New York Makes Work Pay - Developing a path to employment for New Yorkers with disabilities

Policy and Programmatic Recommendations to Address the Systemic Barriers to Employment of People with Psychiatric Disabilities in New York State

  OMH New York State Office of Mental Health Burton Blatt Institute Syracuse University Cornell University ILR School K. Lisa Yang and Hock E. Tan Employment and Disability Institute

New York Makes Work Pay is a Comprehensive Employment System Medicaid Infrastructure Grant (#1QACMS030318) from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) to the Office of Mental Health on behalf of New York State.  It is a joint effort of the Burton Blatt Institute at Syracuse University and the K. Lisa Yang and Hock E. Tan Employment and Disability Institute at Cornell University with the collaborative support of the Employment Committee of the New York State Most Integrated Setting Coordinating Council (MISCC) to develop pathways and remove obstacles to employment for New Yorkers with disabilities.

January 2010

A report presented to the
NYS- Medicaid Infrastructure Grant
New York Makes Work Pay

Joe Marrone Senior Program Manager, Public Policy*
Oscar Jimenez, MPH, Director for Community and Economic Development
Stephen Haimowitz, JD Research Associate, Burton Blatt Institute
Chacku Mathai, CPRP, Associate Executive Director
Harvey Rosenthal, Executive Director
Natalie Johnson, MPH , Research Assistant
Hayley Dittus, MPH, Research Assistant

Institute for Community Inclusion, University of Massachusetts Boston
100 Morrissey Blvd. Boston, MA 02125-3393
Tel: (617) 287-4300 | Fax: (617) 287-4352 | website: www.communityinclusion.org
New York Association of Psychiatric Rehabilitation Services
1 Columbia Place | Albany, NY 12207
Phone: (518) 436-0008 | Fax: (518) 436-0044 | website: www.nyaprs.org
*Institute for Community Inclusion, University of Massachusetts Boston
Northwest Office at: 4517 NE 39th Ave. Portland, OR 97211-8124
Tel: 503-331-0687 | Fax: 503-961-7714 | Email: JM61947@aol.com or joseph.marrone@gmail.com

Table of Contents

Report

Executive Summary
Conceptual Framework: Understanding the Unemployment Problem...
Key Findings: Systemic Barriers to the employment and economic integration of people with psychiatric disabilities
Specific Policy and Program Recommendations
Next Steps
References

Appendices

Appendix 1: Background Paper: Factors affecting the employment outcomes of people with psychiatric disabilities
Appendix 2: Underserved populations: A brief on psychiatric disability, co-occurring substance abuse, criminal involvement and homelessness
Appendix 3: Methods employed in this project
Appendix 4: Summary of Interviews with Key Informants and Administrators
Appendix 5: Summary of Consumer Focus Groups
Appendix 6: Descriptive Inventory of Employment Services
Appendix 7: Summary of state policies, procedures and MOUs
Appendix 8: 2009 MISCC employment data of selected agencies
Appendix 9: ACCES-VR VR Participation of Individuals with Mental Health Disability
Appendix 10: Personalized Recovery Oriented Services and the Implementation of the Evidence-Based Practice of Individual Placement and Support Model of Supported Employment
Appendix 11: NYAPRS' Recovery-Orientation Transformation and Technical Assistance Framework
Appendix 12: Summary of Policy and Programmatic Recommendations

Report

Executive Summary

Overview of New York Makes Work Pay

New York State's Medicaid Infrastructure Grant (MIG), New York Makes Work Pay (NYMWP) is a statewide initiative intended to dramatically improve the rate of employment among people with disabilities. It is funded by the Center for Medicaid Services for calendar years 2009 and 2010.
The goals of New York Makes Work Pay are to:

NYMWP will accomplish these goals by implementing its comprehensive strategic work plan with activities that improve employment policy and practice through research and materials development and dissemination. NYMWP engages with people with disabilities, their families, advocates, employers, disability services providers and other stakeholders to identify best practices, implement strategies consistent with its mission and evaluate the success of those activities. The Learning Communities that were held across the state during 2009 and that will continue in 2010 are examples of the way that NYMWP involves diverse stakeholders in dialogue and training to promote and disseminate knowledge exchange and employment best practices.
One of the NYMWP strategic planning goals is to address the employment needs of traditionally underserved individuals-including those with psychiatric disabilities, co-occurring substance abuse disorders and those who are homeless. This report was commissioned by NY Makes Work Pay through the Syracuse University Burton Blatt Institute to provide guidance in reducing the employment gap among people with psychiatric disabilities.

Purpose and methods of this project

During 2009, NYAPRS and consultant Joe Marrone under contract to BBI and New York Makes Work Pay undertook a statewide effort to better understand barriers and facilitators to employment for people with psychiatric disabilities. The purpose of this policy research project was to identify the most critical systemic barriers that limit the employment outcomes of people with psychiatric disabilities in New York State, as well as policy and program improvement recommendations that can best address these barriers. The conclusions and recommendations presented in this report are based upon interviews with administrators of state agencies and community providers, focus groups with individuals with psychiatric disabilities pursuing employment, and interviews with Disability Program Navigators conducted between August and December of 2009 in Albany, New York City, and Syracuse. This project also entailed a review of the literature on barriers and facilitators to employment for people with psychiatric disabilities and innovative program and policy initiatives underway across the country.

Unemployment: The Enormity of the Problem

Multiple studies statewide and across the nation have established that a majority of people with psychiatric disabilities have a desire to work and are capable of successfully achieving employment in their communities when provided with effective services and supports (Ackerman & McReynolds, 2005; Boardman, 2003; Cook, 2006; Henry & Lucca, 2004). However, over eighty percent of adults in the public mental health system of New York State do not work. This is the case despite growing evidence indicating that long-term unemployment and consequent poverty have harmful effects on the mental and physical health of people with psychiatric disabilities, contribute to their 25-year gap in life expectancy when compared to the overall population, and result in extremely high costs to the state's public health system as well as in significant loss of human potential to our society at large.

Findings: The Systemic Barriers to Employment in New York State

The findings of this report suggest that, at a systemic level, the low participation of people with psychiatric disabilities in the labor force is a manifestation of the illness-orientation still predominating in New York State's public mental health system and its limited capacity to facilitate full recovery in all areas of life.

Furthermore, this project found that the existing policies and practice standards across public mental health, vocational rehabilitation and workforce services do not consistently reflect the belief that all people can work, and do not recognize the harmful effects of long-term unemployment. Consequently, supporting individuals with mental illness to achieve employment has not been a systemic priority for the state's mental health, vocational and workforce systems.
This project also found that the services and supports available to individuals with psychiatric disabilities in New York State are highly fragmented and do not constitute a workforce "system" that provides individuals with a comprehensive service environment to successfully obtain and maintain employment. More specifically, the findings of this study show the predominance of:

Although there are a number of positive initiatives underway in New York State including those being implemented through the state's Medicaid Infrastructure Grant (MIG) to improve the employment infrastructure for people with psychiatric disabilities, a transformation towards a cross-agency recovery-oriented workforce system is a paramount need. This effort calls for the leadership of Office of Mental Health (OMH) and the active participation of multiple state agencies in addressing the problem, including the Department of Labor (DOL), Office of Vocational and Educational Services for Individuals with Disabilities (ACCES-VR), Department of Health (DOH), and Office of Temporary Assistance and Disability (OTDA) as well as public and private agencies serving people with mental illnesses and especially peer-run agencies.

Recommendations

This report presents specific recommendations to OMH, ACCES-VR, DOL, and other state agencies aimed at creating an integrated recovery-oriented workforce system for people with psychiatric disabilities. The research team presents five principles to guide the transformation of employment services:

The recommendations of this report can be summarized in four key actions:

  1. Establish and Maintain a Policy Commitment: Implement a state policy that recognizes the harmful effects of long-term unemployment, conveys the conviction that all persons are capable of working, and creates a mandate to all state agencies to prioritize the improvement of employment outcomes as a clinical priority,
  2. Create an Integrated Workforce System: With the leadership of OMH, create a cross-agency workforce system for people with psychiatric disabilities through policies and procedures that minimize duplication of services, eliminate unnecessary assessments and delays in accessing services, create effective systems for referral and counter-referral of individuals, and provide a comprehensive service environment;
  3. Integrate Funding to Achieve Outcomes: Pursue funding mechanisms that integrate and maximize the utilization of existing resources among state agencies to accomplish what "silo" approaches do not; and
  4. Ensure Consumer Participation: Create mechanisms to ensure the participation of individuals with psychiatric disabilities in all aspects of the system's transformation, increase their demand for employment, and improve their utilization of available services, including peer support services for employment (BBI, 2009).

While implementing these recommendations represents a systemic transformation of great magnitude, there are a series of concrete steps that OMH and other state agencies can initiate immediately to build upon the several promising initiatives currently underway and to move the workforce system for people with psychiatric disabilities towards greater levels of integration and recovery-orientation.

The Human Experience of Unemployment: Dreams, hopes and the reality of a System in their own words
When people with psychiatric disabilities in New York State are asked about their employment and career aspirations, there is often a pause, perhaps because for many ending their unemployment and dependency seems far from reality. Nevertheless, behind the hesitation, there is even more often a myriad of unfulfilled dreams and aspirations.

"I want to buy a home for women in recovery to give them better services, better surroundings, a better life" (Female focus group participant, New York City)

"I want to be an entrepreneur and own a clothing business" (Male focus group participant, New York City)

"I would like to be a music teacher to encourage students to pursue their dreams." (Male focus group participant, Syracuse)

Furthermore, immediately after speaking to their career dreams, many lay out their concrete plans to achieve them.

"Short-term, I have skills to be a plumber or an electrician" (Male focus group participant, Syracuse)

"I want to learn Spanish so I can be a bilingual teacher in the next one to three years" (Male focus group participant, New York City)

"I would like to finish the criminal justice degree I started and help kids or be a counselor" (Male focus group participant, Syracuse)

"I plan on returning to school for a degree in behavioral science or chemistry but first I would like to pay off my loans from community college" (Female focus group participant, Syracuse)

"I plan to get a bachelors degree in counseling" (Male focus group participant, New York City)

The reality of dependency on public benefits is clearly not acceptable to many, and a strong motivation to pursue employment and economic participation.

"I am tired of waiting for $700 a month. I am appreciative for it, but it is not sufficient and I would really like to have a full time job" (Male focus group participant, New York City)

"I would prefer to pay taxes just like any other American"

"I am in the SSI limbo too... my doctors and family say to pursue this, but it takes so much time...I can see how many get stuck in the system" (Male focus group participant, Syracuse)

However, the reality of the employment market is full of barriers that leave discouragement, confusion and frustration among many.

"I have a master's degree in counseling. I am qualified for a lot of jobs but the City does not want to hire me. If you have a criminal background it's a big barrier. The Board of Education has given me a lot of problems because of my criminal justice issues." (Male focus group participant, New York City)

"My life has been transformed after 17 years free of criminal involvement, but I still have not been able to find a job." (Male focus group participant, New York City)

"I had a prestigious job working in an office downtown before I got sick. Do I have to start over now or is there another way to get it back?" (Female focus group participant, New York City)

"I graduated in 1995 with a bachelor's degree in Psychology, but I haven't used it. I got sick soon after graduation so I have limited experience in mental health." (Female focus group participant, New York City)

"I went to college for accounting and was a CPA, had a daughter, and made enough money to do anything I wanted... I went that high but I fell very low" (Female focus group participant, New York City)

The stories of people with psychiatric disabilities also tell us that many try very hard to pursue their employment and career aspirations, but the system of services has plenty of barriers to bring about discouragement and hopelessness. Long waits for services, counselors who do not seem to understand, and not enough supports available often make their dreams not feasible to achieve.

"When I was trying to go back to work some people [and providers] were saying to me 'you're going to fail'" (Female focus group participant, Syracuse)

"[At ACCES-VR] they just gave me an orientation and some forms. I had a lot of questions and when I called them, I never heard back from them. I never really got past the application."(Female focus group participant, New York City)

"I have heard that there is a six-month waiting period. The application process for ACCES-VR seems intimidating." (Female focus group participant, New York City)

"My [ACCES-VR] counselor was not sensitive. You could tell because of her attitude and body language. I felt lectured." (Male focus group participant, New York City)

"ACCES-VR counselors need to be taught how to deal with people with mental health diagnoses. I am 50 years old, not a child, and I used to run background checks on surgeons, and I expect to be treated as an adult." (Male focus group participant, New York City)

"ACCES-VR offered me transportation money, as well as for books, clothes and shoes, but you have to be interested in their education programs to get assistance." (Male focus group participant, Syracuse)

"[At the One Stop] I have a membership and can use their computers...but they can't help me find a job. They are not really an organization that helps people find jobs." (Male focus group participant, New York City)

"[In the One Stop] they were no help [in getting a job]. I might as well stay at home and do the work on the computer there." (Female focus group participant, New York City)

The experiences with services among some have been a lot more encouraging and helpful in obtain funding to access job coaches, certifications, purchase appropriate work attire, and ultimately achieving employment and career goals. Often these accounts not only tell us what is working but what the mental health and workforce system can do more of. Supportive practitioners and programs capable of responding to the goals and needs of individuals seem to be two critical elements to job seekers.

"My residential provider helped me change vocational counselors and my new counselor was very supportive of me." (Female focus group participant, New York City)

"I had a counselor who disclosed his psychiatric problem to me. He was very helpful." (Male focus group participant, New York City)

"ACCES-VR sent me to school to learn. In 1996 they paid for training in Word and Excel." (Male focus group participant, Syracuse)

"[My experience with] ACCES-VR was great. I got a job on the spot." (Male focus group participant, Syracuse)

"ACCES-VR paid for my Associates degree. I had failed before and not completed their program. But ACCES-VR stuck by me until I completed that degree. They thought I could be a good teacher... Now I'm applying for more help..."(Male focus group participant, Syracuse)

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Conceptual Framework: Understanding the Unemployment Problem

The costs of psychiatric disability

Mental health conditions are the leading cause of disability in the adult population in the United States and around the world, and account for more burden of disease than all forms of cancer combined (WHO, 2004; McAlpine & Warner, 2002). Over one quarter of the American population experiences a mental disorder in a given year, while the greatest burden of disability is concentrated in approximately 6 percent of the population who suffer from a serious mental illness (Kessler et al, 2005). As a consequence of this dramatic burden of disease and disability, each year New York State spends millions of public dollars in mental health treatment and rehabilitation services, social security benefits, healthcare, public assistance, safety net supports, and treatment of preventable medical conditions. Therefore, it is not surprising that mental health has become the leading Medicaid expenditure and a leading cause of loss in economic productivity and human potential in New York State and across the nation.

The Linkages between Unemployment, Poverty, and Psychiatric Disability

Psychiatric disability is intimately linked to unemployment and poverty. Unemployment and poverty constitute fundamental causes of psychiatric disability (Fremstad, 2009). People of lower socio-economic status are more likely to experience severe psychiatric conditions and disability (Hudson, 2005; Moren-Cross, 2005; Murali & Oyebode, 2004), through mechanisms such as chronic financial stress, unemployment, lower status occupations, lack of affordable housing, limited access to preventive care and quality treatment, and a lack of internal and external resources to cope with life stressors (Hudson, 2005). Unemployment and poverty also contribute to anxiety, depression, low self-esteem, hopelessness, social isolation and vulnerability for homelessness, substance abuse and criminal justice involvement. Conversely, psychiatric disability also seems to contribute to a "social drift" and further impoverishment through mechanisms such as unemployment and underemployment (Tiffin et al., 2005). Consequently, unemployment, poverty and psychiatric disability create a vicious cycle in which one element reinforces the other two. Therefore, it appears to be virtually impossible to effectively facilitate psychiatric rehabilitation and recovery without addressing the issue of unemployment and poverty; and the ability to effectively support employment and economic integration outcomes of people with psychiatric disabilities outside of a framework of integrated psychiatric rehabilitation and recovery supports is highly unlikely.

Unemployment and Poverty: The Silent Epidemic

Mental health systems are beginning to recognize that dangers related to long-term unemployment almost always outweigh the dangers inherent in the stressors of working for people with serious mental illness (Bruffaerts, Sabbe, & Demyttenaere, 2004; Dooley, Catalano, & Wilson, 1994; Elbogen & Johnson, 2009; Kasl, Rodriguez, & Lasch, 1998; Lennon, 1999; Lattimore, 2007; Mossakowski, 2008; Orpana, Lemyre, & Gravel, 2009; Waddell & Burton, 2006). Furthermore, a review of the scientific literature also highlights that there are few environmental factors more harmful to a person's physical and mental health, even in the absence of pre-existing symptomatology, than long term unemployment (Marrone, 2007; Marrone & Golowka, 2000). Studies have shown that 50% to 90% of people with psychiatric disabilities indicate a desire to work (Casper & Carloni, 2007; Secker, Grove & Seebohm, 2001) only a small proportion (20%) are actually employed (SAMHSA, 2007). It is estimated that no more than 15% of the adults served in the NYS public mental health system every year are engaged in some form of employment (OMH, 2009). Our research revealed that many of these individuals have not only the desire to work but also very specific academic and career plans and aspirations. Often these individuals simply need effective services to help them achieve their goals. Of those who work, the majority are employed only part-time with an average income of less than $25,000 per year. More than 30% of individuals with psychiatric disabilities in NYS live below the federal poverty level and a large number live close to poverty (American Community Survey, 2008). Furthermore, a large majority of people with disabilities in NYS are asset-poor; that is, have few or no assets to support themselves for three months without income. These statistics show that, for many individuals, living with severe psychiatric diagnoses often leads to a life of unemployment, dependency on public programs, poverty, social exclusion, and further disability. Thus, unemployment and poverty constitute a silent epidemic likely to be responsible for a great proportion of the disability experienced by people with severe mental health diagnoses.

