are available to help transition from a day program / sheltered workshop / traditional vocational model to this model?

Answer: There are many tools and resources available at the Dartmouth website: http://www.dartmouth.edu/~ips/. In addition, an Implementation Kit for IPS programs may be purchased by selecting the tab that reads “Order Books and Materials.”

Question: How important is caseload size when working in supported employment?

Answer: Caseload size is very important. Programs should strive for caseloads of 20 or fewer. If that is not possible, then programs should attempt to have caseloads of no more than 25 (which would be the equivalent of a score of 4 on the fidelity scale).

Question: If we know that a job location has a very bad reputation for drugs, etc., and I have a client that has asked to work at that location what should I do?

Answer: You might share the information that you have so that your client can make an informed choice about where to work. If your client still wants to work in the area that has a bad reputation, talk to the person about plans for getting to and from work safely. You might also include a case manager or counselor in the support plan if drugs are a problem for your client.

Engagement

Question: Could you please clarify or point me in the direction re:  Dartmouth’s view re: job shadowing. I was just in a meeting with an employment specialist who suggested a job shadow.

Answer: If a person is not sure what type of work she would like to do, or would like to find out more about a particular company, going to visit a workplace for a few hours is definitely in keeping with the IPS approach. Some examples might be:
A person who hadn’t worked much in her life and didn’t know much about jobs. In this case, an employment specialist might ask her if she would be interested in visiting a few businesses to observe workers. They might talk for awhile first so that the employment specialist had a sense of the types of jobs that might interest the person, and then visit a few places that had those types of jobs.
A person who thought that she might be interested in working as an assistant in an optometrist’s office but didn’t know much about that type of work. The employment specialist could offer to set up an appointment to meet with an optometrist or an assistant to ask questions about the job and, if possible, observe the assistant at work for a few hours.

If the job shadowing is actually an assessment (e.g., to see if the person will arrive on time, will conduct herself appropriately for that environment, and so on) that would not be in keeping with the IPS approach. Further, all job shadowing should be something that the client wants to do, not an activity required by the employment specialist.

Question: How do you determine if an individual is inactive? Often we find that some individuals are active and then do not meet for 3 weeks or 2 months etc. They remain on our data sheets and we don’t know if we should still be making contacts for them or when to cease making those contacts. Having individuals on our data who aren’t active effect the outcomes of the data in a negative way.

Answer: We recommend that employment specialists focus on learning what is getting in the person’s way of continuing with the employment plan. They can do that by talking to members of the mental health team, family members (with permission), trying to call the person, making home visits, sending letters, etc. The focus is not to inform the person that she must attend appointments in order to get a job or to stay in the program. Rather, the focus is to understand, from the person’s point of view, why she has not been available to work on her employment goal. For example, if she has been missing appointments because of childcare issues, the employment specialist might ask team members to help her with that problem. If she has been missing appointments because it is hard to remember, the employment specialist could offer to call on the morning of appointments or provide other types of reminders. If the person reports that she no longer wants to work, the employment specialist would close her case for the time being.

Some of the questions in this column were submitted after a webinar hosted by Hazelden on IPS supported employment. More information about the webinar may be found at www.bhevolution.org.

Supervision of IPS

Question:  I am wondering if an IPS supported employment supervisor with four full-time employment specialists and one part-time peer could also take on the role as lead Microenterprise worker. The lead microenterprise worker would help people set up small businesses that need very little capitol (less than $500) in start-up funds.  The businesses are related to each person’s interests—often expanding someone’s hobby into a way to earn money.  I also wonder how the microenterprise fits with the IPS approach.  

Answer:  Self-employment falls under the definition of competitive employment in IPS because it is work that many people do regardless of disability status.  We encourage employment specialists and supervisors to  follow each person’s preferences, including preferences about self-employment.  We recommend that those who help with self-employment are knowledgeable about small businesses, including setting up systems for bookkeeping, paying taxes, etc.  Many IPS programs partner with Vocational Rehabilitation because of their expertise in this area.

In regards to whether the IPS supervisor will be directly responsible for helping people start microenterprises, we urge you to ensure that he or she has sufficient time for supervision.  In IPS,  the supervisor works side-by-side with employment specialists to help them develop skills for their jobs.  The supervisor also strives to know most people served by the program so that she can provide helpful suggestions to employment specialists.  IPS supervisors act as liaisons with mental health supervisors and Vocational Rehabilitation, and they review program outcomes so that they can develop program goals and strategies to help more people achieve their employment goals.  It may be difficult for a supervisor to accomplish all of this while also helping people set up microenterprises.

Question: What type of training and support do employment specialists receive?

