Psychiatric Rehabilitation Journal 2014, Vol. 37, No. 2, 86 – 89
© 2014 American Psychological Association 1095-158X/14/$12.00 DOI: 10.1037/prj0000049
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Strategies for Integrated Employment and Mental Health Services Sarah J. Swanson
Claire T. Courtney
Dartmouth Psychiatric Research Center, Lebanon, New Hampshire
Minnesota Department of Employment and Economic Development-Vocational Rehabilitation Services, St. Paul, Minnesota
Robert H. Meyer
Steven A. Reeder
University of Wisconsin-Madison
Maryland Department of Health and Mental Hygiene, Catonsville, Maryland
Objective: Individual placement and support (IPS) supported employment for people with mental illness is most effective when mental health and employment services are fully integrated within teams in a single agency. Despite this evidence, there are times when separate mental health and employment agencies must collaborate rather than integrate. This article examines how 3 state implementation teams helped separate agencies to partner on IPS supported employment. Method: The authors used qualitative interviews and direct observations to examine successful collaborations in 3 states. We visited IPS programs on multiple occasions, interviewed multiple stakeholders, and evaluated adherence to the principles of IPS. Results: Leaders used 4 strategies to promote successful collaborations: (a) ensuring that employment specialists, and in some cases, vocational rehabilitation counselors, attended mental health treatment team meetings; (b) providing office space for employment staff at the mental health agency; (c) involving supervisors from both agencies in the implementation; and (d) using fidelity reviews to assess the quality of collaboration. Conclusions and Implications for Practice: Practitioners from separate agencies can coordinate services effectively, but successful coordination requires leadership at the state and local levels. Keywords: individual placement and support, supported employment, integrated services
outcomes than nonintegrated services (Bond, Peterson, Becker, & Drake, 2012; Campbell et al., 2007; Cook et al., 2005; Drake, Becker, Bond, & Mueser, 2003). In addition, both service providers (employment specialists and mental health practitioners) often relate to state vocational rehabilitation counselors who can enhance service provision. Full integration may, however, be difficult or impossible due to local factors, such as organizational and financial constraints. In these situations, mental health and employment personnel from separate agencies must collaborate. Collaboration denotes a lesser degree of integration, implying that mental health and employment personnel work for different agencies, are located in different buildings, use different record systems, have less frequent contact, and so on. State implementation teams have been instrumental in improving collaboration between agencies (Drake, Becker, Goldman, & Martinez, 2006). These teams include a member of the state mental health authority and a member of state vocational rehabilitation. In most cases, a full-time individual placement and support (IPS) trainer also participates on the team. The group attempts to change policies and funding to facilitate IPS implementation, as well as provide technical assistance to IPS programs. Close to 20% of states and regions in the Johnson & Johnson– Dartmouth Community Mental Health Program have some agencies in which collaboration is used rather than full integration. The purpose of this analysis was to describe the background and
Integration means that two types of services are combined and provided by the same team. For evidence-based supported employment, full integration implies that employment specialists and mental health practitioners work for the same agency, participate in weekly meetings together, develop strategies to help find jobs together, share office space, meet informally every day, use the same record system, and share responsibilities, such as supporting a person who is working (Drake, Bond, & Becker, 2012). In integrated services, co-location of services facilitates timely communication between practitioners for planning and coordinating supports to help people with employment. Integrated services robustly produce better employment
This article was published Online First April 7, 2014. Sarah J. Swanson, Geisel School of Medicine at Dartmouth, Dartmouth Psychiatric Research Center, Lebanon, New Hampshire; Claire T. Courtney, Rehabilitation Program Consultant, Minnesota Department of Employment and Economic Development-Vocational Rehabilitation Services, St. Paul, Minnesota; Robert H. Meyer, Department of Rehabilitation Psychology and Special Education, University of Wisconsin-Madison; Steven A. Reeder, Office of Adult Services, Mental Hygiene Administration, Maryland Department of Health and Mental Hygiene, Catonsville, Maryland. Correspondence concerning this article should be addressed to Sarah J. Swanson, Dartmouth Psychiatric Research Center, Rivermill Commercial Center, 85 Mechanic St., Suite B4-1, Lebanon, NH 03766. E-mail: [email protected] 86
INTEGRATED EMPLOYMENT AND MENTAL HEALTH SERVICES
strategies of collaboration in the three states where they were prevalent.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Method As a part of state IPS implementation efforts, the coauthors of this article made multiple visits to agencies that collaborate on IPS to interview practitioners, people served by the IPS programs, and program leaders. The coauthors also observed mental health and IPS practitioners working together and discussed methods to increase team efforts to help clients with work. Finally, we discussed each program in detail to reach consensus regarding successful strategies. Visits to the agencies were part of ongoing technical assistance that occurred over a 2- to 10-year period, based on how long the IPS program had been operating. Initially, agencies received at least monthly technical assistance visits and annual (or twice yearly) fidelity reviews.