Unemployment: a symptom of an illness-oriented system

Multiple long-term studies have demonstrated that people with psychiatric disabilities are able to achieve recovery, not only from symptoms of mental illness, but also in terms of their ability to engage in community participation, which includes work. For example, longitudinal studies throughout the world have demonstrated that significant improvement and even full a full recovery is possible for the majority of people with severe psychiatric conditions (Bleuler, 1972/1978; Ciompi & Muller, 1976; Davidson, Harding, & Spaniol, 2005; DeSisto, et al., 1995a; DeSisto, et al., 1995b; Harding, Brooks, Ashikaga, Strauss, & Breier 2005a; Harding, Brooks, Ashikaga, Strauss, & Breier, 2005b; Hinterhuber, 1973; Huber, Gross, & Schüttler, 1979; Kreditor, 1977; Marinow, 1974; Ogawa & Miya, Watarai, et al, 1987; Tsuang, Woolson, & Fleming, 1979). Multiple studies have also established that a majority of people with psychiatric disabilities express a desire to work and are capable of successfully achieving employment in their communities when provided with effective services and supports (Drake et al, 2005).

Nevertheless, despite the evidence that individuals with severe mental health diagnoses are capable of achieving employment as well as overall significant recovery, and the well-documented linkages between unemployment, poverty and psychiatric disability, the participation of individuals with psychiatric disabilities in the labor force is extremely low (no more than 1 in 6). Our literature review and research suggests that one of the key systemic factors of the low level of participation of people with psychiatric disabilities in the labor force is the illness-orientation still predominating New York State's public health system and its limited capacity to facilitate full recovery in all areas of life. The two most comprehensive reports on mental health of the past decade, the Surgeon General's Report on Mental Health (U.S. Department of Health and Human Services [DHHS], 1999) and the New Freedom Commission Report (DHHS, 2003), established that the single most important problem of the mental health system in the United States is the predominance of an illness-orientation, which aims only to manage symptoms and accepts long-term disability (DHHS, 2003). These reports concluded that transforming services towards a recovery-orientation, that is, improving the capacity to support people with psychiatric disabilities to "live, work, learn and fully participate in their communities," is of paramount importance and urgency (DHHS, 2003; DHHS, 1999)

The process of deinstitutionalization initiated almost half-century ago significantly transformed the landscape of service structures available to people with psychiatric disabilities in New York State and brought mental health care into communities. Nonetheless, despite its best intentions, this process seems to have mainly relocated people to community settings without providing effective supports towards full participation in their communities (Davidson, et al., 2009). Thus, the "deinstitutionalization" produced in many respects a "trans-institutionalization" of individuals from hospitals into new service structures in the community with semi-institutionalized care focused on treating symptoms and maintaining functioning level, and incapable of supporting individuals to work, pursue higher education and careers, achieve economic self-sufficiency, parent, and become active members of their communities. While today approximately eighty percent of episodes of care in the public mental health system occur in community settings, a large majority of individuals do not work, live in poverty, and lead a life of isolation, idleness, and exclusion. Program designs and funding structures seemed to change faster than the orientation and methodologies of care and the ability to facilitate full recovery in all areas of life, including participation in work. The institutional care predominant in state mental hospitals simply transitioned from institutions to community-based services, while maintaining a "chronicity-orientation" (California Association of Social Rehabilitation Agencies, 2007) in which employment is conceived as an unlikely post-recovery and peripheral outcome.

A Recovery-Orientation to Employment

"Recovery" is the concept that people with serious mental illness can get better and lead productive, fulfilling lives as citizens (Anthony, 2000). From a recovery-based orientation, employment is seen not only as a likely outcome for people with severe mental health conditions, but also as an essential component for psychiatric rehabilitation. As New Freedom Commission Chair (and current OMH Commissioner) Michael Hogan has stated during his tenure in Ohio: "Increasing employment for people with mental illness is one of the most urgent priorities in today's mental health system" (excerpted from the Ohio Employment Leadership Alliance brochure). Multiple studies and reports validate this statement and indicate that supporting meaningful employment outcomes must be a fundamental component of a comprehensive psychiatric rehabilitation model (Harding, Brooks, Ashikaga, Strauss, & Breier 2005a; Harding, Brooks, Ashikaga, Strauss, & Breier, 2005b; Davidson, et al., 2009; Ragins, 2009; Farkas et al, 2005; Onken et al., 2002; Ridgway, 2005). Some studies specifically indicate that individuals receiving psychiatric rehabilitation services that support the achievement of meaningful employment, along with strong supports for community integration, meaningful residential, and social opportunities achieve better long-term recovery and rehabilitation outcomes, including fewer symptoms, higher employment rates, and increased social functioning and community adjustment (Harding, Brooks, Ashikaga, Strauss, & Breier 2005a; Harding, Brooks, Ashikaga, Strauss, & Breier, 2005b). Several other studies have also identified the programmatic traits that are most likely to support individual recovery, in which supporting employment is an essential element. Moreover, in a study about the factors that help and hinder recovery, Onken et al (2002) found that several environmental factors are essential in supporting recovery, such as access to material resources (e.g. livable income, safe and decent housing), social relationships, meaningful activities that connect individuals to their communities (including employment), and supportive services and staff who belief that recovery is possible.

A Rights-Based Framework to Employment

This project embraced a rights-based framework to approach the problem of unemployment among people with psychiatric disabilities and guide the formulation of policy and program recommendations.

In our society, participating in the labor force and economic life of a community is regarded both as a right and as a responsibility of citizenship. Regarding work as a right implies a public responsibility to provide the necessary infrastructure, information and protections so that individuals can exert such a right. For instance, laws regulate labor practices to ensure all individuals are free from unjust discrimination based on gender, race, ethnicity, disability, sexual orientation or national origin. It is also a public responsibility to ensure that individuals, employers and organizations have adequate information about these laws, and that effective mechanisms be in place to ensure their enforcement.

Conversely, our social and economic life is also based on the assumption that all individuals able to participate in the labor force and gain enough income to achieve economic self-sufficiency, should indeed do so. It is a public responsibility to provide individuals with temporary or permanent supports to ensure subsistence if and or when they are unable to be economically self-sufficient; yet it is the responsibility of individuals to resume economic activity if and or when they become able to do so again.

A few clarifications are needed to adopt a rights-based framework as an effective guide to policy-making aimed at addressing the unemployment of people with psychiatric disabilities. Regarding work as a right does not wave the reality of competitive labor markets. Although it is a right of an individual to work, the expectations of a certain industry may prevent such an individual from becoming employed in a particular position if she/he does not meet the necessary qualifications.

Another important clarification is that regarding work not only as a right but also as a responsibility of citizenship does not eliminate the public responsibility of providing individuals with the infrastructure and supports necessary to exert such a right and responsibility. An example related to political rights helps illustrate the issue. Voting is considered both a right and responsibility of citizenship. It is not only a right but also a responsibility of individuals to vote and thus participate in ensuring that elections or decisions are based on a democratic process. The fact that voting is also an individual's responsibility does not eliminate the responsibility of states and federal governments to provide individuals and communities with appropriate infrastructure, technology and information. Similarly, regarding work as a responsibility of individuals with psychiatric disabilities who are capable of working does not eliminate the public responsibility to ensure that these individuals receive adequate supports and services to exert their right and fulfill the responsibility to work.

Addressing unemployment from a "capital" framework

Labor and sociological research suggests that different forms of "capital" (or resources) are essential for people with disabilities to successfully achieve and maintain employment. In order to structure inform this project the research team adapted Potts' operationalization of employment capital (Potts, 2005) and identified three forms of capital that are essential for employment: (1) human, (2) economic/material, and (3) social capital. Human capital refers to the training and skills that make individuals able to perform a job (e.g. education, specialized skills). Material capital encompasses the economic and tangible supports that need to be in place for individuals to work (e.g. safe and stable housing, reliable transportation, work tools). Social capital refers to the relationships and connections that make it possible for people to obtain and maintain a job (e.g. social networks producing job opportunities, peer support to cope with job stressors). From this perspective, obtaining and maintaining employment are more likely when an individuals' human capital is supported by broader material and social capital. This framework suggests that a comprehensive approach to employment services ought to incorporate the human, cultural, social, and material dimensions in order to ensure that the necessary "capital" is available to individuals with psychiatric disabilities to obtain and maintain employment. A review of the research on employment suggests that, traditionally, employment services for people with psychiatric disabilities have prioritized a focus on developing individual's human and cultural capital (e.g. providing skills training, interviewing skills, résumé building) and have developed significantly less capacity at addressing the structural supports required to build social and material capital (e.g. ensuring stable housing, improving financial resources, expanding social support networks (Ackerman & McReynolds, 2005; Cook, et al, 2006; Henry & Luca, 2004; Inge, 2008; Litz & Mechanic, 2006; Perkins, et al, 2005; Tschopp, et al, 2007; Tremblay, et al, 2006; Yankowitz, 1990).

An ecological framework to address the multi-level barriers to employment

A review of research available also reveals that structural and systemic factors are critical in shaping the likelihood of individuals with psychiatric disabilities to achieve employment. For instance, the social conditions of people with psychiatric disabilities are critical in predicting employment outcomes. As discussed earlier in this section, psychiatric disability is more likely to occur among people who are poor and already experience disadvantages in accessing human, social and material capital essential to work. Psychiatric disability has also been shown to have a negative impact on critical socio-demographic variables such as educational attainment, thus limiting access to essential employment capital and resulting in unemployment or underemployment. Additionally, substance abuse, crime and homelessness are all social problems more likely to occur among those who are poor. Research shows that these social conditions, which pose important challenges to the employment outcomes of people with psychiatric disabilities, are more associated with the social context in which a large proportion of people with psychiatric disabilities live than with the mental illness itself. Therefore, addressing the employment barriers of people with psychiatric disabilities must take into account the social conditions and other systemic barriers affecting this population. Furthermore, addressing homelessness among people with mental illnesses by making work a priority may be an effective means for addressing recurrent homelessness by increasing self-esteem, facilitating readiness to change and providing financial incentives (Shaheen & Rio, 2007).

A multi-level approach, such as the ecological model of public health interventions, can best help us understand the impact of multiple levels of factors on the issue of employment and economic integration of people with psychiatric disabilities (See Appendix 1 - Figure X for a summary of most important multi-level barriers to employment as identified by our literature review).

The policy research project: purpose and methods

The purpose of this policy research project was to identify the most critical barriers that limit the employment outcomes of people with psychiatric disabilities in New York State and to identify policy and program improvement recommendations that can best address these barriers, in particular by placing particular emphasis on systemic factors (e.g. policies, funding, accessibility and effectiveness of program structures).

The conclusions and recommendations presented in this report are based upon interviews with administrators of state agencies and community providers, focus groups with individuals with psychiatric disabilities pursuing employment, and interviews with Disability Program Navigators conducted between August and December of 2009 in Albany, New York City, and Syracuse; as well as a literature review of the barriers and facilitators to employment among people with psychiatric disabilities and of innovative program and policy initiatives underway across the country (See Methods Section for more details).

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Key Findings: Systemic Barriers to the employment and economic integration of people with psychiatric disabilities

Employment and economic self-sufficiency are not systemic priorities for NYS public health and workforce systems:

The New York State Medicaid Infrastructure Grant - NY Makes Work Pay 2010 Strategic Plan (draft) postulates that "All people can work." Indeed, multiple long-term studies have demonstrated that people with psychiatric disabilities are able to achieve recovery and meaningful community participation. Multiple studies have also established that a majority of people with psychiatric disabilities express a desire to work and are capable of achieving employment in the community when provided with effective supports.

This policy research project found that, despite the evidence that recovery and successful employment is possible for people with psychiatric disabilities, the current policies and infrastructure of New York State's public health and workforce systems do not consistently reflect the notion that all people with psychiatric disabilities can work. Furthermore, the employment of people with psychiatric disabilities has not historically been a systemic priority for New York State. Evidence for this proposition is the lack of policy mandates that recognize the achievement of competitive employment as a clinical and service priority in the rehabilitation and recovery of individuals with psychiatric disabilities; the lack of an adequate service infrastructure to effectively support the employment and career goals of individuals; and a predominant treatment and service orientation tolerant of idleness and unemployment.

The New York State Office of Mental Health is currently leading a series of initiatives to improve the employment infrastructure for people with psychiatric disabilities and to produce a significant transformation in the public mental health system towards a recovery-orientation which prioritizes employment and economic integration. These include the NYS Medicaid Infrastructure Grant and its comprehensive effort to assess cross-agency partnerships and devise research-informed program improvements; the conversion of mental health programs into Personalized Recovery-Oriented Services (PROS) with a strong focus on psychiatric rehabilitation and employment, including assisting PROS providers to become Employment Networks under the SSA Ticket to Work Program; the implementation of the Individualized Placement Support (IPS) model and technical assistance to improve program capacity across the state to provide this emerging evidence-based practice; the "Making Work Everybody's Business" campaign to prioritize employment across OMH-operated programs; and peer-led initiatives like the grassroots campaign "We Can Work" to increase consumer participation and demand for employment.

These efforts appear to be making significant progress towards improving the employment infrastructure for people with psychiatric disabilities, and New York State must continue to support them as well as pursue ways to expand their reach. However, it can be argued that, at a systemic level, the predominant assumption of the public health and workforce systems in New York State is that competitive employment is a goal that only some can achieve after recovery occurs, that is, as a selective post-facto outcome, and not an essential component and facilitator of psychiatric rehabilitation and recovery. As argued in earlier sections, this appears to be symptomatic of a still slow and complex transition from an illness-oriented (medical model) to a recovery-oriented public mental health and workforce system.

From an economic and development perspective, the lack of priority in supporting the employment and economic self-sufficiency of individuals with psychiatric disabilities denotes the systemic tolerance of the economic impact and loss of human potential brought about by their unemployment and economic disengagement.

One of the fundamental conclusions of this policy research project is that supporting individuals with psychiatric disabilities to achieve employment requires a Workforce System for People with Psychiatric Disabilities, that is, an integrated set of cross-agency and comprehensive services. Such an effort calls for the leadership of the NYS Office of Mental Health and commitment and active participation of the entire New York State service infrastructure, including the Department of Labor, Office of Vocational and Educational Services for Individuals with Disabilities (ACCES-VR), Department of Health, and Office of Temporary Assistance and Disability, as well as the Office of Addiction and Substance Abuse Services. Furthermore, since many veterans are returning from the present Middle East conflicts with mental health problems,, more needs to be done to ensure that these individuals get access to employment as well as medical/treatment services.

This project also concluded that a workforce systemic model for people with psychiatric disabilities currently does not exist in New York State. The research team defined "systemic model" (also referred in this report as "system") as a set of coordinated services that provide people with psychiatric disabilities with integrated and comprehensive services and supports to achieve competitive employment as an integral element of recovery. The following are the most critical signs or consequences of the lack of a workforce system for people with psychiatric disabilities:

Fragmented services and supports

This project concluded that there exists no workforce "system" which provides integrated and comprehensive employment and economic integration supports to individuals with psychiatric disabilities in New York State. There exists a complex and bureaucratic set of fragmented services with multiple eligibility criteria and application procedures, and services incapable of integrating the multiple support needs of individuals. For instance, individuals often require and receive services from one or more programs funded and/or operated by NYS OMH (Office of Mental Health), NYC DOHMH (NYC Department of Health and Mental Hygiene), ACCES-VR (Vocational and Educational Services for Individuals with Disabilities), OASAS (Office of Alcoholism and Substance Abuse Services), DOL (Department of Labor), NYS DOH (NYS Department of Health), Social Security and the Department of Social Services and veterans agencies like the Division for Veterans affairs (DVA) or the Department of Labor-Vets. While some Memoranda of Understanding (MOUs) are in place among these agencies, our interviews with state administrators suggest that MOUs make insignificant progress in overcoming the major fragmentation of services. Our interviews with providers and focus groups with consumers indicate that it is often at the community level where, at the initiative of providers or local administrators, true collaboration takes place.

The Disability Program Navigator (DPN) program was conceived as a resource to create linkages between state programs and community providers, facilitate the "navigation" of individuals with disabilities in a complex "system," and thus provide individuals with a more seamless and responsive service environment.

Our interviews with state administrators and DPNs revealed that over time, and in part due to the decentralized administration of this program (in many instances One Stop Centers and DPNs are employees of a sub-contracting agency and not NYS DOL), there exists a great deal of diversity in the focus and expertise of DPNs across the state. While some DPNs spend most of their time creating and maintaining relationships across systems and organizations and referring individuals to providers that can meet their needs, other DPNs dedicate a large part of their time to providing direct job placement. With at most, one DPN per county or New York City borough, it is virtually impossible for DPNs to effectively provide job placement services to hundreds or thousands of individuals pursuing employment and navigating a complex and fragmented system at any given point in time. It was significant that none of the focus group participants had heard about the Disability Program Navigators and that interviews with providers indicated that this resource was not broadly utilized by people with psychiatric disabilities.

