Alysia Pascaris New York Work Exchange, CVMHA Rita Liegner and Richard Meador

New York Work Exchange1

Integrating Employment Services with Community-Based Clinical

Programs: Lessons Learned from the Ways to Work Demonstration Project

Alysia PascarisNew York Work Exchange, CVMHA

Rita Liegner and Richard MeadorRiverdale Mental Health Association

Karin Abrahamian and Anthony CoxBrooklyn Bureau of Community Services

Colleen GillespieCenter for Health and Public Service, NYU Wagner

NYAPRS Conference

September 30, 2004


Why We’re Here Today and Who We Are

Why?: To share multiple and practical perspectives on the process of integrating employment services

Who we are (and what we’ll talk about)? Person who conceived of and oversees the

implementation of the Ways to Work Demonstration• Why implement the Ways to Work Project?

– Immediate and more long-term goals Evaluator of the Ways to Work Demonstration

• What are the outcomes of these programs?• How did these programs implement this new approach?

– Organizational change, staff change, consumer change Staff from two of the Ways to Work Projects (including

both clinical and vocational staff)• What lessons did they learn from setting up and running

these programs?


What is the Ways to Work Project?

Demonstration Project: Integrating Supported Employment and Clinical Services

Research Project: Process and Outcome Evaluation

• Learn from Staff– Administrators, Clinicians and Vocational Staff

• Learn from Consumers

A Bridge Between Research and Practice• Application of Lessons Learned• Increase Employment Goals• Support Organizational Change Process


What is the Ways to Work Project…(continued)

Training and Technical Assistance• NH-Dartmouth Psychiatric Research Center

– Principles of Evidence-Based Supported Employment– The Role of Work in Recovery– Off-site and On-site

• New York Work Exchange– Program of Study

Workshops Seminars


Why Do Ways to Work?

Trends in Mental Health Policy Accountability and Outcomes Funding Evidence-Based Practice

Consumer Needs and PreferencesDoing More than the Status Quo


Beginning Ways to Work

Requests for Proposals Guidelines: Core Evidence-

Based Principles of SE• Competitive, Integrated,

Minimum Wage• Integrated Rehabilitation

and Mental Health• Choice and Preferences• Rapid Job Search• Ongoing Support

Staffing• Funds• Employment Staff

Eligibility• Expressed Desire• Minimum Exclusionary

Criteria Outcomes

• Work-related Outcomes


The Ways to Work Programs

5 agencies Brooklyn Bureau of Community Services CDTP

Project Moving On Jewish Board of Family & Children’s Services CDTP

Coney Island CSS Program Riverdale Mental Health Association CDTP Transitional Services, Inc CDTP

Jamaica Consultation Center Postgraduate Center for Mental Health CDTP & Clinic

Westside CDTP and Outpatient MH Clinic


Diversity of Agencies Hosting Ways to Work Programs

Location 4 NYC Boroughs (Bronx, Brooklyn, Manhattan, Queens) Community location ranges from vibrant, resource-rich to

isolated, barren neighborhoodsSize

From about 1,500 clients served/yr to 55,000Emphasis/Expertise

Some with little employment/vocational experience Others with extensive employment/vocational experience


Ways to Work Clinical Settings

Clinical Settings 4 programs associated with CDTPs 1 program associated with both CDTP and clinic

Size of Clinical Settings CDTPs: 50 – 100 participants Clinic: approximately 250 participants


Ways to Work CDTP Populations

Age (mostly adults, 18 – 55) One program serves mostly older adults, 75% > 40 One program serves more younger adults

Varied Housing adult home residents homeless individuals 40% agency-associated housing

Gender 3 programs have a majority of men, 2 a majority of women

Race/Ethnicity 3 programs majority white (50% - 55%) 2 programs majority African American (52% - 76%) Representation of Latinos/as same across all 5 (15% - 24%)


The Ways to Work Approach

CDTP/Clinic

Participants

Determine Who Wants To Work

Consumer Choice(e.g., sign-up list)

Ways to Work Program

AssessmentJob Profile

Career Interests/Goals

Rapid Job SearchIndividualized Job Development

Individualized Job Placement

Job Support (Follow Along Supports)

Job CoachingPeer Support

Family Support

Integration with CDTP and Mental Health Treatment Services

Work Incorporated

Into All TX Goals/Plans

Integration of Work & Clinical Goals• Team Meetings/Case Conferences• Regular Communication

On-the-Job Assessment• Regular Communication• Management of

MedicationsSymptoms

Other SupportsPsychosocial ClubsFamily Education

HousingBenefits

Counseling


Principles of Supported Employment

The goal is to assist consumers in obtaining competitive and satisfying jobs in community

The work pays at least minimum wage

People are employed in a work setting that includes non-disabled co-workers

Service agency provides ongoing support

Intended for consumers with a desire to work

Includes people with the most severe disabilities

Eligibility for Supported Employment services is based on consumer choice

Consumer preferences are important

Supported employment is integrated with mental health treatment

Competitive employment is the goal

Job search process starts soon after a consumer expresses interest in working

Follow-along supports are continuous for employed consumers


Consumer Experience of the Ways to Work Program: One Example

40 yr old man Realized several years ago that he wants to work

• Cares about what people in the “real world” feel about “people like him”

• Wants to prove to doctors, therapists, family members that he can take care of himself, get a job (tired of people telling him what to do and what he can do)

• Pays his own bills, does own laundry and shopping, self medicates

Has been enrolled in CDTP for about 2 ½ years• Hears voices but knows he can work through the voices because

they have been with him all his life Scant work and education background

• Worked 3 summer jobs in the 1960s• 6 mos of high school


One Man’s Story ….continued

Agreed to work with Employment Specialist as a team Worked on resume together Talked about his skills and interests

• What things made him feel like he was accomplishing something?• What did he like and dislike doing?• What were his interests and hobbies?