Results The three states described in this article are part of a national IPS learning collaborative that requires IPS program supervisors to report a simple set of outcomes each quarter. The average employment rate for all of the programs in the learning collaborative is 43% (Becker, Drake, & Bond, 2011). The quarterly employment rate is the number of people who obtained employment relative to the number of people who received IPS in the quarter. As displayed in Figure 1, brokered IPS programs in Maryland and Minnesota have surpassed 43% employment, while the brokered IPS programs in Wisconsin have not yet reached that milestone. The Wisconsin programs were only 1 to 2 years old when they reported the data presented in this article, whereas the IPS programs in the other states had 6 to 10 years of experience.
Minnesota Two thirds of the IPS programs in Minnesota used collaboration between separate agencies rather than integrated services, due to targeted state funds that Vocational Rehabilitation Services had historically used for grant funding to employment programs. Prior to implementing IPS, Vocational Rehabilitation had set-aside
87
funding for agencies to support community employment for people with serious mental illnesses. Because the mental health authority did not have dedicated funds for employment, the state implementation team decided to build upon the established grant funding and include employment agencies (also known as community rehabilitation providers) in IPS. Although implementing IPS across separate agencies posed challenges, the advantages were an established procedure for paying for services and a positive history of working with employment agencies. To foster collaboration, the state implementation team encouraged leaders at mental health agencies to use weekly mental health treatment team meetings. They addressed concerns about confidentiality by giving agency leaders templates of a business associate’s agreement and by clarifying privacy and confidentiality in accordance with the Minnesota Data Practices Act. Some agency leaders also agreed to create office space for employment specialists within their agencies. The state implementation team assessed adherence to the IPS approach through the use of the Supported Employment Fidelity Scale. Fidelity visits included interviewing practitioners and leaders from both agencies. To enhance collaboration, cross-agency work groups (sometimes referred to as IPS steering committees) developed fidelity improvement plans. The work groups helped mental health practitioners understand their roles in employment, streamlined referrals to the IPS program, and reinforced that employment is the mission of both agencies. The state implementation team trained both mental health and employment practitioners. The IPS programs operated by mental health centers have also struggled to achieve good integration. Other than Assertive Community Treatment teams, mental health practitioners in Minnesota were not typically organized into treatment teams. Implementing IPS meant that these agencies had to create teams. As an example, one mental health center that served three counties developed mental health treatment teams in each county with assigned employment specialists and Vocational Rehabilitation counselors. Collaboration with Vocational Rehabilitation was key in Minnesota. Typically, Vocational Rehabilitation counselors had been unable to collaborate with treatment providers in a meaningful way, due to high caseloads and other factors. To remove this barrier, the state Vocational Rehabilitation leaders assigned one or more counselors to each IPS program. These counselors’ caseloads included a significant number of people from the IPS program, and that allowed them to collaborate, not just with employment specialists but also with mental health treatment providers. Vocational Rehabilitation counselors attended weekly or monthly employment unit meetings and often attended some mental health treatment team meetings. In some cases, counselors also had part-time office space at the mental health center.
Wisconsin
Figure 1. Employment outcomes for brokered IPS programs in three states.