These findings suggest that DPNs could be best utilized in creating sustainable cross-agency relationships and referral and counter-referral systems (See Recommendation #11 for more detail). Our interviews with state administrators revealed that the current vision for this program is not to focus on providing direct services and job placement of individuals, but on facilitating a network of services and supports at the community level. The DOL's Division of Workforce Development has already taken steps to train or retrain DPNs and provide them with technical assistance to fulfill the role of "bridgers" across programs and services available at the community level. With the support of the NYS-MIG, DOL is also planning the implementation of a Learning Community to enhance the effectiveness and utilization of the services provided by DPNs and One Stop Centers.

Some inter-agency practices have shown some encouraging results, but overall only seem to ameliorate a systemic problem. For instance, ACCES-VR district offices in NYC developed a "liaison" program that facilitates more effective communication, collaboration and referral between an OMH certified program and vocational rehabilitation (VR) counselors. In the opinion of providers and consumers interviewed, wherever OMH-ACCES-VR liaisons are in place, beneficiaries and providers experience a much more seamless system. Nonetheless, given the high costs in time devoted to effective liaison activities, and the large caseloads that ACCES-VR offices deal with, this strategy is only being used on a small scale in some NYC district offices, with limited impact at the systemic level.

ACCES-VR and the Department of Labor also have initiated a significant collaborative effort by assigning ACCES-VR vocational rehabilitation counselors to every One Stop locations. In many instances, a ACCES-VR counselor is stationed at the One Stop center one or two days per week. Nevertheless, process and outcome data from this initiative are not available to determine the effectiveness of this strategy in strengthening the linkages and/or referrals between the services provided by both agencies.

In the years to come another opportunity for cross-agency collaboration will be the implementation of the Individual Placement Support (IPS) model. According to the OMH, senior consultants who have been hired for this initiative bring significant experience working in other states on the collaborative relationship between state mental health and state vocational rehabilitation. It is expected that the IPS implementation efforts will provide OMH opportunities to build a stronger coalition with Vocational and Educational Service for Individuals with Disabilities (ACCES-VR) and use IPS as a framework for supporting peer-led employment services.

Silo-like funding structure and inefficient utilization of resources

A silo-like funding structure predominates in the employment services and supports in New York State, creating inefficiency in the utilization of the resources available at the system level. A few instances also indicate that NYS has demonstrated inefficiency in accessing funding opportunities from federal agencies, and in utilizing funding streams available.

Silo funding structure

Each state agency has separate funding streams. Such funding streams almost never function collaboratively. Often, several state programs provide similar services, which create duplication of services and inefficiencies in the utilization of financial resources. For example, state agencies such as OMH and ACCES-VR spend resources in separate assessments and applications processes that often involve similar services and tools. Creating coordinated and/or joint application processes would significantly decrease the duplication of services and improve the overall efficiency of funding utilization.

Table 1 describes the silos of funding available through the three primary agencies providing employment services to individuals with psychiatric disabilities and co-occurring substance abuse, namely, OMH, ACCES-VR, and OASAS. Here are some of the highlights:

These figures also suggest great disparities in the cost per individual served associated with each program type. Informal estimates indicate that the average cost of a yearly placement in a sheltered workshop is approximately $27,000 per individual. The total number of individuals served per program type in a given year was not available to the research team. Nevertheless, it can be noted that while Assisted Competitive Employment (ACE) programs and sheltered workshops serve a relatively similar number of individuals in a given week, the costs associated with sheltered work could be as much as 6.5 times greater than the more integrated employment services.

Significant anecdotal and programmatic data suggest that many individuals participating in sheltered work are willing and capable of exploring and achieving more integrated forms of employment. However, for many individuals, sheltered work does not lead to meaningful and competitive employment in the community and constitutes a form of long-term semi-institutionalization. Considering the high costs involved in sheltered work, and its poor outcomes in fostering integrated competitive employment, it is fiscally irrational to continue to direct such a large proportion of the state funds available to this employment modality. Indeed, a number of states across the country have already eliminated, or are taking significant steps towards eliminating sheltered workshops not only due to the sub-standard labor conditions that this form of "employment" creates, but also due to its inefficacy and inefficiency in improving integrated and competitive employment outcomes.

Table 1: Employment funding per agency and program

Agency/Type of Employment Program

No. of
programs

No. of Individuals Served

Funding Appropriated in SFY 2009-10

Level of Integration (low, medium or high)

OASAS

 

 

 

 

Employment services

9

659

$3,751,075

High

OMH (*)

 

 

 

 

Ongoing Integrated Supported Employment (OISE)

140

1,303

$10,448,446

High

Personalized Recovery Oriented Services (PROS)

20

1,079

$919,160 (this funding will increase as the numbers registered in PROS increase statewide)

High

Assisted Competitive Employment (ACE)

89

1,142

$7,531,547

High

Temporary Employment Program (TEP)

34

208

$2,624,431

High

Affirmative Business Initiative (ABI)

29

310

$2,946,543

Medium

Enclave in Industry

10

97

$417,323

Low

Work Programs (Mobile Work Crews)

 

445

$1,491,198

Low

Sheltered Employment

56

1,199

$46,041,318

Low

SED/ACCES-VR

 

19,026 PWPD (**)

 

 

Vocational Rehabilitation
VR Title I

 

59,016 (all disabilities)

$182 Million
Federal - $127M
State - $54M Plus $5M in FederalSocial Security Reimbursements)

High

Vocational Rehabilitation:
Supported Employment Intensive

 

14,800 (all disabilities)

$25 Million
State - $5.1 M
Federal - $20M

High

Vocational Rehabilitation:
Supported Employment Extended

 

3,801 (all disabilities)

$10 Million (State)

High

Sources: The data presented in this figure has been extracted from a report presented by the NYS Most Integrated Setting Coordinating Council (MISCC) in October of 2009. (*) Snapshot of the number of individuals served by OMH-funded program in a given week (2007 estimation). (**) The total number of individuals with psychiatric disabilities served by ACCES-VR in 2008, from "ACCES-VR VR Participation of Individuals with Mental Health Disability Preliminary- Draft of Findings (September 2009)."

Each of the funding mechanisms available across state agencies has drawbacks, while also provides opportunities for synergy. State funding of mental health employment services is probably constrained by the current fiscal climate and by the multiplicity of medical as well as rehabilitation needs that must be addressed. ACCES-VR funding is constricted by by the need to respond to its own distinct federal and state mandates, which in essence can reduce providers to function as vocational rehabilitation vendors rather than active participants of a workforce system for people with psychiatric disabilities (See Table 2).

Table 2: Funding model uses, advantages and disadvantages

Source of funding

Uses

Advantage

Disadvantage

 

State MH

  • Create incentives for clinical employment interventions
  • Fund pilots
  • Targeted to agency consumers
  • Can set own agency priorities aligned with OMH strategic plan
  • Can reinforce EBP
  • The NYS OMH is the controlling agency for the NYS MIG CEO
  • Reinforces need for clinical and rehabilitation integration
  • Limited funding available
  • Multiplicity of needs of consumers
  • Employment is often seen as an adjunct to core health services
  • Clinical staff not often well trained in employment issues

 

ACCES-VR

  • Fee for service employment services
  • Creation of joint or braided funding models
  • Ability to fund training for both education and on-the-job
  • Employment expertise available in staff
  • Employment is core focus of the whole agency and concrete outcomes are expected
  • Serves many people with mental health disabilities already
  • In service training available focused on serving people with psychiatric disabilities
  • Limited funding dwarfed by OMH budget
  • Must serve many constituencies of clients not just those with psychiatric disabilities
  • Very large caseloads and often long wait times for service
  • Many staff still focus on "readiness" as a pre qualification for referral

 

MEDICAID

  • Can fund the supportive parts of Supported Employment
  • Can fund many elements of service plan leading to employment
  • NYS has a MIG which is has as one goal assistance systems in use of Medicaid services to support employment goals
  • Elements of CMS have interest in ways to support use of Medicaid to support employment goals
  • Expandable funding stream under fee for service methodology

Options now available under 1915[i] and [j] that can support employment related service delivery

  • All services funded under Medicaid have to be justified as "medically necessary"
  • Medicaid is essentially a health insurance program not a human service intervention
  • Federal and state pressure to control Medicaid costs
  • Fear of audits

Uncertainty due to early stages of PROS implementation in NYS

 

WIA

  • Employment related services and vocational training through federal and state funding
  • Job search resources and many groups

Focus on meeting local labor market needs in workforce board areas

  • Locally driven services controlled by local workforce boards
  • Most workforce centers have better equipment and electronic resources than many mental health agencies
  • Centralized source of employer and employment information in local areas
  • There is a cadre of Disability Program Navigators in existence at workforce centers
  • USDOL requires access and outreach to [potential] customers with disabilities
  • Some workforce areas have customized employment projects
  • Limited funding dwarfed by OMH budget
  • Must serve many constituencies of clients not just those with psychiatric disabilities
  • Many staff still focus on "readiness" as a pre qualification for referral
  • Many services are geared towards a resource room/ self service philosophy rather than intensive support

 

This scenario calls for New York State to pursue concerted efforts to maximize funding through the use of different funding streams that can be combined to serve the complex needs of people with psychiatric disabilities, including ACCES-VR, Medicaid, and WIA (See Recommendations).

Medicaid as a funding source for employment

Medicaid has been increasingly used in states as a source to expand funding. However, this is limited by the complexities of Medicaid funding mechanisms for employment, such as rehabilitation options, system waivers, and, potentially now, the DRA - 1915[i] option).

In New York State, the Personalized Recovery-Oriented Services (PROS) model offers an opportunity to access moneys through the rehabilitation option in order to provide employment related services within Medicaid funding. OMH's roll out and implementation plan of PROS also includes the "braiding" of state aid moneys to fund aspects of the supported employment process not allowable through Medicaid, such as job development, and has been providing such aid since April 2009 (Please See Appendix #9 for a Summary of OMH's PROS and IPS implementation plan). Nevertheless, our interviews with providers revealed a great deal of concern about the sufficiency of such a "braided" scheme to fund all aspects of effective supported employment services (e.g. job development, job placement, intensive and ongoing follow-up). In addition, several providers raised the concern about the impact that failed Medicaid audits can have on the sustainability of relatively small organizations. These concerns reflect the prevailing fear among providers regarding this Medicaid funded program, which is exacerbated by stories of agencies that were forced by audits to return several thousands of dollars to Medicaid and facing the threat of closing down programs.

However, interviews conducted also revealed some hope and optimism toward the new PROS model. Occupations, Inc. was referred to as a case in which a provider has been able to provide meaningful employment services within PROS. Further interviews revealed that Occupations Inc. seems to have successfully transitioned to PROS and integrated several programs (e.g. Intensive Psychiatric Rehabilitation Treatment [IPRT], Continuing Day Treatment [CDT], and follow-along employment program) providing multiple services under "one roof," which offers a series of advantages to recipients, including being able to receive more than one distinct service in a given day. These services include an Ongoing Rehabilitation Services component, which is aimed at assisting individuals retain employment. Nevertheless, a more detailed observation revealed that this PROS program works in tandem with an existing employment services program within the same agency. Often individuals receive job development or placement funded through ACCES-VR and other funding sources. In sum, this case suggests that the success of this program seems to lie more in the de-facto "braiding" of funding from several funding sources that providers on the ground have made happen, than in the funding mechanisms provided by the PROS model itself. Furthermore, if PROS employment programs leveraged resources through other systems like the SSA Ticket to Work Program, by becoming part of Employment Networks (ENs)-two objectives might be met: 1) New sources of revenue might be secured based upon achievement of demonstrable outcomes and 2) New partnerships with employers, other disability agencies, community development agencies, etc that participate in the EN might improve sustainability.

Missed Opportunities and Underutilization of funding

During the past few years, New York State has missed several opportunities for funding from federal agencies to advance the employment of people with psychiatric disabilities. In 2001 NYS was awarded the Medicaid Infrastructure Grant for the establishment of the Medicaid Buy-In for People with Disabilities. Nevertheless, upon the conclusion of this grant NYS opted to not pursue an application for the Comprehensive Employment Services Medicaid Infrastructure Grant. As a result, NYS missed an opportunity for a five-year grant to improve the employment infrastructure. By the time NYS had the political willingness to apply for this grant only two years were available before a federal re-authorization.

In year 2000, NYS received the State Partnerships Initiative Grant from the Social Security Administration to establish the NY Work Project. This program enabled individuals enrolled to obtain four waivers to: (1) decrease the amount of SSI benefits taken away as a result of gainful activity (one-dollar-for-every-four dollars, instead of the required one-for-every-two according to currentregulations); (2) simplify the re-enrollment process of SSI if gainful activity is lost; (3) increase allowable assets (from $2,000, the limit at the time, to $10,000); and (4) increase the income limits to maintain Medicaid insurance through the 1619B. This program also funded highly skilled "super job coaches" who provided extensive and individualized supports; as well as access to comprehensive benefits advisement. While this project was showing very positive outcomes as a result of several of the enhanced supports provided, NYS opted to not pursue the renewal of this grant and individuals enrolled in the project stopped benefiting from the waivers and expert coaching. This federal grant eventually ended with NYS not pursuing a renewal and it is not longer available. Anecdotal data suggests that this program was crucial for many individuals to pursue employment. Indeed, one of the providers and advocates interviewed asserted vehemently that NY Works was the program that enabled her to leave her semi-institutionalized and jobless life. Several interviewees indicated their disappointment about the fact that NYS did not pursue the renewal of this grant.

Interviewees reported that ACCES-VR had returned in the recent years a significant amount of unspent federal funds. When questioned about this matter, ACCES-VR clarified that funds were not returned to the federal government but instead carried over to subsequent fiscal years. In FFY 2007, ACCES-VR had accumulated unspent federal funds that we were carried forward into the next fiscal year and made a concerted effort to utilize those funds. ACCES-VR did so through a number of initiatives, including a change in ACCES-VR's college policy and related allowable postsecondary costs. ACCES-VR also increased the economic need thresholds amounts (so that more individuals could meet the criteria and receive services that were contingent on economic need). According to ACCES-VR these changes reduced the carryover considerably over the past 3 years, and in fact a few special initiatives were ended early to ensure sufficient funds were available for ACCES-VR's core vocational rehabilitation services. ACCES-VR did not provide an explanation about the amount of the carryover funds during those years, why funds were unspent in the fiscal years for which they were allocated, and did not indicate if the "special initiatives" produced equivalent employment outcomes as those that would have been produced through the regular VR services. Therefore, it is not clear if these strategies to utilize carryover funds effectively overcame the gap in services inevitably caused by unspent resources.

In the current fiscal environment it is unacceptable for NYS to miss opportunities for continued or new funding streams available through the federal government, or that available funds go underutilized. A commission ought to be formed to identify mechanisms that maximize the utilization of existing resources, monitor opportunities for new or continued funding from the federal government, make recommendations to state agencies regarding grant applications, and maintain a strong level of accountability regarding the effectiveness of state and federal moneys.

Jointly funded initiatives

A few efforts to fund joint initiatives across state agencies are documented in this project. ACCES-VR and DOL have signed a Memorandum of Agreement (MOU) in regards to the Disability Program Navigator (DPN) Program. Under this MOU, ACCES-VR provided partial funding during the last two fiscal years for DPNs and emphasized the expectation that DPNs will be actively engaged in increasing accessibility at the One Stops through local advisory working groups. Currently ACCES-VR is in the process of identifying ACCES-VR liaisons for each of the DPNs to facilitate the communication and access to VR services. OMH and DOL recently initiated a joint project funded by the American Recovery and Reinvestment Act of 2009 to incentivize the hiring of people with psychiatric disabilities. This project pays up to $5,000 in training courses at community colleges for individuals who have a job offer at mental health agencies.

Limited cross-agency data systems on employment outcomes:

Another important finding is that data systems also follow a silo structure with each agency collecting data on the outcomes of individuals receiving services though the respective programs of each agency. Furthermore, data available are often limited to short-term outcomes (e.g. achievement of the goals set forth by a particular funding stream and program requirements). Cross-agency data that evaluate the long-term outcomes of individuals towards achieving employment and economic integration receiving multiple services are not available. A cross-agency data system would provide valuable information about the effectiveness of different program components within the workforce system for people with psychiatric disabilities and enhance the accountability of the system to ensure that individuals continue to receive supports through other services even if they do not achieve program-specific benchmarks.

With the funding of the current MIG, New York State intends to develop an overarching data system to monitor and document services across multiple state agencies. Such a data system would contribute to a much more seamless and No-Wrong-Door service environment, and enable Employment Networks to upload DOL wage reports for individuals served thus facilitating access to information essential to secure reimbursements from SSA. The recommendations for a cross-agency data system will be available in early 2010.

Access to services and eligibility:

Heterogeneity in assessment and application procedures

State agencies and programs have their own eligibility criteria and application procedures. While specific information can be expected to ensure that a particular funding stream and program requirements are met, the fragmentation of services often create an irrational heterogeneity of application procedures. Individuals are often required to present similar documentation multiple times to each program for which they apply, and required to undergo similar assessments to fulfill the requirements of a specific agency or program. For instance, it was reported that ACCES-VR will often require an assessment from their own psychiatrists when psychiatric evaluations from OMH certified clinicians are available.