Answer: Because very few people come to the job with related experience, we recommend that IPS supervisors develop an orientation program for each employment specialist that includes a long period of training. Examples of some activities might include:
1. Reading about IPS supported employment. Many materials can be found at this website. Another source of information about IPS is the online course which is also described at this website.
2. Shadowing another employment specialist while he or she conducts job development and client contacts.
3. Going out with the IPS supervisor to conduct job development weekly for at least the first month, and then 1-2x/month for the next couple of months at least.
4. Shadowing a case manager or other mental health practitioner.
5. Attending some mental health treatment team meetings with the IPS supervisor who can model how to be a member of the team.
6. Observing the IPS supervisor as she or he works on the career profile with a client new to the program.
7. Weekly individual supervision for the first six months.

Education

Question: I work in the UK and appreciate that IPS focuses on paid employment and education, could you help me define what you would regard as educational goals? At the moment our programme would see people who want to attend a craft course or a confidence building course, for example, and refer to this as an educational goal even if it has no relevance to their work aspirations or if they have no work aspirations at all.

Answer: If a person wanted to go to school for personal enrichment, such as taking a craft course or confidence building course, we would encourage the case manager or therapist to provide support. Because IPS is almost always a limited resource, we encourage IPS supported employment programs to reserve space in the program for people who have competitive employment goals. For example, if someone wanted to get a degree in Human Resources so that they could eventually work in that field, then the IPS supported employment program might provide support. Another example might be a person who wanted to take a QuickBooks class in order to get a job as a bookkeeper. It’s also important to consider whether or not the person needs the kind of intensive supports provided by IPS programs. If a person just needed some encouragement to persist at her education goals, she might not need a referral to IPS.

Question: What is the place of attending college in the IPS model?  In a multi-agency collaborative offering wellness, housing and employment support,  a number of the clients are full-time students (both BA and graduate) who would benefit from a focus on career counseling rather than direct, immediate employment.  How does supporting a person in college fit into ‘individualized placement and support” ?  Thank you for your assistance in this.

Answer:  Education is a service that can be offered by IPS supported employment programs if the following apply:
1.       The education or training program is open to the public, not a program intended just for people with disabilities.  For example, a work adjustment program that taught good work behaviors and janitorial skills would not be utilized by IPS programs.  On the other hand, IPS programs would help people learn about local options such as colleges, community colleges, joint vocational schools and GED programs.
2.       The person’s long-term goal is employment.  For example, if a person wanted to pursue a degree in accounting so that she could eventually obtain a job in accounting, she might be a good referral to IPS.  If a person wanted to take some courses for personal enrichment, that person would not be a good referral to IPS.  In that situation, we would suggest that the mental health practitioner could provide supports for school.
3.       The person needs a significant amount of help to succeed at school.   If the person only needs some ongoing encouragement and a bit of help with problem-solving, we would suggest that the mental health practitioner could provide those services.  Typically, IPS is terrifically understaffed–there are usually just a handful of employment specialists in relationship to the number of people served by the behavioral health agency.  Therefore, agencies must use that resource well and ask mental health practitioners to provide school supports when they are able to meet a client’s needs.

Examples of supported education services an IPS program might provide include: taking a person to visit schools, arranging meetings with a guidance counselor to talk about the different types of degrees or programs available, helping a person sign up for services with the school’s office for students with disabilities, helping a student talk to a professor to ask for extra help, helping students structure study time and learn study skills, helping students apply for financial aid, and so on.   If a program decided that employment specialists should provide career counseling (as you suggested), then the program should be sure to hire people who are well qualified in that area.  For example, have degrees in vocational rehabilitation, experience and training in career counseling, etc.  Otherwise, programs might collaborate with Vocational Rehabilitation when clients are unsure about their career goals.

Finally, just to clarify, rapid job search means that most people in the IPS program have contact with an employer soon after entering the program.  It is understood that some people may attend school or just spend time learning about available jobs in the community.

Question: What is the place of attending college in the IPS model?  In a multi-agency collaborative offering wellness, housing and employment support,  a number of the clients are full-time students (both BA and graduate) who would benefit from a focus on career counseling rather than direct, immediate employment.  How does supporting a person in college fit into ‘individualized placement and support” ?

Answer:  Education is a service that can be offered by IPS supported employment programs if the following apply:
1.       The education or training program is open to the public, not a program intended just for people with disabilities.  For example, a work adjustment program that taught good work behaviors and janitorial skills would not be utilized by IPS programs.  On the other hand, IPS programs would help people learn about local options such as colleges, community colleges, joint vocational schools and GED programs.
2.       The person’s long-term goal is employment.  For example, if a person wanted to pursue a degree in accounting so that she could eventually obtain a job in accounting, she might be a good referral to IPS.  If a person wanted to take some courses for personal enrichment, that person would not be a good referral to IPS.  In that situation, we would suggest that the mental health practitioner could provide supports for school.
3.       The person needs a significant amount of help to succeed at school.   If the person only needs some ongoing encouragement and a bit of help with problem-solving, we would suggest that the mental health practitioner could provide those services.  Typically, IPS is terrifically understaffed–there are usually just a handful of employment specialists in relationship to the number of people served by the behavioral health agency.  Therefore, agencies must use that resource well and ask mental health practitioners to provide school supports when they are able to meet a client’s needs.