In Wisconsin, the county mental health boards have had significant latitude in developing local mental health services. Some county administrators were reluctant to approve hiring any additional staff, forcing mental health agency leaders to contract with local employment agencies to provide IPS services. This approach was sometimes more expensive for mental health agencies than hiring employment specialists directly. Another disadvantage was that mental health agencies had less control over how IPS services
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
88
SWANSON, COURTNEY, MEYER, AND REEDER
were provided. For example, when a vocational agency did not deliver good employment outcomes, the mental health agency had to wait until the year ended to change the contract or find another employment provider. The most effective method for improving integration was to create office space for employment specialists at mental health agencies. Shared office space fostered daily communication about shared cases. Close proximity also led to personal relationships that enhanced trust and collaboration. Employment specialists returned to the employment agency only for vocational meetings and individual supervision. As a part of IPS, employment specialists and Vocational Rehabilitation counselors met to collaborate about cases. In addition, Vocational Rehabilitation counselors also attended mental health treatment team meetings each month, thus allowing practitioners from all three systems to discuss strategies. Further, when Vocational Rehabilitation counselors, who help pay for IPS, attended meetings they were demonstrating the importance of integrated services. The state IPS trainer helped to boost collaboration through in-person technical assistance and fidelity reviews. He attended mental health treatment team meetings to discuss collaboration and to engage the mental health practitioners in discussions about employment. During annual fidelity reviews, the trainer assessed the level of collaboration between service providers and afterward worked with both agencies to coauthor a written plan for improvement. Business associates agreements between the mental health agency and employment agency allowed employment specialists to participate in the entire mental health treatment team meetings, including discussions of people who had not yet been referred to IPS. When the mental health agency listed the employment specialist as part of the treatment team during the state’s recertification process, some programs were reimbursed for the employment specialist’s time in team meetings.
Maryland Maryland’s move to a fee-for-service Medicaid system in the late 1990s included robust efforts to include specialized mental health treatment providers in the mental health system, especially those providers who could provide culturally competent services. The goal was to provide client choice regarding mental health providers from specific countries, faiths, and so forth. One disadvantage of this system was that as clients chose providers from mental health agencies, group practices, and single practitioners, employment specialists sometimes needed to coordinate services with mental health practitioners who were not part of their own organizations. To improve collaboration, Maryland’s Department of Mental Health and Hygiene used two strategies: payment for time spent integrating services and annual fidelity reviews to ensure good quality of collaboration. When clients did not receive clinical and employment services at the same agency, employment specialists met monthly with primary mental health providers. Contact could be by phone or in person, but the contact must have substantively influenced both service plans. Some IPS programs shared reimbursement with mental health providers to encourage good collaboration. When clients received services from a mental health agency, employment
specialists attended weekly mental health treatment team meetings. The state also paid agencies to have treatment team meetings for individual clients every 6 months. IPS fidelity reviews ensured the quality and quantity of collaboration required by the state. Trained fidelity reviewers conducted annual reviews that included speaking with some people served by the program, looking for congruence of service plans from both systems, and reviewing documentation of communications between providers.
Discussion Evidence-based practices are optimally implemented just as they were designed in order to produce the best outcomes. Because some aspects of IPS supported employment may not align with local services, state implementation teams must make adjustments. This article describes three states in which the implementation teams assisted programs in achieving varying levels of collaboration. Using a brokered system to implement IPS requires extra work and extra expense, especially when state implementation teams must provide technical assistance to two agencies. Another challenge is that some mental health agency leaders (especially those who have not provided employment services) do not view employment as part of their mission, but instead expect employment agencies to address employment. Employment agencies may find it awkward to outsource staff who will receive direction from mental health practitioners. Agency leaders and practitioners from separate agencies may also have concerns about confidentiality. State implementation teams must address all of these issues. At the agency level, successful strategies included requiring employment specialists to join mental health team meetings, colocating employment specialists with mental health teams, using fidelity reviews to develop plans for improvement, involving agency leaders in defining employment as a central part of recovery, and involving counselors from Vocational Rehabilitation. All state implementation teams have required that employment specialists join mental health treatment teams, and some states have also provide financial incentives for collaboration. Co-location of employment specialists appears to be an especially helpful method to integrate services. State implementation teams use fidelity reviews as a tool to ensure that integration is of good quality. Further, the state implementation teams model the partnership by including people from both agencies in fidelity reviews and the planning process for improving IPS services. Another method to improve integration between mental health services and IPS is to intensify collaboration with state Vocational Rehabilitation. Vocational Rehabilitation counselors are better able to join the teams if they are identified to be liaisons to the project and will receive most of the IPS referrals. Vocational Rehabilitation counselors also benefit from learning about IPS and receiving direction from Vocational Rehabilitation leaders about how to incorporate IPS principles into their practice. With all of these steps, separate agencies can collaborate successfully and approximate complete or functional integration. Of course, the real goal is successful employment for all interested consumers, not process. Collaboration and integration are strategies to help people to achieve and maintain successful employment.