The interviews with state administrations revealed that very positive and encouraging efforts were underway to improve cross-agency accessibility. For instance, a partnership between OASAS and ACCES-VR yielded an assessment form and procedure to determine the comprehensive support needs of individuals with substance abuse to successfully achieve employment. Nonetheless, while this project has shown promising results in a number of districts in New York City, it was reported that ACCES-VR's central office does not see it feasible to adopt it as a standard statewide.

More broadly, the systemic issue persists regarding the fact that individuals eligible for services under OMH and deemed "ready" to pursue vocational rehabilitation services by that agency, are not automatically eligible for ACCES-VR services, which forces clients to experience significant waiting periods before receiving services and a great deal of discouragement at a time when clinicians and staff supporting the individual, and the individual, agree that the time is right to pursue competitive employment and/or training programs leading to employment.

Narrow and illness-oriented definitions of readiness predominates

Across the "system" individuals are labeled as "ready" or "not ready" for employment based on the narrow definition of a particular program or funding stream. As a system, readiness is defined in relation to their appropriateness for a particular service or program. For instance, interviews with state administrators and providers indicate that DOL One Stop Centers often deem an individual "job ready" if she/he has a résumé ready to be presented to a prospective employer. Following federal guidelines, ACCES-VR determines "readiness" at least in part based on the likelihood that an individual will "benefit" from vocational rehabilitation services and achieve employment as a result of such services. These specific determinations seem to make sense from the perspective of each specific program, funding source, and resources available. Nevertheless, at the systemic level, and for the individual pursuing employment, these narrow definitions of "readiness" create a dichotomy (yes/no, ready/not ready) not only unhelpful but potentially harmful, considering the circular (non-linear) and complex process of rehabilitation and recovery (Citation for Anthony), which fails to incorporate the individual's perspective. A recent study on employment readiness suggests that "job readiness" assessment is most effective not when utilized as a screening mechanism but as a tool to determine the support needs that individuals require to be successful at achieving employment (Roberts & Pratt, 2007). From this vantage point, if an individual approaches a service provider indicating desire to work, this individual is "ready" to be engaged and must be supported by the system to determine what services she/he needs. Thus, "readiness" not only refers to the preparedness for immediate employment, but also to the desire to pursue employment. An individual may not be ready to apply for jobs immediately, but her/his desire to pursue employment is in and of itself an indication of readiness. "Readiness" assessments ought to be approached with the open-ended question "what is the level of readiness of this individual?" and followed by the question "what supports does she/he need to meet that level of readiness?" The USDOL Office of Disability Employment Policy has promulgated the use of 'Customized Employment' with its emphasis on person-directed and centered 'discovery' as an alternative to traditional assessment and a job development process that meets the needs of both job-seeker and employer through job task and work site accommodations (Callahan, 2002). New York makes Work Pay is currently testing this model that may hold promise as a method for improving employment and self-employment outcomes for people with mental illnesses.

In a system with fragmented services, and in which individuals are often not referred to the services that would best support their needs, narrow definitions of readiness based on the eligibility criteria of a particular agency/program are likely to "screen out" individuals and exacerbate the discouragement and hopelessness of those willing to pursue employment.

Significant waiting time to receive services

Individuals with psychiatric disabilities interviewed reported significant waiting times prior to receiving services such as those provided by ACCES-VR. When questioned about this matter, ACCES-VR officials indicated that in their experience it was best for beneficiaries to be informed about their eligibility when a vocational counselor is available to work with them, and not be informed they were eligible months before a counselor was actually available to provide services. ACCES-VR explains that with caseloads of over 200 individuals per counselor, and significant backlogs, it is difficult to assist everyone immediately. The focus groups conducted, as well as informal conversations held with ACCES-VR beneficiaries, indicate that for individuals willing to attempt work it is extremely discouraging to wait for several months in the uncertainty of whether or not they will receive services. The great level of discouragement and uncertainty that this waiting period produces makes it likely that in some instances individuals abort their employment or vocational pursuit.

Lack of Systemic Accountability and Ineffective referral and counter-referral systems

The fragmentation of services, silo-like funding structures, and lack of cross-agency data systems result in a lack of accountability at the system level in regards to the effective provision of employment services and supports to individuals with psychiatric disabilities. Individuals are often "dropped" or "left behind" by the system in the process of applying and/or referral to other services. Focus groups conducted with people with psychiatric disabilities pursuing employment provided instances in which applicants did not complete the eligibility determination for ACCES-VR services due to the perceived lack of communication with and responsiveness from the respective ACCES-VR district office. A particular individual reported never learning whether or not she was eligible for services, and not accessing other services that would have better met her employment support needs at the time. These instances, and many others, that the research team learned about from accounts by employment seekers across the State indicate that, at the system level, no one agency is responsible for ensuring that individuals access the services that would meet their employment support needs. For instance, if an individual is determined as ineligible for ACCES-VR services, it is not the agency's responsibility to ensure the individual is engaged in the services that would best meet her/his needs at that point in time.

Focus groups with individuals and interviews with administrators and staff of peer-operated programs (the latter also conducted in the context of the Medicaid Infrastructure Grant) indicated that peer-operated programs and other community providers often provide the accountability lacking at the system level, ensuring that individuals are not "dropped" or "left behind."

Underutilization of services available

This project also found that there is a dramatic underutilization of existing services and work incentives, such as the Medicaid Buy-In for Working People with Disabilities (MBI), Ticket to Work (TTW) and Plans to Achieve Self-Support (PASS). This underutilization seems to result from multiple systemic barriers such as poor infrastructure to support utilization, limited staff competencies, and disincentives to programs.

For instance, interviewees reported that data systems do not adequately flag the eligibility of individuals for the MBI, and often Medicaid/Social Services misinformed employees mistakenly enroll individuals for the Medicaid "spend-down" (which essentially forces people to remain in poverty and maintain eligibility for Medicaid). Some efforts are currently underway under the MIG to improve the utilization of the MBI through deputizing of screening and enrollment in New York City through a selected number of programs, and most recently through an effort led by the NYC Coalition of Behavioral Health Agencies. Another effort in progress is a partnership with the United Way operated "211" hotline to provide MBI information and enrollment services to callers. While these initiatives are fairly incipient, the MIG reported that through the multiple efforts underway there was an increase of approximately 25% in MBI enrollees in 2009 (from 6,000 to approximately 7,500). Nonetheless, these systemic barriers still persist and may require long-term commitments and broader scale initiatives. It is estimated that approximately 125,000 individuals are potentially eligible for the MBI in New York State which is significantly more than the less than 5% currently enrolled.

The new TTW also constitutes a promising source of supplemental funding for vocational programs and creates opportunities for consumers to choose among multiple providers. Nonetheless, there seems to lack an appropriate infrastructure to support Employment Networks (EN) overcome systemic barriers (e.g. billing, long-term engagement and tracking of Ticket holders) and perceived barriers. Currently, the relatively small number of certified ENs in New York State actively taking the "Tickets" does not provide consumers with a real improvement in choice at the present time unless more concerted efforts are undertaken to create MH consumer-friendly ENs..

The Social Security Administration Plan to Achieve Self-Support (PASS) enables individuals to save money towards an employment goal without affecting SSI payments. Of the hundreds of thousands of individuals with disabilities who are potentially eligible for the work incentive, there are only 85 individuals in NYS who currently have a PASS.

Limited availability of integrated and comprehensive care

Many people with psychiatric disabilities suffer from more than one mental disorder at any given time. Nearly half (45%) of those with any mental disorder meet criteria for two or more disorders. Similarly, about one in two individuals with a severe psychiatric disability have a co-occurring substance abuse disorder (Kessler et al, 2005; citation on COD-SA). Research has demonstrated that integrated care significantly improves overall recovery and employment outcomes (Cook, 2006). In a fragmented service structure limited by siloed funding sources, and compartmentalized competencies among practitioners, highly integrated care is virtually impossible. Focus groups with individuals and accounts from people with multiple support needs (e.g. psychiatric and substance abuse rehabilitation, psychiatric and physical/sensory disability) indicate that often these individuals are left with the dilemma of choosing what will be their primary concern (e.g. mental health or substance abuse), or even worse, the system will decide for them based on the professional determination of a clinician with whom they come in contact.

As it was discussed in the background section of this report, labor and sociological research show that individuals with disabilities require several types of "capital" or resources to successfully achieve employment (Potts, 2005), including human (e.g. skills, certifications)., material/economic (e.g. stable housing, reliable transportation, work incentives, asset-building programs), and social capital (e.g. employment connections, support networks). As a result of the predominant fragmentation of services, comprehensive supports to improve the employment capital individuals need to succeed at employment are often inaccessible to them. In many instances the resources seem to indeed be available in a particular community or region, but the fragmentation of services and compartmentalized knowledge and competencies of practitioners result in de-facto lack of availability. For example, a Work Incentives Planning Assistance benefits advisor may be available at an Independent Living Center, but mental health providers and individuals considering employment may not know about this resource, failing to access this important service. Similarly, asset building programs may be available in particular community, which could potentially provide the employment seeker with information about economic self-sufficiency resources, but typically mental health programs have limited or null connections with the asset development and financial communities, failing to link individuals to comprehensive care to achieve employment and economic self-sufficiency.

Limited capacity of programs to provide recovery-oriented employment services and compartmentalized provider competencies

As a result of the fragmented service structure, siloed funding sources, and limited linkages between agencies, the competencies of practitioners and support staff appear to be equally compartmentalized. For instance, mental health clinicians often have little or no training in vocational issues, which often slows down an individuals' engagement in vocational planning or discouraging work with the misinformed assumption that employment may increase the likelihood of psychiatric relapse. Similarly, support providers (e.g. residential staff, peer counselors, etc) often hold misconceptions about the role of employment in recovery and the supports available, such as work incentives. During our interviews it was reported that support staff will often make generalizing statements such as "you will lose your benefits if you go back to work" and dismiss the individual's desires and potential for recovery. Interviews and focus groups suggest that these misconceptions among mental health clinicians and support staff have the power to create a significant, and at times difficult to reverse, negative impact on the belief and hope of individuals about the possibility of achieving employment.

While competencies at the practitioner/staff level require improvement, this competency gap is a result of the overall programmatic capacity to implement recovery-oriented employment services. Implementation and organizational change research indicate that the training of individual practitioners is insufficient to affect the change often needed to improve the capacity of programs to be implemented (Fixsen and Naoom, 2005). From this vantage point, the full implementation of recovery-oriented employment services requires not simply the improvement of knowledge and competencies of individual practitioners or staff, but also the enhancement of the overall capacity of programs to implement recovery-oriented employment services across program domains such as program design (e.g. mission statement, integration of services), physical environment (e.g. hope-building about recovery and employment), staff development systems (e.g. competency-based training), service provision (including first contact and engagement, assessment & planning, delivery of services, progress review, and continuity of services), and quality improvement and evaluation.

Our interviews revealed an important initiative currently underway in New York State to improve the technical capacity of OMH-funded programs to implement evidence-based supported employment within a recovery-oriented approach. The Evidence-Based Practice Technical Assistance Center (EBP-TAC), operated by the New York State Psychiatric Institute at Columbia University, has been funded to provide technical assistance in order to move evidence-based practices into clinical practice in OMH funded programs. OMH has funded the Supported Employment Technical Assistance Center within the EBP-TAC. This Center has hired trainers and consultants specialized in Individualized Placement Services (IPS) to support the implementation of this evidence-based practice. It is OMH's plan to begin implementing IPS in Personalized Recovery-Oriented Services (PROS) and later on phase it into the service delivery of other program types. The process will include regional IPS forums, mentoring to a small number of PROS programs and non-traditional use of distance learning systems in order to bring IPS to scale with the PROS programs.

This initiative has the potential of effecting a significant change in the capacity of programs to provide recovery-oriented employment services within PROS, and in time, across OMH-funded programs. Nevertheless, it is paramount that the implementation of evidence-based practices be guided by an ongoing assessment of the actual employment and economic integration outcomes of individuals served and at the population level. National studies raise some caution about the over-reliance on evidence-based as the "magic bullet" to solve the unemployment problem. Evaluations of the Johnson and Johnson-Dartmouth national projects and SAMHSA federal transformation grants suggest that the implementation of "evidence-based practices" only produce minimal improvements in employment outcomes at the population level (Marrone, Smith & Foley, 2009). Therefore, OMH's expressed commitment to monitor the outcomes of the IPS initiative will be of vital importance (See Appendix XX for OMH's PROS and IPS Implementation Plan).

Hopelessness and limited social capital

The interviews conducted with state administrators and community providers, as well as the focus groups with individuals pursing employment revealed that the belief that people with psychiatric disabilities can work and become economically self-sufficient is seriously compromised by the great deal of systemic barriers that individuals have personally experienced, seen other individuals with psychiatric disabilities experience, or simply heard about through their social networks or providers. Thus, individuals are often able to easily relay "negative" experiences with "the system" and numerous reasons why achieving employment and economic self-sufficiency is extremely difficult for a person with psychiatric disabilities.
Another important phenomenon affecting people with psychiatric disabilities is their limited and segregated social networks, which is, at least in part, a consequence of the predominantly segregated, fragmented and illness-oriented service environment. Individuals who have received services in the public mental health system for a long period of time appear to have their social networks limited to other program participants and providers in the mental health system. This is particularly concerning since research on social capital and employment reveals that a majority of individuals in the overall population (50% to 70%) find jobs through their personal networks, either people they know directly or indirectly and not through more formal venues (e.g. internet or newspaper ads) (Potts, 2005; Condeluci, 2009). Adults in the mental health system appear to only count with small and "redundant" networks (i.e., networks in which everyone knows the same people), which fundamentally limits the flow of information about employment opportunities and relationships of trust and reciprocity essential to achieving employment. From a sociological point of view, the limited social capital of individuals with psychiatric disabilities seems to be a fundamental cause of their high level of unemployment.

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Specific Policy and Program Recommendations

Based on the findings of this project, the research team presents several specific recommendations to New York State aimed at making employment a systemic priority and an essential component of mental health, rehabilitation and recovery services and supports for individuals with psychiatric disabilities; and establishing a cross-agency recovery-oriented workforce system for people with psychiatric disabilities. The research team presents five principles to guide the transformation of employment services:

Making employment and economic integration systemic priorities

All people with psychiatric disabilities are capable of achieving integrated competitive employment and economic self-sufficiency. Unemployment, long-term dependency on social security benefits and the life of poverty resulting from them, are factors that contribute to further psychiatric and physical disability and constitute barriers to rehabilitation and recovery. All public health and workforce services of New York State must be geared to effectively support individuals with psychiatric disabilities to achieve their self-determined employment and economic self-sufficiency goals in a coordinated and integrated fashion. Considering that people with psychiatric disabilities experience multiple systemic barriers to achieve employment and economic self-sufficiency, it is of paramount importance that New York State develop an integrated and coordinated SYSTEM that provides individuals with all the services and supports needed, by implementing innovative funding structures (including braided-funding modalities, No-Wrong door policies and infrastructure (multiple points-of-entry), engagement and support of all individuals in the rehabilitation process, inclusive definitions of readiness and eligibility criteria, No-One-Left-Behind policies (accountability of all parties within the system), and competency-based training of clinicians and support staff. With the leadership of the NYS Office of Mental Health, all state agencies will work together to create such a system and provide individuals with the supports they need to achieve their vocational and economic self-sufficiency goals.

Overcoming the fragmentation of services

Maximizing impact of funding and resources available

Improving accessibility to services and engagement of individuals

Increasing systemic accountability

Improving utilization of services

Improving availability of cross-agency data on employment and economic integration outcomes

Improving the effectiveness of services: integrated and comprehensive care

Improve program capacity and competencies of practitioners

To illustrate the aspects involved in a transformation effort toward a recovery-oriented employment service provision, please find attached the "Recovery-Oriented Transformation Technical Assistance Framework" (NYAPRS, 2009).

Training of practitioners ought to follow a competency-based approach. All practitioners and staff involved in the planning and delivery of services for PWPD must possess a set of core competencies including recovery-oriented employment programming, person-centered planning, inclusive and comprehensive readiness assessment, effective engagement of individuals across stages of employment readiness and effective linkage and referral to appropriate employment and wraparound services. Below are some of the key competency areas that ought to be considered for all practitioners and staff interacting with mental health recipients:

To illustrate the curriculum content proposed, attached are NYAPRS Core Competencies for Facilitating Narrative Change and Person-Centered Employment Programming. The article included as a separate attachment related to Assessing Job Readiness not as a screening mechanism but as a tool for assistance and success maximization for clients (Roberts & Pratt, 2007) is illustrative in this regard and might serve as an excellent training vehicle for both OMH providers and ACCES-VR staff.

Increasing consumer participation to improve utilization and employment outcomes

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Next Steps

Implementing the recommendations offered above represent a systemic transformation of great magnitude. Nevertheless, there are a series of concrete actions that OMH and other state agencies can initiate immediately to build upon the several positive initiatives currently underway, while moving the workforce system for people with psychiatric disabilities towards greater levels of integration and recovery orientation.

Empower OMH to lead coordinated systems of accountability across all state agencies involved in the provision of employment services for individuals with psychiatric disabilities. The improvement of employment and economic integration for people with psychiatric disabilities will require the leadership of one state agency. Considering the impact that the unemployment of people with psychiatric disabilities has on the public mental health systems, and the ongoing initiative to improve the state employment infrastructure, OMH is the agency best positioned to take such leadership role. With such leadership and in coordination with other state agencies, OMH can takes steps towards:

Follow-up Commissioners' Summit: A number of Commissioners convened for the NYS-Medicaid Infrastructure Grant (MIG) in September 2009. This Commissioners summit symbolized the State's acknowledgement of the enormity of the unemployment problem among individuals with disabilities. Nevertheless, a report or collective statement has not been made public. Specifically, OMH can propose a statement to be adopted by all state agencies, expressing their willingness to work collaboratively and support cross-agency mechanisms and setting the foundation for more specific Memoranda of Understanding and collaborative projects.

