Integrating Employment Services
with Community-Based Clinical
Programs: Lessons Learned
from the Ways to Work
Demonstration Project
Alysia Pascaris
New York Work Exchange, CVMHA
Rita Liegner and Richard Meador
NYAPRS Conference
September 30, 2004
Riverdale Mental Health Association
Karin Abrahamian and Anthony Cox
Brooklyn Bureau of Community Services
Colleen Gillespie
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Center for Health and Public Service, NYU
Wagner
New York Work Exchange
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)
2
• What lessons did they learn from setting up and running
these programs?
New York Work Exchange
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
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New York Work Exchange
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
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New York Work Exchange
Why Do Ways to Work?
Trends in Mental Health Policy
 Accountability and Outcomes
 Funding
 Evidence-Based Practice
Consumer Needs and Preferences
Doing More than the Status Quo
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New York Work Exchange
Beginning Ways to Work
 Requests for Proposals
 Guidelines: Core EvidenceBased Principles of SE
• Competitive, Integrated,
Minimum Wage
• Integrated Rehabilitation
and Mental Health
• Choice and Preferences
• Rapid Job Search
• Ongoing Support
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 Staffing
• Funds
• Employment Staff
 Eligibility
• Expressed Desire
• Minimum Exclusionary
Criteria
 Outcomes
• Work-related
Outcomes
New York Work Exchange
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
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New York Work Exchange
Diversity of Agencies Hosting Ways
to Work Programs
 Location
 4 NYC Boroughs (Bronx, Brooklyn, Manhattan,
Queens)
 Community location ranges from vibrant, resourcerich to isolated, barren neighborhoods
 Size
 From about 1,500 clients served/yr to 55,000
 Emphasis/Expertise
 Some with little employment/vocational experience
 Others with extensive employment/vocational
experience
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New York Work Exchange
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
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New York Work Exchange
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
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 3 programs majority white (50% - 55%)
 2 programs majority African American (52% - 76%)
 Representation of Latinos/as same across all 5 (15% - 24%)
New York Work Exchange
The Ways to Work Approach
CDTP/Clinic
Participants
Determine Who
Wants To Work
Consumer Choice
(e.g., sign-up list)
Other Supports
Psychosocial Clubs
Family Education
Housing
Benefits
Counseling
Ways to Work Program
Assessment
Job Profile
Career
Interests/Goals
Work
Incorporated
Into All TX
Goals/Plans
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Rapid Job Search
Individualized Job Development
Individualized Job Placement
Integration of Work & Clinical Goals
• Team Meetings/Case Conferences
• Regular Communication
Job Support
(Follow Along Supports)
Job Coaching
Peer Support
Family Support
On-the-Job Assessment
• Regular Communication
• Management of
Medications
Symptoms
Integration with CDTP and
Mental Health Treatment Services
New York Work Exchange
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
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 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
New York Work Exchange
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
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• Worked 3 summer jobs in the 1960s
• 6 mos of high school
New York Work Exchange
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
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• 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!
New York Work Exchange
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?
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New York Work Exchange
Number of W2W Participants (n=190)
47
50
35
40
28
30
20
23
19
13
11
8
10
0
Q1
Q2
Q3
Q4
Q5
Q6
Q7
Q8
(2002) (2002) (2002) (2002) (2003) (2003) (2003) (2003)
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New York Work Exchange
Characteristics of W2W Participants
Gender
Race/Ethnicity
3% Asian
Latino/a 11%
43%
46%
African American
57%
Male
5%College
White
39%
36%
29%
Less
than
HS
Some
College
HS
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Education
31%
New York Work Exchange
Characteristics of W2W Participants
Housing Situation
Assisted
33%
Primary Diagnosis
Depression
Ind/Family
27%
35%
4%
Shelter
6%
Adult
Home
26%
18
69%
Other
Schizophrenia
New York Work Exchange
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
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New York Work Exchange
Characteristics of Jobs
 Types of Jobs










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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
New York Work Exchange
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
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New York Work Exchange
What Did the Ways to Work Programs DO
to Help 27% of Participants Get Jobs? (2)
 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
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• Provided education about benefits and working
New York Work Exchange
What Did the Ways to Work Programs DO
to Help 27% of Participants Get Jobs? (3)
 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 realistic
 Changed How Failures Were Viewed
 Encouraged consumers and staff to view jobs as
transitions
• Failures are instructive
• Failures are expected and unavoidable
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New York Work Exchange
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
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New York Work Exchange
Integrating Employment Services
 Communication between Clinical and
Employment Staff
 Sharing Information
 Expertise/Training Background
 Culture Clashes
 Role of Employment Specialist
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New York Work Exchange
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
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New York Work Exchange
Job Coaching and Support
 Interpersonal Skills vs. Job Skills
 Difficulties 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 Work
 Consumers’ Expectations About Working




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Fear of Failure
Culture of Dependency
Access to Role Models/Success Stories
Benefits
 Family Members and Other Providers (Housing)
New York Work Exchange
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
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New York Work Exchange
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
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New York Work Exchange
Sustaining Ways to Work
 Organizational Change
 Attitude Change
 Billing, Billing, Billing
 PROS
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New York Work Exchange