INTEGRATED EMPLOYMENT AND MENTAL HEALTH SERVICES
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
References Becker, D. R., Drake, R. E., & Bond, G. R. (2011). Benchmark outcomes in supported employment. American Journal of Psychiatric Rehabilitation, 14, 230 –236. doi:10.1080/15487768.2011.598083 Bond, G. R., Peterson, A. E., Becker, D. R., & Drake, R. E. (2012). Validating the revised Individual Placement and Support Fidelity Scale (IPS-25). Psychiatric Services, 63, 758 –776. doi:10.1176/appi.ps .201100476 Campbell, K., Bond, G. R., Gervey, R., Pascaris, A., Tice, S., & Revell, G. (2007). Does type of provider organization affect fidelity to evidencebased supported employment? Journal of Vocational Rehabilitation, 27, 3–11. Cook, J. A., Lehman, A. F., Drake, R. E., McFarlane, W. R., Gold, P. B., Leff, H. S., . . . Grey, D. D. (2005). Integration of psychiatric and vocational services: A multisite randomized, controlled trial of supported employment. The American Journal of Psychiatry, 162, 1948 – 1956. doi:10.1176/appi.ajp.162.10.1948
89
Drake, R. E., Becker, D. R., Bond, G. R., & Mueser, K. T. (2003). A process analysis of integrated and non-integrated approaches to supported employment. Journal of Vocational Rehabilitation, 18, 51–58. Drake, R. E., Becker, D. R., Goldman, H. H., & Martinez, R. A. (2006). Best practices: The Johnson & Johnson–Dartmouth Community Mental Health Program: Disseminating evidence-based practice. Psychiatric Services, 57, 302–304. doi:10.1176/appi.ps.57.3.302 Drake, R. E., Bond, G. R., & Becker, D. R. (2012). IPS supported employment: An evidence-based approach to supported employment. New York, NY: Oxford University Press. doi:10.1093/acprof:oso/ 9780199734016.001.0001
Received November 7, 2013 Revision received January 6, 2014 Accepted January 7, 2014 䡲
© 2014 American Psychological Association 1095-158X/14/$12.00 DOI: 10.1037/prj0000049
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Strategies for Integrated Employment and Mental Health Services Sarah J. Swanson
Claire T. Courtney
Dartmouth Psychiatric Research Center, Lebanon, New Hampshire
Minnesota Department of Employment and Economic Development-Vocational Rehabilitation Services, St. Paul, Minnesota
Robert H. Meyer
Steven A. Reeder
University of Wisconsin-Madison
Maryland Department of Health and Mental Hygiene, Catonsville, Maryland
Objective: Individual placement and support (IPS) supported employment for people with mental illness is most effective when mental health and employment services are fully integrated within teams in a single agency. Despite this evidence, there are times when separate mental health and employment agencies must collaborate rather than integrate. This article examines how 3 state implementation teams helped separate agencies to partner on IPS supported employment. Method: The authors used qualitative interviews and direct observations to examine successful collaborations in 3 states. We visited IPS programs on multiple occasions, interviewed multiple stakeholders, and evaluated adherence to the principles of IPS. Results: Leaders used 4 strategies to promote successful collaborations: (a) ensuring that employment specialists, and in some cases, vocational rehabilitation counselors, attended mental health treatment team meetings; (b) providing office space for employment staff at the mental health agency; (c) involving supervisors from both agencies in the implementation; and (d) using fidelity reviews to assess the quality of collaboration. Conclusions and Implications for Practice: Practitioners from separate agencies can coordinate services effectively, but successful coordination requires leadership at the state and local levels. Keywords: individual placement and support, supported employment, integrated services