Pursue OMH-ACCES-VR- DOL interagency agreement to pilot referral and counter-referral system: There are several initiatives currently underway among OMH, ACCES-VR and DOL. For instance, ACCES-VR and DOL have agreed to have VR counselors at the One Stop sites in order to facilitate the referral and engagement of individuals, and this is occurring in multiple One Stops. Several ACCES-VR district offices and OMH-funded programs have "liaisons" that facilitate the referral and communication between parties. OMH and DOL have a collaborative program to fund the training of people with psychiatric disabilities who have a job offer within an OMH funded program. All of these initiatives create a momentum for an inter-agency agreement to build a more integrated system. Specifically, OMH can propose to pilot an agreement on mechanisms for referral and counter-referral among programs funded by each of the three agencies in a small number of communities. This would require ongoing communication and specific referral standards between ACCES-VR counselors, OMH funded programs and Disability Program Navigators in those communities. This can also put in practice an initiative to empower community providers to complete Individualized Plans for Employment (IPE's) with applicants on behalf of the vocational rehabilitation agency. This would expedite the application process, offer the applicant a more seamless experience, and reduce the likelihood of individuals being "lost" in the process.

Continue efforts to redefine the role of Disability Program Navigators (DPNs): DPNs were conceived as a resource to create linkages between state programs and community providers, that is, to create a service environment that is responsive to the complex employment support needs of individuals with disabilities. In time, and in part as a result of the decentralized administration of this program (in many instances One Stops and DPNs are employees of a sub-contracting agency), DPNs often take a role of direct providers offering job development/placement and connecting individuals to other services. Given the small number of DPNs per region (at most one per county or NYC borough) it is virtually impossible that these individuals can effectively provide services to hundreds or thousands of individuals pursuing employment at any given point in time. OMH and the DOL's Division of Workforce Development have already taken steps to train/retrain DPNs and provide them with technical assistance to fulfill the role of "bridgers" across programs and services available at the community level. To advance the redefinition of the DPN roles, DOL can develop a policy guide to clarify the role of DPNs within DOL, sub-contractors, and community providers.

Build on MISCC cross-agency employment data: In October 2009, the Most Integrated Setting Coordinating Council (MISCC) presented a compilation of data on funding and other key items per state agency and employment program type (See Appendix "2009 MISCC Employment Data"). This cross-agency effort reveals a great deal of transparency and willingness to move the employment agenda forward. OMH can request further estimates from other state agencies to determine the approximate number of individuals with psychiatric disabilities served by other state programs (e.g. ACCES-VR, OASAS). If these are not available, a request ought to be made to ensure that all state agencies indeed collect information about the employment needs and outcomes of individuals with psychiatric disabilities.

Continue efforts to integrate OMH funded employment initiatives: OMH is currently funding or leading multiple initiatives to advance the employment of people with psychiatric disabilities, including the NYS MIG, the roll out of PROS, the implementation of Individualized Placement and Support (IPS), the "Work is Everybody's Business" campaign across OMH operated programs, and the grassroots "We Can Work" campaign. While all these initiatives have relatively distinct objectives it is paramount that they all maintain not only a significant level coordination but also create opportunities for synergy. Specifically, OMH can promote inter-project collaborations to maximize the impact of interventions. For instance, the implementation of IPS can be complemented with consumer forums and education through the "We Can Work" campaign. Demonstration projects funded by the MIG can help enhance the impact of the PROS implementation.

Deliver Benefits Advisement through MIG-Work Incentives Network: The MIG has trained approximately one hundred advisors specialized on work incentives. These individuals were recruited through multiple organizations that have agreed to ensure trainees deliver advisement to individuals served. Participants of these trainings have provided very positive feedback and it all suggests that this training effort is being successful at improving the competencies of trainees. Nevertheless, an implementation plan to guide the delivery of benefits advisement and estimate its impact on employment outcomes, does not appear to have been developed. In order to ensure that this tremendous training effort is reflected on delivery of benefits advisement leading to work, OMH and the MIG can make an explicit implementation plan that specifies the target of each advisor and provides tools to monitor impact.

Improve the infrastructure to access Ticket to Work funds and expand Employment Networks: The Ticket-To-Work represents an opportunity for supplemental funding for employment services. Nevertheless, providers face multiple barriers to become Employment Networks (ENs) or to in fact take Tickets and receive reimbursements from Social Security. Informally, providers report the disincentive involved in tracking an individual for extended periods of time. Specifically, OMH and ACCES-VR can develop resources and tools in order to increase the number of Employment Networks (EN) in New York State effectively providing employment supports. This can be accomplished by developing a technical assistance plan to address the barriers of providers to become ENs and make effective use of the Ticket-to-Work funding; developing a New York State specific electronic system for cost-effective tracking of Ticket-to-Work holder outcomes and facilitating of billing and reimbursement requests to SSA; creating an Employment Network Coordinating Center which provides support to multiple ENs; and is in charge of tracking data, billing, and redistributing reimbursements to ENs.

We Can Work Campaign: In 2008, OMH funded the New York Association of Psychiatric Rehabilitation Services (NYAPRS) to launch and conduct a grassroots campaign aimed at building the hope of individuals with psychiatric disabilities around employment, improving the demand for employment, and increasing the utilization of work incentives and services available. This campaign has had a significant impact on the communities of people with psychiatric disabilities and providers. OMH has motivated the synergy between the actions of this campaign and other OMH teams and sub-contractors, such as the Regional Advocacy Specialists, Mental Health Empowerment Project, and Empowerment Center. This initiative has the potential to create synergetic impacts as individuals may be "touched" by resources of several programs. OMH can continue fostering the collaboration between this campaign and other OMH funded programs.

Table 3: Next Steps- Suggested Action Plan

Strategy

Actions

Outputs
(and time required)

Responsible agencies

Empower OMH to lead coordinated systems of accountability

  • Outline a proposal for an interagency statement and commitment to build a coordinated system, and OMH's lead regarding PWPD
  • Introduce proposal to executive branch and non-executive branch agencies
  • Conduct a mapping of all employment program types serving PWPD per agency, funding stream and readiness definition
  • Convene peer employment support programs to identify their potential role in engagement, cross-agency referral, and follow up.
  • Convene state agencies to discuss principles of coordinated system (e.g. referral, data systems)
  • Agreement among state agencies for OMH to lead a coordinated system (dependent on political willingness)
  • Inventory of employment services across all state agencies (including readiness definitions)

(3-6 mos.)

  • Agreement among state agencies on principles for referral and counter-referral system (dependent on political willingness)

OMH
DOL
ACCES-VR
DOH
DSS
OASAS
DVA.DOL-VETS

Pilot OMH-DOL-ACCES-VR referral and counter-referral system

  • Identify funding stream to pilot cross-agency referral system in 3 or more communities in NYS
  • Sub-contract implementation of pilot
  • Identify pilot communities to represent a diversity of contexts
  • Convene administrators of state and community providers to agree on key components
  • Implement pilot program
  • Evaluate pilot program
  • Plan for pilot on referral and counter-referral system (3-6 mos.)
  • Implementation of pilot in 3 communities (1 yr.)
  • Plan to bring referral system to scale based on lessons of pilot (3-6 mos.)

OMH
DOL
ACCES-VR

Provide ACCES-VR managers and staff with recovery-oriented employment tools

  • Identify a training group with expertise in recovery-oriented employment tools (e.g. employment readiness and engagement, person-centered employment)
  • Convene district managers and offer training and tools on recovery-oriented vocational planning
  • Provide training to vocational counselors via webinars, tele/video conf, etc.
  • Develop supervision tools for managers to foster competency development of vocational counselors
  • In-person training of district managers on recovery-oriented tools (3mos.)
  • Web-based training of vocational counselors statewide (3-6mos.)

ACCES-VR

Redefine role of DPNs

  • Develop policy guidance for DPNs to redirect effort from direct job placement to providing linkages and referrals across programs in their communities
  • Create standards on data collection (e.g. directory of organizations, referrals)
  • Develop plan to provide training and TA to DPNs in coordination with OMH
  • Conduct training of DPNs
  • Policy guidance defining role of DPNs (1-3mos.)
  • Standards for data collection
  • Delivery of training and technical assistance to DPNs to develop related competencies (1 yr.)

DOL

Support expansion of MISCC employment data

  • Conduct census of individuals served per OMH program type (i.e., ACE, OISE, sheltered) and length of stay (if census is not possible, conduct survey of representative sample )
  • Develop system to ensure continued availability of data within OMH
  • Convene agencies to agree on a minimum set of indicators and establishing ongoing mechanisms to gather employment data for PWPD
  • Complete census or survey on OMH employment services (6-9mos.)
  • Agreement among agencies to monitor a minimum set of indicators (6-9 mos. depending on political willingness)

OMH
ACCES-VR
DOL

Integrate OMH funded initiatives (i.e., MIG, Making Work Everybody's Business, deputizing of MBI enrollment, PROS/IPS implementation, We Can Work Campaign)

  • Identify opportunities for synergy and collaboration (e.g. referrals between Work Incentives Network and We Can Work campaign; referral from PROS/IPS to deputized MBI enrollment)
  • Develop a plan for coordinated initiatives

 

  • Plan for coordinated initiatives among OMH funded projects (3-6mos.)
  • Implementation of coordinated initiatives among OMH funded programs (6mos. - ongoing)

 

OMH
NYC Coalition of Behavioral Health Agencies
NYAPRS
Cornell University
Syracuse University

Connect Work Incentives Network (WIN) advisors to programs across systems

  • Make contact information and certification level of WIN advisors available and accessible to all providers of PWPD
  • Establish formal referral and counter-referral system between WIN advisors and We Can Work peer facilitators
  • Directory of WIN advisors available and accessible (1-3mos.)
  • Formal connections between WIN and other statewide initiatives, e.g. WCW campaign, Making Work Everybody's Business, PROS programs (3-9mos.)

MIG -Syracuse University/ Cornell Univ.
OMH
NYAPRS

Improve capacity for increased utilization of Ticket to Work and expansion of ENs

  • Develop a technical assistance plan to address the barriers of providers to become ENs
  • Conduct a survey to assess readiness level of providers and prioritize those most likely to become ENs
  • Provide training and TA to providers
  • Evaluate the barriers and further TA needs of providers
  • Technical assistance plan to support providers become ENs (3 mos.)
  • Survey to assess readiness level (3 mos.)
  • Provision of TA to providers (9mos.-1yr.)

OMH
NYAPRS

Expanding "Making Work Everybody's Business" Campaign

  • Develop training and TA plan for OMH licensed providers (e.g. clinical, day program, residential) to maximize effectiveness and efficiency of outreach
  • Develop training and TA tools utilizing web-based and electronic technology to reach diverse provider audiences
  • Deliver training and TA
  • Training and TA plan for OMH licensed providers (3mos.)
  • Training and TA tools accessible to all providers
  • Delivery of training and TA to (6 mos. - ongoing)

OMH

Expanding "We Can Work/We Can Save" Campaign

  • Support the We Can Work/We Can Save Campaign to establish partnerships with OMH peer-operated sub-contractors and OMH funded programs to expand the number of peer facilitators
  • Identify funding stream to expand training efforts from 25 to 100 peer facilitators statewide
  • Train 100 peer facilitators statewide
  • Coordinate activities and provider TA to network of peer facilitators
  • Delivery of training to 100 peer facilitators (6mos.)
  • Delivery of peer support activities across communities in 5 regions (6 mos. - ongoing)

OMH
NYAPRS
OMH peer-operated programs

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The theory of "fundamental cause" of disease was developed by Columbia University and NYS Psychiatric Institute researchers J. Phelan and B. Link to highlight the structural factors of disease. Reviewing the history of epidemics they argue that when a society develops the ability to control disease and death, the benefits of this new-found ability are distributed according to resources of knowledge, money, power, prestige, and beneficial social connections. Therefore, those with greatest access to these resources are most capable of responding to and preventing disease, disability and death. Traditional public health interventions have focused on changing immediate factors (e.g. condom use, smoking, symptoms management) failing to address underlying factors such as poverty and socioeconomic inequalities. In their opinion, only addressing the underlying disparities can ensure the long-term overcoming of illness and disability (Phelan & Link, 2005).

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Appendix 1: Background Paper: Factors affecting the employment outcomes of people with psychiatric disabilities

Employment and poverty among PWPD in NYS

People with psychiatric disabilities in New York State are grossly unemployed and are more likely to live in poverty compared to the non-disabled population. According to SAMHSA (2007) less than 25% of adult public mental health consumers are employed at any level, compared to over 90% of employment in the overall United States population. However, in New York State, the Office of Mental Health (2009) estimates that only 12 to 15% of people with psychiatric disabilities are actually employed- much lower than the national average- yet 50 to 70% indicate that they want to work (2008). People who use mental health services typically want to work, "regardless of how 'severe' their symptoms and related social disabilities may appear" (Evans & Repper, 2000). Surveys of needs and quality of life find employment to be consistently highly ranked as a priority by mental health service users themselves. Poverty also shows a disparity among those with disabilities and those without. Thirty-four percent of people with disabilities live in poverty, compared to only 10% of people without disabilities (American Community Survey, 2006). Almost 40% of people with a mental disability live in poverty and more than 50% of those with a mental disability have annual incomes of less than $24,000 (American Community Survey, 2007). Additionally, only 25% have some form of employment, and a mere 11% report a full-time job.

The consequences of unemployment on mental and physical health

In addition to the evident socioeconomic impact of unemployment and poverty, this picture is particularly troublesome as research has demonstrated that unemployment has harmful effects on the physical and mental health of individuals, and increase psychiatric disability. Financial stress is a risk factor for depression, anxiety, and psychiatric relapse. For those with psychiatric disabilities, loss of employment causes a decline in self-esteem and psychological health and a perception of seeing themselves as not 'mentally well', even when receiving full pay (Rudas, et al., 1991; Evans & Repper, 2000). According to a study by Murali and Oyebode (2004), being unemployed increases the odds of having a psychiatric diagnosis between two and four times. In this study, Murali and Oyebode found that as social class decreases, mental health disorders increase (see Figure 1). The risk of alcohol and substance abuse was found to be several times higher among those with lower socioeconomic status (SES). The risk for psychosis was also found to increase as social class decreases; psychosis is more than 4 times higher among the lowest classes (17%) compared to the highest (4%). The study also found that the risk for depression was also about 4 times higher for those with the lowest SES (35%) as compared to the highest class (9%). The risk for obsessive-compulsive disorder was found to be 3 times higher in lowest social class (21% versus 6%). Wing and Brown (1970) found that lack of employment was the only factor differentiating inpatients with a diagnosis of schizophrenia who did not improve compared to those who did show improvement. The idea of social isolation poses a serious problem, as work is an important source of forming social relationships. Losing a job or not being able to return to the workforce deteriorates these social supports, and financial stress and low self-esteem increases a worker's inactivity and social isolation. Thus, it is a vicious cycle which continues as long as unemployment continues.

Consequences of poverty on mental health

As Hudson (2005) points out, low socioeconomic status has been found to be an outcome of psychiatric disability; however, the reverse has also commonly been found. The social causation theory validates this comment, stating that poverty causes psychiatric conditions through factors such as low income and financial stress, unemployment, lower status occupations, high costs of housing, limited access to preventive care and quality treatment, and a lack of internal and external resources to cope with life stressors (Hudson, 2005). Research shows that having low socioeconomic status /poverty increase the likelihood of psychiatric disability; individuals in a lower socioeconomic stratum experience disproportionately more mental disorders than those in a higher socioeconomic stratum (Moren-Cross, 2005). The effect of poverty on mental health is so prevalent because "poverty structures the social and material conditions of everyday life by shaping social relationships, living conditions, and access to health care" (Moren-Cross, 2005). These conditions are essential factors to a stable mental condition. A study by Fan (2001) found that low income children are 1.86 times more likely to report emotional or nervous condition in adult life, and low income boys (aged 7-8) are 3.2 times more likely to report a psychiatric condition in adult life. In the same study, it was shown that as level of income decreases (thus causing poverty to worsen), the prevalence of psychiatric disorders increase drastically (2004). Poverty and low socioeconomic status make mental health recovery more difficult for those with psychiatric disabilities. It is incredibly important to reduce poverty and increase socioeconomic status as a response to psychiatric disability and a method to improve outcomes for those with psychiatric disabilities.

Figure 1: Prevalence of psychiatric disorders by social class
(Murali & Oyebode, 2004)

graph indicating pyschiatric disorders by social class. Disorders include Depressive disorder, psychosis,alcohol dependency, Drug, dependency, Generalized anxiety, OCD.  Classes include Class I, Class II, Class III, Class IV, Class V

Moreover, a recent national study also found that people with psychiatric disabilities die on average twenty five years younger, largely due to chronic diseases associated with low-income and poor access to preventive care (Newcomer & Hennekens, 2007). For many individuals to experience psychiatric disability means to be sentenced to a life of unemployment, poverty, isolation and premature death.