Immediately began canvassing the neighborhood• Went to stores, filled out applications, went on interviews

– Wore his tie and interview clothes but refused to wear his upper dentures as he felt that must hire him with the real person showing

Said he’d like to work as a messenger• Studied the NYC subway maps• Got an interview – went to interview on his own, completed the

application, and even included a cover letter with his resume• HE GOT THE JOB!


Evaluation of the Ways to Work Programs

Two major goals To document the outcomes of integrating

employment services with clinical services• Do the Ways to Work programs work?

To describe the process of implementing and sustaining the Ways to Work projects in order to be able to share that information with other providers seeking ways to most effectively promote competitive employment within clinical settings

• How do the Ways to Work programs work?• What had to change? How was that change achieved?


Number of W2W Participants (n=190)

19

47

28

35

13

23

118

0

10

20

30

40

50

Q1(2002)

Q2(2002)

Q3(2002)

Q4(2002)

Q5(2003)

Q6(2003)

Q7(2003)

Q8(2003)


Characteristics of W2W Participants

43%

57%

Gender

Male

46%

39%

11%3%

Race/Ethnicity

African American

AsianLatino/a

White

36%

31%

29%

5%

EducationHS

Less than HS

Some College

College


Characteristics of W2W Participants

35%

6%

33%

26%

Housing Situation

27%

4%

69%

Primary Diagnosis

Schizophrenia

Other

DepressionAssisted Ind/Family

Shelter Adult Home


Job Outcomes

• 58 jobs obtained over two years

• 51 unique jobs (190 participants)

• 27% employment rate

• Time in Ways to Work programs until employed

• Year 1: 4.8 months and Year 2: 8.4 months

• Job tenure (5.5 months)

• Year 1: 7.7 months and Year 2: 2.6 months


Characteristics of Jobs

Types of Jobs Security Guard Newspaper Salesperson Retail Messenger Maintenance Tutor Administrative Assistant Telemarketer Construction Worker Child Care Worker

Wages $6.75/hr $5.75 - $15.00

# Hours 23 hrs/week 6 – 40 hrs/wk


What Did the Ways to Work Programs DO to Help 27% of Participants Get Jobs? (1)

Changed agency structure Integrated employment and clinical services

• Employment Specialist attends all team meetings Re-allocated resources

• 1-on-1 individualized sessions, small caseload Changed the intake process

• Asked all consumers about career goals• Eliminated entry criteria

Created new way of delivering services• Not group-based• Job search begins immediately, no “readiness” work



Changed attitudes Changed clinicians’ beliefs about consumers’ ability to work

• Provided staff with latest evidence on what works– David Lynde, Evidence-Based Practice Project

• Advertised unexpected successes• Shared information about consumers’ abilities outside of CDTP

Changed consumers expectations about what was possible• Provided role models• Encouraged peer support• Responded immediately to consumers’ job interests

Helped families support employment goals• Provided education about benefits and working



Changed How Jobs Were Developed Developed specific jobs for specific people

• Individualized• Explored full range of consumers’ employment-related goals

to identify job matches• Used local resources

– Went out into community with consumers Encouraged staff to allow consumers to get feedback

from the real world on what was realisticChanged How Failures Were Viewed

Encouraged consumers and staff to view jobs as transitions

• Failures are instructive• Failures are expected and unavoidable


How’d They Do All That?

Lessons Learned Radiating impact of initial changes

• Small changes paved the way for bigger changes

Strategies for overcoming barriers to change• Realistic assessments of how much effort and time is

required to achieve changes

Tensions between ideal and real• Values and philosophical approaches• Situational and contextual constraints

Maintaining and sustaining changes


Integrating Employment Services

Communication between Clinical and Employment Staff

Sharing Information

Expertise/Training Background

Culture Clashes

Role of Employment Specialist


Changing Attitudes

Beliefs about CDTP Consumers and Employment

Clinicians’ Attitudes About Consumers’ and Jobs

Consumers’ Expectations About Working Fear of Failure Culture of Dependency Access to Role Models/Success Stories Benefits

Family Members

Other Providers Housing


Job Coaching and Support

Interpersonal Skills vs. Job SkillsDifficulties of Disclosure

Supporting Consumer Choice Disclosure vs. Job Coaching/Support Disclosure vs. Reasonable Accommodations Disclosure vs. Keeping Employer as Future Prospect

Groups vs. Individual Meetings and 1-on-1 WorkConsumers’ Expectations About Working

Fear of Failure Culture of Dependency Access to Role Models/Success Stories Benefits

Family Members and Other Providers (Housing)


Job Development

Individualized Job Development vs. Slots Balancing Needs of Consumers with Wanting to

Maintain Employer as Future Prospect for Others

Volunteer Positions vs. Competitive Jobs Transitional? Varied Approaches to Match Diversity of Consumer

Needs/Preferences


Maintaining Ways to Work Approaches

Initial Success May Wane Over Time Most motivated, most capable consumers may get jobs fast Remaining may need more encouragement, support, time

• Jobs and job experiences that help them– Get closer to identifying their career goals– Get closer to achieving their career goals

• More work in changing expectations, addressing fears

Role of the Employment Specialist Rare set of skills (generalist w/ specialist employment

skills) Alone (no one else like them, no “home” department) Burn-out/Turnover Providing proper balance of challenge and support


Sustaining Ways to Work

Organizational Change

Attitude Change

Billing, Billing, Billing

PROS

Documents

Alysia Pascaris New York Work Exchange, CVMHA Rita Liegner and Richard Meador