outcomes than nonintegrated services (Bond, Peterson, Becker, & Drake, 2012; Campbell et al., 2007; Cook et al., 2005; Drake, Becker, Bond, & Mueser, 2003). In addition, both service providers (employment specialists and mental health practitioners) often relate to state vocational rehabilitation counselors who can enhance service provision. Full integration may, however, be difficult or impossible due to local factors, such as organizational and financial constraints. In these situations, mental health and employment personnel from separate agencies must collaborate. Collaboration denotes a lesser degree of integration, implying that mental health and employment personnel work for different agencies, are located in different buildings, use different record systems, have less frequent contact, and so on. State implementation teams have been instrumental in improving collaboration between agencies (Drake, Becker, Goldman, & Martinez, 2006). These teams include a member of the state mental health authority and a member of state vocational rehabilitation. In most cases, a full-time individual placement and support (IPS) trainer also participates on the team. The group attempts to change policies and funding to facilitate IPS implementation, as well as provide technical assistance to IPS programs. Close to 20% of states and regions in the Johnson & Johnson– Dartmouth Community Mental Health Program have some agencies in which collaboration is used rather than full integration. The purpose of this analysis was to describe the background and
Integration means that two types of services are combined and provided by the same team. For evidence-based supported employment, full integration implies that employment specialists and mental health practitioners work for the same agency, participate in weekly meetings together, develop strategies to help find jobs together, share office space, meet informally every day, use the same record system, and share responsibilities, such as supporting a person who is working (Drake, Bond, & Becker, 2012). In integrated services, co-location of services facilitates timely communication between practitioners for planning and coordinating supports to help people with employment. Integrated services robustly produce better employment
This article was published Online First April 7, 2014. Sarah J. Swanson, Geisel School of Medicine at Dartmouth, Dartmouth Psychiatric Research Center, Lebanon, New Hampshire; Claire T. Courtney, Rehabilitation Program Consultant, Minnesota Department of Employment and Economic Development-Vocational Rehabilitation Services, St. Paul, Minnesota; Robert H. Meyer, Department of Rehabilitation Psychology and Special Education, University of Wisconsin-Madison; Steven A. Reeder, Office of Adult Services, Mental Hygiene Administration, Maryland Department of Health and Mental Hygiene, Catonsville, Maryland. Correspondence concerning this article should be addressed to Sarah J. Swanson, Dartmouth Psychiatric Research Center, Rivermill Commercial Center, 85 Mechanic St., Suite B4-1, Lebanon, NH 03766. E-mail: [email protected] 86
INTEGRATED EMPLOYMENT AND MENTAL HEALTH SERVICES
strategies of collaboration in the three states where they were prevalent.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Method As a part of state IPS implementation efforts, the coauthors of this article made multiple visits to agencies that collaborate on IPS to interview practitioners, people served by the IPS programs, and program leaders. The coauthors also observed mental health and IPS practitioners working together and discussed methods to increase team efforts to help clients with work. Finally, we discussed each program in detail to reach consensus regarding successful strategies. Visits to the agencies were part of ongoing technical assistance that occurred over a 2- to 10-year period, based on how long the IPS program had been operating. Initially, agencies received at least monthly technical assistance visits and annual (or twice yearly) fidelity reviews.
Results The three states described in this article are part of a national IPS learning collaborative that requires IPS program supervisors to report a simple set of outcomes each quarter. The average employment rate for all of the programs in the learning collaborative is 43% (Becker, Drake, & Bond, 2011). The quarterly employment rate is the number of people who obtained employment relative to the number of people who received IPS in the quarter. As displayed in Figure 1, brokered IPS programs in Maryland and Minnesota have surpassed 43% employment, while the brokered IPS programs in Wisconsin have not yet reached that milestone. The Wisconsin programs were only 1 to 2 years old when they reported the data presented in this article, whereas the IPS programs in the other states had 6 to 10 years of experience.