According to the theory of social selection, a psychiatric disability causes a decline in socio-economic status through factors such as geographical drift(congregation in lower SES communities) or economic drift (unemployment or underemployment) (Hudson, 2005). A study by Tiffin, et al. (2005) found that poor mental health was associated with a downward socio-economic trajectory over the course of life. Shur (1988) also found in a study of people with schizophrenia that the socioeconomic status of the individual was more associated with the condition than the socioeconomic status of the father, suggesting that schizophrenia may cause a decline in socioeconomic status. The SES drift begins with frustrated education, low occupation status, unemployment, dependence on public programs, and a lower income. These limited competencies as a result of long-term unemployment and low education then lead to poor job skills, unskilled labor, and poor financial skills. Once this point has been reached, the individual's social capital drastically declines. This includes dependence on relations or connections with the mental health system, deterioration of family and community relationships, and social isolation.

Figure 2: Bi-directional relationship between poverty and psychiatric disability
Addressing unemployment from a "capital" framework

Flow chart. First box includes: Low education, High unemployment, Low occupational status, Poor psychiatric care Leads to Psychiatric Disability, that leads to Unemployment, Dependency on public programs, Limited assets for social mobility, Limited skills/ competencies, reliance on MH programs, Limited social capital which leads to Poverty. The flow repeats itself.

Labor and sociological research suggests that three forms of capital are required for people to be successful at achieving employment for people with disabilities: (1) human, (2) social, and (3) material capital (Potts, 2005). Human capital refers to the training and skills that make individuals able to perform a job (e.g. education, specialized skills). Social capital refers to the relationships and connections that make it possible for people to obtain and maintain a job (e.g. social networks producing job opportunities, peer support to cope with job stressors). Material capital encompasses the economic and tangible supports that need to be in place for individuals to work (e.g. safe and stable housing, reliable transportation, work tools). From this perspective, obtaining and maintaining employment are more likely when individuals' human and cultural capital is supported by broader social and material capital available to them.

This framework suggests that a comprehensive approach to employment services ought to incorporate the human, cultural, social, and material dimensions in order to ensure that the necessary "capital" is available to individuals with psychiatric disabilities to obtain and maintain employment. A review of the research on employment suggests that, traditionally, employment services for people with psychiatric disabilities have prioritized a focus on developing individual's human and cultural capital (e.g. providing skills training, interviewing skills, résumé building) and have developed significantly less capacity at addressing the structural supports required to build social and material capital (e.g. ensuring stable housing, improving financial resources, expanding social support networks).

Furthermore, a review of research available reveals that the social conditions of people with psychiatric disabilities are critical predicting factors of employment outcomes. Psychiatric disability is more likely to occur among people who are poor and already in disadvantage to accessing human, social and material capital essential to work. Psychiatric disability has also been shown to have a negative impact on critical socio-demographic variables such as educational attainment and income, thus contributing to further impoverishment and limited access to employment capital. Substance abuse, crime and homelessness are all social problems more likely to occur among those who are poor. Research shows that these social conditions, which pose important challenges to the employment outcomes of people with psychiatric disabilities, are more associated with the social context in which a large proportion of people with psychiatric disabilities live than with the mental illness itself. Therefore, a systemic approach to addressing the employment barriers of people with psychiatric disabilities must take into account the social conditions affecting this population.

Ecological framework

From a public health perspective, many of the approaches and issues are presented based on the ecological model. The ecological model is a framework that has been used to conceptualize a problem with the understanding of the impact of multiple levels of influence. Given the discussion of employment, we have altered the names of the levels to policy, employers (community), providers (organizational), peer support (interpersonal) and individuals.

Systemic factors: availability, accessibility and effectiveness of services

These structural factors can be broken down into three categories: availability, accessibility, and effectiveness of employment-related employment services. Many programs lack person-centered planning and services or "wraparound" services, making it difficult for consumers to actively and effectively participate in the program. These comprehensive services should meet every need in a consumer's life, from peer support to housing to transportation. Many programs also lack services capable of responding to varying support needs, such as an extended time in the system, or intensive help for certain consumers. Programs should be able to deliver care to culturally diverse populations as well as underserved or vulnerable populations, such as those with a co-occurring disorder or a physical health disorder. Services such as benefits advisement are also not often offered for a consumer looking for employment assistance.
When it comes to the accessibility of services, paperwork and misinformation can intimidate consumers from pursuing employment. Eligibility determination and exclusionary criteria can often pose as a barrier to people with psychiatric disabilities. Some may believe that the criterion for acceptance into the program is more arbitrary and less methodical. Applications processes and wait times for work incentives can also be complex and confusing, and there is often misinformation among providers about these work incentives and benefits. The rights of the disabled individual can also be left behind; there is limited training among providers and staff to support ADA accommodations and other rights of the individual, and sometimes a lack of information among employers about the rights of the individual can arise.

The effectiveness of employment services is also an area that could be improved upon when considering the barriers people with psychiatric disabilities face. To start, many providers emphasize consumers getting a job, rather than focusing on maintaining a job or pursuing a career, which does not make for effective services. The program's capacity to engage and responsiveness to people with psychiatric disabilities with co-occurring disorders, physical health challenges, those who are socioeconomically disadvantaged, and racial and ethnic minorities relates directly to the effectiveness of the program as well. As highlighted as a practitioner competency barrier, a program's "readiness assessment" to determine whether a consumer is ready and willing to work can be a strong barrier for people with psychiatric disabilities. This tool often does not correctly or effectively assess the consumer's desire or ability to work, and thus can create a barrier between the consumer and employment.

Knowing that barriers exist regarding the availability, accessibility, and effectiveness of employment programs for people with psychiatric disabilities has encouraged us to focus on the system and policy barriers to employment for people with psychiatric disabilities. In order to make a substantial breakthrough for this population, changes must be made at the structural level, rather than focusing on individual and provider competency barriers. Below are many factors that limit the access of people with psychiatric disabilities to employment from structural and systemic factors to individual barriers, based on current literature on the topic.

Practitioner level factors

Misconceptions among providers concerning work and mental health, including the low expectations of providers about the potential of people with psychiatric disabilities, are a very real barrier that people face daily. In fact, a study in Brooklyn found that practitioners' referrals to supported employment management were much lower than participants' actual desire to work. That is, the practitioners perceived much fewer participants wanted to or were ready to work than was actually the case.

Studies show how important it is to improve provider competencies in order to help people with psychiatric disabilities toward recovery. However, research shows that knowledge and provider competencies are not necessarily enough to effect changes at the programmatic level. Changes in administrative practices or organizational structures are often needed for significant change to occur (Fixsen and Naoom, 2005).

Individual level factors

Several misconceptions about the reasons for the low labor participation of individuals with psychiatric disabilities still predominate among traditional mental health programs and society at large. One inaccurate assumption is that people with psychiatric disabilities experience a significant degree of complacency and do not want to work. In fact, research shows that 70- 90% of people with psychiatric diagnoses want to return to work, and as mentioned before, 50-70% of adults in the mental health system in New York indicate they want to work (Grove, 1999; Rinaldi & Hill, 2000; Secker, Grove, & Seebohm, 2001; OMH, 2008).

Although these assumptions are often incorrect, there still remains a disparity between those with psychiatric disabilities and those without when it comes to employment. So what are the actual barriers limiting the employment of individuals with psychiatric disabilities? In actuality, there are many barriers that limit the access to employment for those with psychiatric disabilities, from individual to systemic to societal obstacles.

To many individuals with psychiatric disabilities, employment means a loss of cash and health benefits. Individuals also may fear not being able to manage stress and symptoms of their disorder, or may have negative ideas about their personal potential. In addition to these, people with psychiatric disabilities live their entire life with stigma and negative perceptions surrounding them. Stigma, discrimination, and ignorance about individuals with psychiatric disabilities, as well as negative perceptions of their work ethics and potential often prove to be enormous barriers to employment.

Improving employment services as part of a recovery-oriented transformation

Multiple longitudinal studies throughout the world have demonstrated that recovery is possible for the majority of people with severe psychiatric conditions (Bleuler, 1972/1978; Ciompi & Muller, 1976; DeSisto, et al., 1995a; DeSisto, et al., 1995b; Harding, Brooks, Ashikaga, Strauss, & Breier 2005a; Harding, Brooks, Ashikaga, Strauss, & Breier, 2005b; Hinterhuber, 1973; Huber, Gross, & Schüttler, 1979; Kreditor, 1977; Marinow, 1974; Ogawa & Miya, Watarai, et al, 1987; Tsuang, Woolson, & Fleming, 1979). All of these studies found that approximately one half to two thirds of people with psychiatric conditions can achieve significant improvement or full recovery, thus showing not only that recovery is possible, but also that recovery is more common than persistent impairment (Davidson, Harding, & Spaniol, 2005). Nevertheless, people with psychiatric disabilities in New York State and across the country continue to experience much poorer quality of life than the non-disabled population. On average, people with psychiatric disabilities die twenty five years younger than those without disabilities (Newcomer & Hennekens, 2007); over eighty percent are unemployed (OMH, 2009; Marrone, Gandolfo, Gold, & Hoff, 1998; Anthony, 1994); more than thirty percent live in poverty (Bjelland, Erickson, & Lee, 2008); and many more spend their lives in some form of semi-institutionalization in the mental health system. As a result, mental illness is the number one cause of disability in the country, accounting for more burden than that associated with all forms of cancer (McAlpine & Warner, 2002). Why is it that, despite the potential for full recovery, the quality of life of people with psychiatric disabilities in New York State continues to be much poorer than that of people without disabilities?

Figure 3: An ecological approach to the factors limiting the access of people with psychiatric disabilities to employment

Structural/systemic factors:

Natural and peer supports:

Individuals' hope and competencies:


The two most comprehensive reports on mental health of the past decade, the Surgeon General's Report on Mental Health (U.S. Department of Health and Human Services [DHHS], 1999) and the New Freedom Commission Report (DHHS, 2003), established that the single most important problem of the mental health system in the United States is the predominance of an illness-orientation, which aims to only manage symptoms and accepts long-term disability (DHHS, 2003). These reports concluded that transforming services towards a recovery-orientation, that is, improving the capacity to support people with psychiatric disabilities to "live, work, learn and fully participate in their communities," is of paramount importance and urgency (DHHS, 2003; DHHS, 1999). Existing research supports the findings of these landmark reports. During the past two decades, research has provided evidence that services structured to support recovery are more effective at improving the quality of the life and community integration of people with psychiatric disabilities and it has also identified the most essential standards for the effective implementation of recovery-oriented services (Harding, Brooks, Ashikaga, Strauss, & Breier 2005a; Harding, Brooks, Ashikaga, Strauss, & Breier, 2005b; Davidson, et al., 2009; Ragins, 2009; Farkas et al, 2005; Onken et al., 2002; Ridgway, 2005). A now classic study comparing individuals with schizophrenia from Vermont and Maine, found strong evidence for the effectiveness of the recovery-orientation. Vermonters- who participated in a model psychiatric rehabilitation program with strong supports for community integration, and meaningful residential, work and social opportunities - achieved better long-term outcomes across multiple domains, including fewer symptoms, higher employment rates, and increased social functioning and community adjustment (Harding, Brooks, Ashikaga, Strauss, & Breier 2005a; Harding, Brooks, Ashikaga, Strauss, & Breier, 2005b). Several studies have also identified the programmatic traits that are most likely to support individual recovery. In a study about the factors that help and hinder recovery, Onken et al (2002) found that several environmental factors are essential in supporting recovery, such as access to material resources (e.g. livable income, safe and decent housing), social relationships, meaningful activities that connect individuals to their communities (e.g. employment), and supportive services and staff who belief that recovery is possible. Most recently, a study by Davidson et al. (2009) identified a number of programmatic standards that promote and sustain recovery. These include conducting strengths-based assessments, offering individualized recovery planning, building communities, and supporting community-based continuity of care.

If recovery-oriented services can improve quality of life more effectively, why is it that an illness-orientation continues to predominate? To us, the answer lies in the failure of the mental health system to shift the illness-oriented paradigm that has predominated since the time of state mental hospitals. Almost a half-century ago, the process of deinstitutionalization held the promise of a "normal" life in the community (Joint Commission on Mental Illness and Health, 1961). Since then, multiple federal and state laws have promised community integration and better lives for people with disabilities, such as the Community Mental Health Center Act of 1963, the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990. Indeed, today most people with psychiatric disabilities receive care in their communities. In the early fifties almost eighty percent of mental health care episodes in New York State took place in state psychiatric hospitals, while now less than one quarter of them occur in inpatient programs (Aneshensel & J. Phelan, 1999). Nonetheless, despite the best intentions of the deinstitutionalization, this process seems to have mainly relocated people to community settings without effective supports to participate fully in their communities (Davidson, et al., 2009). The "deinstitutionalization" was in many respects a process of "trans-institutionalization" that landed people with psychiatric disabilities in new institutions with limited capacity to support their full mental health recovery, meaningful community integration, and overall quality of life. Program structures and funding changed faster than the approaches and methodologies guiding mental healthcare. The institutional care predominant in state mental hospitals transitioned from institutions to community-based services maintaining what has also been referred to as a "chronicity- orientation" (California Association of Social Rehabilitation Agencies, 2007).

Over the past three decades, multiple efforts to increase awareness and build practitioners' knowledge about recovery approaches do not seem to have improved the capacity of the mental health system to facilitate recovery, largely because this lack of capacity is a systemic failure, not a practitioner failure (Davidson, et al. 2009). Consequently, the transformation of the system cannot only rely on the retraining of practitioners, but must be aimed at improving the implementation capacity of programs. Retraining of practitioners is necessary but not sufficient. Most importantly, the system requires significant changes in the ways in which services are organized and delivered, that is, in the predominant paradigm of care. This can only be accomplished by providing administrators and practitioners with a framework for change, assessing their programmatic capacity with concrete tools, measuring their progress over time and offering technical assistance to transform their services. The mental health system has failed to not only improve programmatic capacity, but also to provide programs with concrete tools to transform their practice in order to facilitate meaningful recovery and quality of life. Without such resources, the call for systems transformation and the promise of community integration will remain illusory.

Multiple initiatives are currently underway in New York State with the stated purpose of transforming traditional service models to a recovery-orientation. In many regions, Continuing Day Treatment programs are converting into Personalized Recovery Oriented Services (PROS), and outpatient clinics are undergoing transformations to provide care that responds to the unique quality of life goals of individuals receiving services. Once again, people with psychiatric disabilities are presented with the promise that service transformations will improve their lives. But the limitations and failures of the transformation efforts of the past half-century across the country make evident the need to not repeat the same mistakes. NYAPRS' experience in training and technical assistance of the past decade has shown that even well-intentioned administrators and practitioners cannot change their practice and services without three essential ingredients: (1) an operational understanding of what "facilitating recovery" means and looks like on the ground; (2) a reliable way to assess program capacity across multiple program domains and measure progress over time; and (3) practical and effective tools to improve practitioners' competencies and overall program capacity.

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Appendix 2: Underserved populations: A brief on psychiatric disability, co-occurring substance abuse, criminal involvement and homelessness

Three populations are at even greater risk for unemployment and the consequences that ensue: those with a co-occurring substance abuse disorder, those who have faced incarceration due to a substance abuse disorder, and those who are homeless. These groups have an even greater disadvantage when it comes to finding and sustaining employment.
Substance abuse is the most common dual diagnosis among adults with severe mental illness (Drake, et al., 2004). A study by Gelberg and Linn (1988) found that 50% of the study participants they interviewed reported having used illicit drugs in the previous month. Drake, et al. (2001) report that about 50% of individuals with severe mental disorders are also affected by substance abuse. Bassuk, et al. (1984) found that of the homeless group they interviewed, 29% were alcoholics, and of this group, almost 22% had a secondary diagnosis of psychosis. Mental illness with a co-occurring substance abuse disorder is also associated with many other negative outcomes, such as hospitalization, violence, incarceration, homelessness, higher rates of relapse, and infections such as HIV and hepatitis (Drake, et al., 2004). For those with co-occurring substance abuse disorders, recovery revolves around four main sources of support: having stable, safe, and substance-free housing; having a trusting relationship with a clinician who promotes recovery; having a social network of non-substance abusers; and having a meaningful daily activity (such as work). Becker, et al. (2005) found that with less than three of these supports available, those with dual disorders are unlikely to recovery. With three or four of these supports, the odds of a stable recovery increase drastically. Another important feature in recovery for those with dual diagnosis is integrated care. Often those with co-occurring disorders get lost in a non-integrated system due to lack of access, miscommunication, and incomplete interventions. With the current United States mental health and substance abuse delivery so fragmented, the chance of a person getting "lost" in the system is great, and results in ineffective care and lack of recovery (Becker, et al., 2005; Drake, et al., 2004).

Incarceration, particularly due to substance abuse, is another factor that can limit employment for those with a mental disability. In the 1984 study by Bassuk, et al. listed above, 44% of the participants had been in jail at least once, and more than two-thirds of these arrests were due to minor offenses most likely related to alcoholism. The 1988 study by Gelberg and Linn (1988) also found that 45% of the study participants had been arrested for an alcohol offense in their lifetime. Studies throughout the years have consistently found arrest rates of those with serious mental illness to be around 42-50% (Draine, et al., 2002). Looking at the relationship from another angle, the National Institute of Justice estimated that 16% of those in prison have a mental illness (Ditton, 1999). According to Draine, et al. (2002), "individuals with mental illness are also members of other groups with a high risk of being arrested. [People] who are substance users, are unemployed, have fewer years of formal education, and have low incomes have a greater risk of incarceration."