Examples of supported education services an IPS program might provide include: taking a person to visit schools, arranging meetings with a guidance counselor to talk about the different types of degrees or programs available, helping a person sign up for services with the school’s office for students with disabilities, helping a student talk to a professor to ask for extra help, helping students structure study time and learn study skills, helping students apply for financial aid, and so on.   If a program decided that employment specialists should provide career counseling (as you suggested), then the program should be sure to hire people who are well qualified in that area.  For example, have degrees in vocational rehabilitation, experience and training in career counseling, etc.  Otherwise, programs might collaborate with Vocational Rehabilitation when clients are unsure about their career goals.

Finally, just to clarify, rapid job search means that most people in the IPS program have contact with an employer soon after entering the program.  It is understood that some people may attend school or just spend time learning about available jobs in the community.

Question: I work in the UK and appreciate that IPS focuses on paid employment and education, could you help me define what you would regard as educational goals? At the moment our programme would see people who want to attend a craft course or a confidence building course, for example, and refer to this as an educational goal even if it has no relevance to their work aspirations or if they have no work aspirations at all.

Answer: If a person wanted to go to school for personal enrichment, such as taking a craft course or confidence building course, we would encourage the case manager or therapist to provide support. Because IPS is almost always a limited resource, we encourage IPS supported employment programs to reserve space in the program for people who have competitive employment goals. For example, if someone wanted to get a degree in Human Resources so that they could eventually work in that field, then the IPS supported employment program might provide support. Another example might be a person who wanted to take a QuickBooks class in order to get a job as a bookkeeper. It’s also important to consider whether or not the person needs the kind of intensive supports provided by IPS programs. If a person just needed some encouragement to persist at her education goals, she might not need a referral to IPS.
Collaboration with VR

Question: A pilot program is attempting to implement true IPS SE but is having difficulty because the local DVR office, which must approve all cases, continues to use the traditional, restrictive definition of job readiness.  One reason for this is the DVR counselors are evaluated on performance standards that encourage counselors to serve as many people as possible, leading them to ‘cream’- i.e., serve only the seemingly more capable consumers and not help those deemed ‘not ready’ to seek work. Have you encountered this problem and would you have any solutions to suggest?  Do you know of organizations that have revised counselors’ performance standards to go beyond mere numbers and reflect the challenges of working with those having more severe conditions?

Answer:  If you check the VR page of our website, you will see some examples of how state VR offices have made changes so that their counselors can faithfully implement IPS.  To do this, leaders at the state level first became interested in having IPS programs and then worked with agencies and local offices to make changes.  Something else that is important to note is that in most states, not every person who receives IPS services also receives VR services.  Instead, state mental health helps local programs identify sources of funding so that a few people can receive IPS without VR funding, and also so that people can receive job supports after their VR case is closed.

Collaboration with Vocational Rehabilitation

Question: I have implemented IPS model for adults in the mental health system. I will soon begin working on a project to develop interagency collaboration with Special Education and the Department of Rehabilitation (VR)  with day treatment programs within a school district. My  goal is to school to work transition outcomes for  students ages 14-21 for youth with psychiatric disabilities.   I want to implement the some aspects of the IPS model and would like some feedback about whether this intervention  might be a course action to take or if an alternative method/model has been researched.  I am currently conducting a literature review and would like some feedback on  studies/models that  I can implement or  research.

Answer:  IPS supported employment has been implemented in programs for people experiencing a first episode of psychosis (typically adolescents and young adults) with success in the U.S and other countries.  References for those research studies are below.  In these instances, IPS specialists helped many people with work and school.  We have limited research experience in the area of transition age youth.

Killackey, E., Jackson, H. J., & McGorry, P. D. (2008). Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual. British Journal of Psychiatry, 193, 114-120.

Nuechterlein, K.H., Subotnik, K.L., Turner, L.R., Ventura, J., Becker, D.R., & Drake, R.E. (2008).  Individual placement and support for individuals with recent-onset schizophrenia: Integrating supported education and supported employment. Psychiatric Rehabilitation Journal, 31, 340-349.

Rinaldi, M., Killackey, E., Smith, J., Shepherd, G., Singh, S.P., & Craig, T.  (2010)    First episode psychosis and employment:  A review.  International Review of Psychiatry, 22, 148-162.

 

© 2010 Matt Merrens Contact Me