Minnesota Two thirds of the IPS programs in Minnesota used collaboration between separate agencies rather than integrated services, due to targeted state funds that Vocational Rehabilitation Services had historically used for grant funding to employment programs. Prior to implementing IPS, Vocational Rehabilitation had set-aside
87
funding for agencies to support community employment for people with serious mental illnesses. Because the mental health authority did not have dedicated funds for employment, the state implementation team decided to build upon the established grant funding and include employment agencies (also known as community rehabilitation providers) in IPS. Although implementing IPS across separate agencies posed challenges, the advantages were an established procedure for paying for services and a positive history of working with employment agencies. To foster collaboration, the state implementation team encouraged leaders at mental health agencies to use weekly mental health treatment team meetings. They addressed concerns about confidentiality by giving agency leaders templates of a business associate’s agreement and by clarifying privacy and confidentiality in accordance with the Minnesota Data Practices Act. Some agency leaders also agreed to create office space for employment specialists within their agencies. The state implementation team assessed adherence to the IPS approach through the use of the Supported Employment Fidelity Scale. Fidelity visits included interviewing practitioners and leaders from both agencies. To enhance collaboration, cross-agency work groups (sometimes referred to as IPS steering committees) developed fidelity improvement plans. The work groups helped mental health practitioners understand their roles in employment, streamlined referrals to the IPS program, and reinforced that employment is the mission of both agencies. The state implementation team trained both mental health and employment practitioners. The IPS programs operated by mental health centers have also struggled to achieve good integration. Other than Assertive Community Treatment teams, mental health practitioners in Minnesota were not typically organized into treatment teams. Implementing IPS meant that these agencies had to create teams. As an example, one mental health center that served three counties developed mental health treatment teams in each county with assigned employment specialists and Vocational Rehabilitation counselors. Collaboration with Vocational Rehabilitation was key in Minnesota. Typically, Vocational Rehabilitation counselors had been unable to collaborate with treatment providers in a meaningful way, due to high caseloads and other factors. To remove this barrier, the state Vocational Rehabilitation leaders assigned one or more counselors to each IPS program. These counselors’ caseloads included a significant number of people from the IPS program, and that allowed them to collaborate, not just with employment specialists but also with mental health treatment providers. Vocational Rehabilitation counselors attended weekly or monthly employment unit meetings and often attended some mental health treatment team meetings. In some cases, counselors also had part-time office space at the mental health center.
Wisconsin
Figure 1. Employment outcomes for brokered IPS programs in three states.
In Wisconsin, the county mental health boards have had significant latitude in developing local mental health services. Some county administrators were reluctant to approve hiring any additional staff, forcing mental health agency leaders to contract with local employment agencies to provide IPS services. This approach was sometimes more expensive for mental health agencies than hiring employment specialists directly. Another disadvantage was that mental health agencies had less control over how IPS services
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
88
SWANSON, COURTNEY, MEYER, AND REEDER
were provided. For example, when a vocational agency did not deliver good employment outcomes, the mental health agency had to wait until the year ended to change the contract or find another employment provider. The most effective method for improving integration was to create office space for employment specialists at mental health agencies. Shared office space fostered daily communication about shared cases. Close proximity also led to personal relationships that enhanced trust and collaboration. Employment specialists returned to the employment agency only for vocational meetings and individual supervision. As a part of IPS, employment specialists and Vocational Rehabilitation counselors met to collaborate about cases. In addition, Vocational Rehabilitation counselors also attended mental health treatment team meetings each month, thus allowing practitioners from all three systems to discuss strategies. Further, when Vocational Rehabilitation counselors, who help pay for IPS, attended meetings they were demonstrating the importance of integrated services. The state IPS trainer helped to boost collaboration through in-person technical assistance and fidelity reviews. He attended mental health treatment team meetings to discuss collaboration and to engage the mental health practitioners in discussions about employment. During annual fidelity reviews, the trainer assessed the level of collaboration between service providers and afterward worked with both agencies to coauthor a written plan for improvement. Business associates agreements between the mental health agency and employment agency allowed employment specialists to participate in the entire mental health treatment team meetings, including discussions of people who had not yet been referred to IPS. When the mental health agency listed the employment specialist as part of the treatment team during the state’s recertification process, some programs were reimbursed for the employment specialist’s time in team meetings.
Maryland Maryland’s move to a fee-for-service Medicaid system in the late 1990s included robust efforts to include specialized mental health treatment providers in the mental health system, especially those providers who could provide culturally competent services. The goal was to provide client choice regarding mental health providers from specific countries, faiths, and so forth. One disadvantage of this system was that as clients chose providers from mental health agencies, group practices, and single practitioners, employment specialists sometimes needed to coordinate services with mental health practitioners who were not part of their own organizations. To improve collaboration, Maryland’s Department of Mental Health and Hygiene used two strategies: payment for time spent integrating services and annual fidelity reviews to ensure good quality of collaboration. When clients did not receive clinical and employment services at the same agency, employment specialists met monthly with primary mental health providers. Contact could be by phone or in person, but the contact must have substantively influenced both service plans. Some IPS programs shared reimbursement with mental health providers to encourage good collaboration. When clients received services from a mental health agency, employment
specialists attended weekly mental health treatment team meetings. The state also paid agencies to have treatment team meetings for individual clients every 6 months. IPS fidelity reviews ensured the quality and quantity of collaboration required by the state. Trained fidelity reviewers conducted annual reviews that included speaking with some people served by the program, looking for congruence of service plans from both systems, and reviewing documentation of communications between providers.