A well documented idea is that homelessness goes hand in hand with a variety of other illnesses or disabilities, including mental illness. It has been documented that of people treated for serious mental illness, between 10-20% are also homeless, as compared to 2.8% of the general population (Folsom, et al., 2005). A study by Folsom, et al. (2005) found that 15% of their study population being treated for serious mental illness was homeless at the time of at least one service encounter in a 12-month period. This study also found that patients with schizophrenia were 2.4 times and those with bipolar disorder 1.6 times more likely to be homeless than those with major depression (Folsom, et al., 2005). A study by Culhane, et al. (1997) found that 10% of the patients treated for schizophrenia and 7% of those treated for affective disorders used a public shelter during a 3-year period. In a study of hospitalized patients by Rosenheck and Seibyl (1998), 20% of veterans were homeless at the time of admission to a VA psychiatric ward and in a study by Herman et al. (1998), 15% of people with psychotic disorders hospitalized for the first time were homeless. Obviously homelessness affects a sizable portion of persons with psychiatric disabilities and this population group is at an increased risk for homelessness than the general population. Conversely, it is also widely reported that mental illness affects between 30-50% of homeless individuals (Crisis, 2003). In one study by Bassuk, et al. (1984), almost 45% of the study population, consisting of shelter guests, reported having major medical disorders, "such as heart disease, high blood pressure, ulcers, emphysema, asthma, or severe cellulitis." Approximately 46% of the group had major mental illnesses, and 29% were chronic alcoholics. Almost 75% of the participants were unemployed (Bassuk, et al., 1984). In another study by Roth and Bean (1986), nearly 30% of those interviewed had been hospitalized at least once for mental health problems, and 33% of the respondents had a physical health problem serious enough that a doctor should be consulted. Often, a lack of resources of lack of understanding by health care providers inhibits the homeless from seeking medical care until their health problems have become much more severe, which can translate into an even more disabling condition, thus increasing the rates of illness among the homeless (Crisis, 2003). Zuvekas and Hill (2000) found that 23% of their homeless participants had a major mental health disorder at some point in their lifetime, compared to the general population's 15.4%. Gelberg and Linn (1988) found that homeless adults are more than twice as likely to have mental illness as the general population, and in their study, 40% of their homeless participants had psychotic symptoms in the previous two weeks. However, in this study, almost 88% of respondents held a job at some point in their life, pointing to the idea that they are, in fact, employable and able to sustain a job. So what led them astray? And why are they no longer able to find and sustain employment? This could be due to the traumatic life circumstances of homelessness.

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Appendix 3: Methods employed in this project

Key informant interviews

Group interviews were held between August and October 2009 with approximately 60 administrators of New York State and community programs in Albany and New York City. Interviewees were presented with general and group-specific questions about structural factors and policies limiting the availability, accessibility and effectiveness of employment services for people with psychiatric disabilities. Interviewees were also asked about best practices and policy recommendations to improve services and supports available. The state agencies that participated in the interviews include OMH (Office of Mental Health), ACCES-VR (Adult Career and Continuing Education Services-Vocational Rehabilitation), DOL (Department of Labor), OASAS (Office of Alcoholism and Substance Abuse Services), NYS DOH (New York State Department of Health), the New York State Division of Housing and Community, NYC DOHMH (New York City Department of Health and Mental Hygiene) and Coalition of Behavioral Health Agencies (CBHA). The set of interviews included a roundtable discussion held in New York City, which was attended by representatives from statewide provider organizations including Empire State APSE (Association for Persons in Supported Employment), ACL (Association for Community Living), Burton Blatt Institute (BBI) and MHANYS (Mental Health Association in New York State); as well as senior administrators from provider agencies in the New York City metropolitan area such as FEGS (Federation Employment and Guidance Service), CUCS (Center for Urban Community Services), Baltic Street, Community Access, Howie the Harp Advocacy Center, Venture House, Institute for Community Living and SUS (Services for the Underserved).

Inventory of Memoranda of Understandings and policies

An inventory of state agency memoranda of understandings (MOUs) was conducted. (See chart on agency procedures and policies in Appendix ) More information on service eligibility, reimbursement structures and interagency agreements. From this brief overview, we discovered that currently there is not much collaboration when we looked at service eligibility, reimbursement schedules and interagency agreements.

Local case studies

Focus group sessions were held in November 2009 with approximately 40 consumers of mental health services in New York City and Syracuse (Central region). Plans to hold focus groups in Plattsburg (North Country) did not occur given time constraints. We were able to obtain support from mental health peer advocacy organizations such as Baltic Street and Howie the Harp in New York City and Unique Perspectives in Syracuse to host the focus groups. The topic of these groups were centered around 3 central themes- a general group with individuals suffering from psychiatric diagnoses, individuals with psychiatric diagnoses who are homeless or have experienced homelessness and individuals with co-occurring conditions of substance abuse or forensic experiences. The aim was to obtain perspectives from different regions of the state and also learn more about prevalent issues that people with psychiatric diagnoses often face.

The discussions during these sessions have provided an improved understanding and awareness of current issues. We were also able to learn more about utilization of mental health programs, barriers and challenges to obtaining services and which programs and services have been helpful. As much as the participants in the focus groups shared information with us, it was also a valuable opportunity for them to share, connect and empower each other.

This brief provides a synopsis of some common issues that participants mentioned. However, we believe that more saturation is necessary to identify some more consistency and reoccurring themes. Nevertheless, information concerning consumer background, service awareness, barriers to obtaining employment and limitations to the analysis will be discussed in further detail.
The local case studies also included interviews with the respective Disability Program Navigators. Interviews were held with DPNs in Brooklyn, Northern Manhattan and Syracuse.

Limitations of this study and report

We must account for selection bias, as all of the administrators were chosen for their roles within the mental health community and focus group participants were recruited through our partner peer organizations. The data obtained for the report was heavily based on the collection of qualitative data. Given that the data is primarily individual perspectives and experiences, we must acknowledge that the external validity of these experiences may not be an accurate representation to generalize to the mental health system or individuals with psychiatric conditions overall in New York State. Therefore, our findings may not have strong statistical significance, but there is a great deal of practical significance. We saw considerable value in obtaining perspectives directly from involved individuals rather than depending solely on research findings. Logistics and time constraints prevented facilitators from collecting data from the North Country and Western New York regions, which may have provided a wider range of experiences.
We are aware that these policy and programmatic recommendations may appear to be a daunting task to tackle, but some immediate next steps are offered, which should play into but need to be expanded to become a meaningful part of a long range transformation and system change strategy. Nonetheless, it is clear that to truly affect meaningful change, a comprehensive approach is needed, which will be discussed in the recommendations section in further detail.

Acknowledgements

We would like to acknowledge all of the administrators, partner organizations and focus group participants for their assistance with this project. Their input served as a major component to the formulation of this report and provided additional validation to our research findings.

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Appendix 4: Summary of Interviews with Key Informants and Administrators

This section summarizes key themes from group interviews held between August and October 2009 with approximately 60 administrators of state and community programs in Albany and New York City (See Methods for more information).
Analysis of the Interviews:This thematic summary below does not necessarily reflect the views of the authors but rather represents a summary and analysis of the perceptions and opinions of interviewees. The recommendations of the research team are presented in the main body of the report (Policy and Program Recommendations Section).

Fragmented structure and a lack of integrated care

The interviews with state administrators revealed a fragmented structure of mental health, vocational rehabilitation, substance abuse, and workforce services. Services are often fragmented, duplicative and overlapping, with few or no connections across systems. As a result, the access of consumers to the clinical, professional, and wrap-around supports needed to achieve employment is compromised.

One contributing factor to the lack of wrap-around supports is the lack of effective collaboration and mandates across state agencies. There is no integrated network between OMH, ACCES-VR, One-Stop Centers, DPNs and similar organizations. Standards have been set by individual agencies, but few agency agreements are indeed in place.

An example of an inter-agency effort to provide a broader service environment is the collaboration between ACCES-VR and the Department of Labor to place (ACCES-VR) vocational rehabilitation counselors in One Stop locations. While the research team did not have access to process or outcome data from this initiative, interviews with Disability Program Navigators suggest that this effort is strengthening the linkages and synergy between the employment services provided by both agencies. As this one, other instances of creative inter-agency collaboration seem to be challenged by their limited scope and extreme variability across regions and/or districts. For instance, efforts to integrate assessment forms and processes between ACCES-VR and OASAS seem to yield very positive outcomes, but these are however limited to some districts in New York as the innovative procedures have not been made a standard for the state.

Funding

Inadequate funding for services and maintenance of programs continues to be an issue that was raised in almost all of the meetings. Budget cuts and the economy, which triggered the New York State hiring freeze, have also contributed to the problem. State allocations have been reduced and there is an increased struggle to obtain Medicaid benefits. Several attendees also brought up the availability of Title I funds. While OMH seeks to redirect its state operated facilities employment funding away from sheltered work towards community employment service, there still remains too many resources that could be used for community supported employment directed instead to segregated, non inclusive options.

Budget cuts forced OASAS to reduce employment by 10 percent this year, which meant a reduction in sponsored programs. ACCES-VR experienced losses from veteran counselors retiring and the inability to hire replacements due to the freeze.
The issue also remains of the best approach to remove the funding and structural "silos" which makes an individual eligible for services at one agency and ineligible at another, which many saw as almost an insoluble problem from their end, yet wanted someone to attend to. People with psychiatric disabilities are not always able to turn to Medicaid for coverage because of eligibility criteria. For example, only 30 to 40 percent of participants at Venture House in Queens are Medicaid eligible.

Lack of employment data across agencies

There is a lack of employment data across state agencies and programs. A director of Vocational Rehabilitation District Office Administration noted that at the central office they often are unaware of what is happening at the local level, indicating the need for improved intra-agency communication. It appears that there is some data-sharing concerning unemployment insurance; however the NYS Department of Labor has strict distribution guidelines under its federal guidelines.
Several interviewees mentioned that, even when outcome data is expected, there is an emphasis on performance measures (i.e.: number of successes and level of economic integration) rather than what the respondents perceived as the effect that services are having on clients. Many felt that performance measures do not tell the whole story, so it is important to obtain additional documents, though the exact nature of what this additional information would be, in what form would it be developed, who would collect it, and to whom should it be disseminated was not clear from these ideas.

Heterogeneity of job readiness and eligibility determination assessment tools

The determination of job readiness is a very subjective assessment. Currently there is no standardized tool or process as each agency follows individual guidelines though there has been some excellent research in this regard in terms of people with psychiatric disabilities and access to and readiness for employment (Casper & Carloni, 2007; Roberts & Pratt, 2007). The heterogeneity of tools imposes great burdens on consumers due to the multiplicity of assessment processes. It is important to recognize the relationship between access and eligibility. As mentioned during the meeting with ACCES-VR, eligibility does not indicate automatic access to services because of inadequate counselor to client ratios and insufficient resources to provide services. When speaking to a DPN in New York City, we learned that the definition of readiness in the One Stop Center is whether or not an individual possesses a résumé without any consideration of the individual's perception of self-readiness.

Under-utilization of programs

In general, interviewees indicated that several programs and services available, such as the Medicaid Buy-In (MBI) program, were underutilized. Providers indicated an inability to access MBI information, forms, etc. on the NYS Health Department website, and little awareness of the MBI training that NYS DOH reported is being delivered under a contract with SUNY Buffalo. A representative from the New York City Medicaid Office mentioned that Medicaid employees are trained about MBI, but confusion remains, which trickles down to the clients. He noted that this is a public relations issue because correct information has not been disseminated. An administrator from the NYC DOHMH added that staff members are not equipped with information about all the programs, leading to misconceptions about the actual benefits of MBI. The disconnected infrastructure of mental health programs does not promote use of services or encourage enrollment.

A strong perception among interviewees across state agencies and community providers was that counselors within ACCES-VR do not embrace a recovery-orientated model in their practice. Counselors often do not believe that recipients have the potential to fully recover and be successful at work. To overcome this barrier, a Coalition of Behavioral Health Agencies (CBHA) administrator encouraged collaboration or facilitated discussion between OMH and ACCES-VR. There was also a strong belief among interviewees that incentivizing providers to improve employment outcomes would be beneficial. Discussing the issue of recovery potential also plays a role in the theme of discouragement and hopelessness among people with psychiatric disabilities.

"ACCES-VR and the ICLs are trying to direct my career path." (female, Brooklyn)

"My counselor told me 'down the line you can get employment, but right now, just get the things that you need'." (male, Syracuse)

"My ACCES-VR counselor lost my test scores, but still concluded that I was not stable enough to teach." (female, Harlem)

"She [my ACCES-VR counselor] did not listen to my goals, but she said that she would help me with the things that she thought were best." (female, Harlem)

"They [ACCES-VR] were very accommodating in the beginning. When I started to mention anything past Howie the Harp, they were not encouraging to help me to go back to school because they do not think that you can go back to school." (male, Harlem)

Compartmentalized competencies of providers

Mental health providers often have poor knowledge and skills concerning the benefits, work incentives and other systems. Each agency is well versed in its individual policies and may only have limited knowledge about other agencies. Some interviewees expressed a need for inter-agency liaisons who can act as informants to assist providers with information about options for their clients. Vocational rehabilitation providers are seldom skilled in engaging people with psychiatric disabilities but usually expect applicants to demonstrate motivation (as evidenced by inexact measures such as treatment compliance or clear vocational goals in place) as a sign of appropriateness for services.

Many of the partners discussed the negative impacts of a compartmentalized approach to the provision of care. One of the directors at the Coalition of Behavioral Health Agencies (CBHA), in particular mentioned that there is no real systematic connection between all the agencies. A Department of Labor representative reinforced the CBHA administrator's point by saying that we are "kidding ourselves" if we do not recognize that other providers and agencies have expertise in areas that One-Stop Centers cannot provide. Therefore there needs to be multiple entry portals for individuals to access services. It should be noted though that the penetration of customers with disabilities into Wagner-Peyser funded programs is 4.4% of applicants versus the national average of 2.8% so NYS does a commendable job of outreach to customers with disabilities comparatively (ICI, 2009). Unfortunately no publicly available national data exists that breaks down this figure by disability category or tracks it further by outcomes.

Discouragement and hopelessness among people with psychiatric disabilities

The positive implications associated with achieving meaningful employment are important. Clients feel a sense of empowerment and will be more likely to follow their treatment plan if they have the confidence and motivation to achieve their goals (as discussed during a meeting with OMH). However, without prioritizing employment generally and making services available, the current framework contributes to feelings of hopelessness. As seen with the quotes above, some individuals have not had positive experiences with ACCES-VR, which has contributed to a sense of discouragement. Some of the experiences have been so discouraging that a few individuals have made the decision not to return. The power of shared experiences is very important here. One individual's portrayal of their experience has the potential to encourage or discourage another from seeking assistance with ACCES-VR.
The negative connotations associated with being labeled as a "permanently disabled" individual impede on the recovery process and implicitly indicate that the individual has no chance of achieving employment. In addition, the policies and eligibility protocol for many programs act as disincentives to work and lead to dependence on the system for assistance.

The tension, identified by ACCES-VR, between eligibility and access to services should be addressed. High case loads have led to long wait times. While consumers wait to receive services, their feelings of discouragement and hopelessness increase. As a result, they are more likely not to return when a counselor calls, further perpetuating the dependence on services. Given budgetary concerns, enabling dependence on services unnecessarily further contributes to increased expenditures.

Clients experience an external locus of control, based on the knowledge that they have received in regards to their inability to work. They also experience frustration when trying to obtain employment only to (1) find out that they may automatically become ineligible for services, (2) wonder if they will be able to re-obtain SSI/SSD if they fail or (3) realize they have to contribute to their expenses which exceeds their income (which makes it easier to remain unemployed).

Programs such as MBI are available to clients. Interviewees indicated that a predominant belief among beneficiaries seems to be the fear of losing coverage or being required to pay for services. However, misinformation about the program leads to skepticism among clients and under-utilization of services. A Community Access administrator stated that fear of losing benefits is key; individuals often choose not to work from fear of not being able to support themselves.

Ongoing initiatives and promising practices

Feedback from the meetings and interviews held with the key administrators provided valuable information concerning ongoing initiatives and promising practices throughout the State. In particular we heard about a ACCES-VR-OASAS partnership, ACCES-VR liaisons and their provider toolkits, the PROS conversions and the IPS implementation and technical assistance programs.
The ACCES-VR-OASAS partnership established a streamlined and comprehensive assessment for individuals with substance abuse support needs. Currently, the form is being used across all districts in New York City and has thus far appeared to be very useful to plan with consumers. A pilot was conducted by the Brooklyn/Queens Consortium to determine how to implement the pilot statewide. The providers involved with this initiative spoke of trust building and improved communication between the organizations and clients since inception.

ACCES-VR has also instituted liaisons, who assist with a lot of the preliminary work, which helps to speed up the eligibility determination process. The presence of the liaisons improves the level of collaboration with other programs such as treatment centers and outpatient and day habilitation programs. One of the administrators noted that it is ACCES-VR responsibility to ensure that liaisons are educated and able to explain "eligibility" to consumers. Liaisons prepare clients of the process and what they can expect. The presence of the liaisons has increased expedience of reviewing cases, in some instances less than 60 days.
ACCES-VR has designed a toolkit for providers aimed to clarify the roles of ACCES-VR and its liaisons. The goal is to collect data to evaluate access and outcomes. An administrator from a meeting with ACCES-VR regional managers in New York City noted that they want to ensure that the people referred to ACCES-VR offices are referred appropriately. There is a 94% positive eligibility rate, so when case managers have caseloads of over 200, proper referrals becomes very important. Other administrators discussed the individualized planning that is provided to each client.