Discussion Evidence-based practices are optimally implemented just as they were designed in order to produce the best outcomes. Because some aspects of IPS supported employment may not align with local services, state implementation teams must make adjustments. This article describes three states in which the implementation teams assisted programs in achieving varying levels of collaboration. Using a brokered system to implement IPS requires extra work and extra expense, especially when state implementation teams must provide technical assistance to two agencies. Another challenge is that some mental health agency leaders (especially those who have not provided employment services) do not view employment as part of their mission, but instead expect employment agencies to address employment. Employment agencies may find it awkward to outsource staff who will receive direction from mental health practitioners. Agency leaders and practitioners from separate agencies may also have concerns about confidentiality. State implementation teams must address all of these issues. At the agency level, successful strategies included requiring employment specialists to join mental health team meetings, colocating employment specialists with mental health teams, using fidelity reviews to develop plans for improvement, involving agency leaders in defining employment as a central part of recovery, and involving counselors from Vocational Rehabilitation. All state implementation teams have required that employment specialists join mental health treatment teams, and some states have also provide financial incentives for collaboration. Co-location of employment specialists appears to be an especially helpful method to integrate services. State implementation teams use fidelity reviews as a tool to ensure that integration is of good quality. Further, the state implementation teams model the partnership by including people from both agencies in fidelity reviews and the planning process for improving IPS services. Another method to improve integration between mental health services and IPS is to intensify collaboration with state Vocational Rehabilitation. Vocational Rehabilitation counselors are better able to join the teams if they are identified to be liaisons to the project and will receive most of the IPS referrals. Vocational Rehabilitation counselors also benefit from learning about IPS and receiving direction from Vocational Rehabilitation leaders about how to incorporate IPS principles into their practice. With all of these steps, separate agencies can collaborate successfully and approximate complete or functional integration. Of course, the real goal is successful employment for all interested consumers, not process. Collaboration and integration are strategies to help people to achieve and maintain successful employment.
INTEGRATED EMPLOYMENT AND MENTAL HEALTH SERVICES
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
References Becker, D. R., Drake, R. E., & Bond, G. R. (2011). Benchmark outcomes in supported employment. American Journal of Psychiatric Rehabilitation, 14, 230 –236. doi:10.1080/15487768.2011.598083 Bond, G. R., Peterson, A. E., Becker, D. R., & Drake, R. E. (2012). Validating the revised Individual Placement and Support Fidelity Scale (IPS-25). Psychiatric Services, 63, 758 –776. doi:10.1176/appi.ps .201100476 Campbell, K., Bond, G. R., Gervey, R., Pascaris, A., Tice, S., & Revell, G. (2007). Does type of provider organization affect fidelity to evidencebased supported employment? Journal of Vocational Rehabilitation, 27, 3–11. Cook, J. A., Lehman, A. F., Drake, R. E., McFarlane, W. R., Gold, P. B., Leff, H. S., . . . Grey, D. D. (2005). Integration of psychiatric and vocational services: A multisite randomized, controlled trial of supported employment. The American Journal of Psychiatry, 162, 1948 – 1956. doi:10.1176/appi.ajp.162.10.1948
89
Drake, R. E., Becker, D. R., Bond, G. R., & Mueser, K. T. (2003). A process analysis of integrated and non-integrated approaches to supported employment. Journal of Vocational Rehabilitation, 18, 51–58. Drake, R. E., Becker, D. R., Goldman, H. H., & Martinez, R. A. (2006). Best practices: The Johnson & Johnson–Dartmouth Community Mental Health Program: Disseminating evidence-based practice. Psychiatric Services, 57, 302–304. doi:10.1176/appi.ps.57.3.302 Drake, R. E., Bond, G. R., & Becker, D. R. (2012). IPS supported employment: An evidence-based approach to supported employment. New York, NY: Oxford University Press. doi:10.1093/acprof:oso/ 9780199734016.001.0001
Received November 7, 2013 Revision received January 6, 2014 Accepted January 7, 2014 䡲