Directors at the Coalition of Behavioral Health Agencies (CBHA) highlighted the work of a PROS (Personalized Recovery Oriented Services) program at Occupations, Inc (Middletown, NY). They also mentioned that PROS has been seen as an influential method of incentivizing employment and that programs will be coming to the New York City area in the near future. Although mention was made of the limitations to the PROS model, the administrators did mention that there is significant leadership support and resources available.

The implementation of Individualized Placement Services (IPS) was also mentioned as a positive effort to improve the capacity of programs to provide effective employment supports. In the opinion of several providers, IPS improves the clients' feelings of being able to accomplish positive work experiences by designing specific program goals appropriate for their needs.

Limitations

The conduct of interviews and roundtable meeting with administrators of state and community programs provided valuable data given their role as key informants to this evaluation. Nonetheless, key informants were selected intentionally based on their leadership role and do not constitute a statistically representative sample of all administrators of state and community programs pertaining employment. Therefore, the findings of these interviews ought to be considered exploratory and reflecting the perceptions of those who participated in the study.

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Appendix 5: Summary of Consumer Focus Groups

The purpose of the focus groups was to obtain first-hand experiences from individuals actively receiving services within the NYS public mental health system. By holding a focus group, we reduced the extent of intimidation by holding the sessions in the offices of peer advocacy agencies. We specifically asked about the participants' career goals, their perceived support needs, awareness of employment services and supports in their respective communities, experience with mentioned services and recommendations for program and policy improvements. In particular, we made sure to ask participants in each group of their awareness and experience with DOL, One Stop Centers and DPNs.

The discussions during these sessions have provided an improved understanding and awareness of current issues. We were also able to learn more about the use of mental health programs, barriers and challenges to obtaining services and what programs and services have been helpful. As much as the participants in the focus groups shared information with us, it was also a valuable opportunity for them to share, connect and empower each other.

Our analysis provides a synopsis of some common issues that participants mentioned. However, we believe that more saturation is necessary to identify some more consistency and reoccurring themes. Nevertheless, information concerning consumer background, service awareness, barriers to obtaining employment and limitations to the analysis will be discussed in further detail.

These key themes were obtained from focus group sessions that were held with various consumers of mental health services throughout New York State. Original plans were to hold focus groups in 3 regions of the State; in New York City, Syracuse (Central region) and Plattsburg (North Country); however, we were unable to organize the Plattsburgh focus group for logistical reasons. We obtained support from mental health peer advocacy organizations such as Baltic Street and Howie the Harp in New York City and Unique Peerspectives in Syracuse to host the focus groups. The topic of these groups were concentrated around 3 central themes- a general group with individuals suffering from psychiatric diagnoses, individuals with psychiatric diagnoses who are homeless or have experienced homelessness and individuals with co-occurring conditions of substance abuse or forensic experiences. The aim was to obtain perspectives from different regions of the state, learn more about prevalent issues that people with psychiatric diagnoses often face and also what recommendations we can make to the State to improve outcomes.

The discussions during these sessions have provided an improved understanding and awareness of current issues. They also provided more insight about mental health program utilization, barriers and challenges to obtaining services and what programs and services have been helpful. As much as the participants in the focus groups shared information with the facilitators, it was also a valuable opportunity for them to share, connect and empower each other.

Participants

We thank the aforementioned peer advocacy organizations for their assistance with recruitment of individuals to attend the focus groups. As a result, we were able to obtain a broad perspective of experiences and issues around employment. Of the approximately 40 participants, there was equal representation of men and women, with an average of 9 participants in each group. The age range of participants was wide- from mid-twenties to sixties- which provided diversity and possible impacts of cognizance and satisfaction with mental health services. Although we requested that all participants were unemployed, 5 individuals stated that they were currently working. Many of the other participants were currently involved with internships.

Career plans and goals regarding desire to work

Each of the participants expressed very specific short and or long-term goals for professional or academic advancement. Some mentioned their desire to work in areas of health services such as psychologists, counselors, therapists, social workers and peer specialists, while others expressed aspirations to be entrepreneurs, managers, teachers and studio producers. One participant made a particularly poignant comment; as an immigrant, she said she has "achieved the American Dream and will not let her illness set her back."

"I want to have a women's home to provide them with services." (female, Brooklyn)

"I hope to be a producer or a music teacher to encourage students to pursue their dreams. For the short-term, I have skills to be a plumber or an electrician." (male, Syracuse)

"I work well with people and I have gifts that I would like to use." (female, Brooklyn)

These responses highlighted the wide range of interests and that all individuals are not interested in pursuing careers in the mental health field, although some mentioned their desire to improve the experience that others have with mental health services. Others had a particular interest in ending the cycle of substance abuse and forensic involvement and sharing their life experiences to encourage youth not to get involved.

Programmatic and anecdotal experience suggests that many people with psychiatric disabilities, when asked if they want to work, say they "do not want to work" because they do not think it is possible, and not because they do not want to work. Many years of unemployment and systemic reinforcement to remain in the margins of the labor market have reaffirmed the misconception that people with psychiatric disabilities cannot work. Thus, this percentage of those indicating they want to work may be an underrepresented number. Another common misconception is the idea that people with psychiatric disabilities simply cannot work. However, research shows that people with psychiatric disabilities can in fact achieve employment. There are numerous benefits to employment including decreased potential for relapse, increased self-esteem, increased income and social status and positive perceptions about the future. One participant even mentioned that "employment brings dignity" while another said that work provides "hope...a reason to get up." Studies in the United States show that with current employment supports, up to 75% of people with serious psychiatric disabilities can achieve and maintain competitive employment (Bond, et al., 2001; Drake, et al., 1999). The results of focus groups conducted in the context of this project further suggest that people with psychiatric disabilities are often able to articulate what their career dreams are as well as identify the stepping stones that will allow them to achieve these dreams (Summary of Consumer Focus Groups, Appendix 5).

These individuals also expressed the importance of completing or advancing their education, obtaining job experience and completing internships and certifications as necessary components to obtaining employment and achieving their goals.

"I was a phlebotomist and I hope to finish my criminal justice degree." (male, Syracuse)

"I plan on returning to school for a degree in behavioral science or chemistry but I would like to pay off my loans from community college." (female, Syracuse)

"I want to learn Spanish so I can be a bilingual teacher in the next 1 to 3 years." (male, Harlem)

"I plan to get a bachelors degree in counseling." (male, Harlem)

In addition to achieving these goals, participants also discussed the roadblocks that are preventing them from securing reasonable jobs, or being limited to 4F jobs: food, filth, filing and flowers (Mulligan, 2001). One individual stated that 4F, retail and maintenance jobs do not provide a future for her since she already has a bachelor's degree and is looking for something more meaningful. Another major issue was SSD (Social Security Disability Insurance) and SSI (Supplemental Security Income) benefits. While many of the focus group participants were receiving one or both of these benefits, many spoke of being afraid of losing benefits and the compromises that they have been forced to make regarding employment opportunities. One participant stated that he does not want to be on SSI anymore; "I am tired of waiting for $700 a month. I am appreciative for it, but it is not sufficient and I would really like to have a full time job." Another individual mentioned that he "would prefer to pay taxes just like any other American." Many spoke of being caught in the "SSD/SSI limbo" or as one individual called it a "survival game"; unable to seek valuable employment opportunities for the fear of losing their benefits that they need to survive.

Some participants indicated that their psychiatric symptoms became more severe during their youth and therefore were unable to complete their education, while others held prestigious positions before onset of their illness. The gaps in employment in addition to fragmented education and lack of relevant work experience have presented considerable roadblocks to attaining employment again. For those with forensic history, the background checks have presented significant setbacks despite changes in lifestyle.

"I graduated in 1995 with a bachelor's degree in Psychology, but I haven't used it. I got sick soon after graduation so I have limited experience in mental health." (female, Brooklyn)

"I have a master's degree in counseling and am overqualified for jobs because of my credentials, but the Board of Education is giving me problems because of forensic issues." (male, Harlem)

"My life has been transformed after 17 years free of criminal involvement, but I still have not been able to find a job." (male, Brooklyn)

"I had a prestigious job working in an office downtown before I got sick. Do I have to start over now or is there another way to get it back?" (female, Harlem)

"I have a bachelor's degree in accounting and was a CPA. We need to stop this revolving door called jail. I want a part-time job in forensics and to hone in on my skills." (female, Harlem)

One of these individuals specifically stated that he has done his best to move past his criminal past and changed his life, but employers will not give him a chance. He said he "needs someone to advocate for him now" because he does not know what else to do. Clearly, there is a disconnect between the individual efforts to make life changes and efforts of the public mental health system to assist. Perpetuation of this cycle may further contribute to feelings of discouragement, hopelessness and dependence on OMH services.

Service awareness and experiences

One issue that was of particular interest to us was the extent of knowledge individuals had concerning services available to those within the mental health community, which programs were found to be useful and the programs with which they had problems. We wanted to determine if consumers were aware of the services at their disposal and if there is a difference in service availability throughout the State. Participants were specifically asked at the end of the sessions if they had heard of Ticket to Work, the Medicaid Buy-In program, the Department of Labor (DOL), One Stop Centers and Disability Program Navigators (DPNs).

One Stop Center and Disability Program Navigators (DPNs)

Some of the participants indicated knowledge of One Stop Centers, but in general these were not perceived as helpful in getting actual jobs. Those with experience indicated that the One Stop Centers were helpful with résumé building services, using computers and the internet and taking computer classes. Surprisingly, only one of the participants in Syracuse had heard of One Stop Centers.

"I have a membership and can use their computers...but they can't help me find a job. They are not really an organization that helps people find jobs." (male, Brooklyn)
"They were no help [in getting a job]. I might as well stay at home and do the work on the computer there."
(female, Harlem)
"They help pay for trainings and transportation."
(female, Harlem)

The DPNs were widely unknown at all of the group sessions. At least in the small sample of focus group participants who were actively pursuing jobs and/or careers, none of them had heard of the DPNs.

Only one participant in Syracuse had an experience with the One Stop Center and one participant in New York City had knowledge of Ticket to Work. We took advantage of this opportunity to provide them with some information about these programs. Appendix A has more region-specific details.

ACCES-VR

Sentiments and experiences with ACCES-VR (Vocational and Educational Services for Individuals with Disabilities) were both positive and negative. It appeared that most of the negative experiences came from individuals who have used mental health services for an extended period of time

The opinions focus groups participants had about ACCES-VR seemed to be heavily dependent on how they viewed ACCES-VR counselors. Based on responses of negative feedback, some individuals have chosen not to return to ACCES-VR. Others have expressed long waiting times to access services, intimidating application processes and lack of communication as reasons for not returning to ACCES-VR or lack of confidence in service provision. However, many participants also expressed their appreciation for the existence of a program like ACCES-VR, which has helped them get back on their feet and seek employment despite "wasting the state's money" each time they did not complete a program. Participants highlighted the availability of financial support to buy books, obtain transportation and work uniform in addition to finding a job. There was also mention of the commitment to education with ACCES-VR that is necessary to receive services. The responses obtained during these focus groups demonstrate the power of word of mouth. It suggests that it only takes a few negative experiences with ACCES-VR, its counselors or other programs to spread the perception of poor customer service. These perceptions may not represent the majority of individuals or counselors, but it is important to recognize that individuals who have heard these misconceptions may come to the office with preconceived ideas of the assistance they will receive. Therefore, it is the responsibility of counselors, as well as the peer community to help foster a change and improve the availability of valuable and accurate information. It is also the responsibility of people with psychiatric disabilities to be mindful of the images they portray when discussing their experiences so as not to discourage others from attaining services.
In relation to accessing VR services, some of the participants described the barriers they experienced in receiving actual support. In some instances, individuals were discouraged by the initial contact and what they experienced as lack of responsiveness from ACCES-VR.

"[At the ACCES-VR orientation] they just gave me an orientation and some forms. I had a lot of questions and when I called them, I never heard back from them. I never really got past the application." (female, Brooklyn)

In some instances, participants referred to the long waiting period before actually receiving services or the necessary funding to pursue their career goals.

" ACCES-VR was unavailable. They never responded to my messages so I didn't bother to follow up with them." (female, Brooklyn)

"I heard there is a 6 month waiting period. The application process for ACCES-VR seems intimidating." (female, Brooklyn)

"ACCES-VR offered me transportation money, as well as for books, clothes and shoes, but you have to be interested in education programs to get assistance." (male, Syracuse)

In relation to the interactions with vocational rehabilitation counselors, some focus group participants indicted that their experience with ACCES-VR counselors had been very discouraging and, at times, affected their own ability to attempt work.

"My [ACCES-VR] counselor was not sensitive. You could tell because of her attitude and body language. I felt lectured." (male, New York City )

"My ACCES-VR counselor put me down. She said 'you are intelligent but there is no way you'll become a mental health counselor. Who's going to hire you?' She encouraged me to do piece work, go back to day programs, etc. They just want you to do what they want you to do. This was over twenty years ago, but I don't think they have changed." (female, Brooklyn)

"ACCES-VR counselors need to be taught how to deal with people with mental health diagnoses. I am 50 years old, not a child, and I used to run background checks on surgeons, and I expect to be treated as an adult." (male, New York City)

Nonetheless, focus groups did reveal very diverse experiences. In several instances, the use of ACCES-VR services was mentioned as a facilitator to achieving employment and career goals. In other instances, participants indicated that ACCES-VR had helped them obtain funding to access job coaches and obtain certifications or purchase uniforms or appropriate work attire.

"It depends on the counselor you get. Some have a lot of issues." (male, New York City)

"I had to change my ACCES-VR counselor. My residential provider helped me change vocational counselors and my new counselor, she did support me." (female, New York City)

"I had a counselor who disclosed his psychiatric problem to me. He was very helpful." (male, New York City)

"ACCES-VR is very supportive of people going back to work." (woman, Syracuse)

"They [ACCES-VR] helped me every time I messed up even though I was wasted the State's money." (male, Syracuse)

"ACCES-VR sent me to school to learn. In 1996 they paid for training in Word and Excel." (male, Syracuse)

"[My experience with] ACCES-VR was great. I got a job on the spot." (male, Syracuse)

"ACCES-VR paid for my Associates degree. I'm going through ACCES-VR again. I had failed before and not completed their program. Now I'm applying for more help...ACCES-VR stuck by me until I completed that degree. They thought I could be a good teacher." (male, Syracuse)

Based on these responses, there appears to be significant differences in the experience of individuals according to region and district. This suggests that the experience of individuals may be affected by the service culture and supports available to each district office.

This also suggests that ACCES-VR may want to consider increasing the standardization of procedures and competencies available to counselors and districts. However, our discussions with administrators also provided some insight of limitations or apprehension of the Central Office to make state-wide requirements. It was observed that a partnership between ACCES-VR and OASAS in a pilot program in New York City proved to be very effective. However, there is apprehension to make this a requirement throughout New York State given the expectations to meet or exceed requirements.
Other programs that were frequently mentioned during the focus groups include Fountain House, Transitional Learning Services (TLS), Independent Living Centers (ILCs), Pathways to Housing, NetWork Plus, FEGS and Howie the Harp. Similarly to sentiments about ACCES-VR, experiences were both positive and negative, but overall, these programs were perceived in a positive regard.

Services and supports needed to achieve employment

The purpose of conducting the focus groups was to hear from individuals currently seeking employment, the barriers that they have experienced in obtaining desired employment positions and their recommendations for programmatic improvements. We decided to present these findings from an ecological perspective, as it seemed most appropriate in focusing on the range of services and supports participants mentioned as essential components to improving their economic and employment development.
From the individual perspective, participants had a great deal to say concerning services and supports that they needed to achieve employment. They discussed their illness and lack of education or work experience as major barriers to pursuing competitive employment.

Peer support was a "hot topic" for discussion in each of the focus groups. All participants expressed the importance of interpersonal relationships and the benefits they have provided. Others mentioned the benefit of job coaches to assist with applications, job preparation and how to deal with co-workers and employers. Two young men spoke of the need for programs like Unique Peerspectives to stay open later at night to provide support, motivation and stay out of trouble. Research has shown that the combination of unemployment and poverty can contribute to the perpetuation of social isolation, depression and vulnerability to homelessness, substance abuse and criminal justice involvement. Although previous experiences may have shaped who they are today, these individuals do not want the cycle to continue and are reaching out to make changes and obtain necessary supports to reach their goals.

The need for more providers who are recovery-oriented is important. Providers can represent significant setbacks in pursuing employment options. A few participants discussed the difficulty in scheduling therapy sessions once they have obtained employment that will also accommodate their work schedules. Others discussed their desire for improved frequency of sessions and time spent with their [ACCES-VR] counselors.

"The counselors cannot do it alone- they are so overwhelmed [with large case loads], so I only go once a week." (male, Syracuse) But there is only so much that they can do to ensure that I will get a job." (male, Brooklyn)
Participants expressed their hope for improved employer sensitivity in regards to providing care to people with psychiatric disabilities, in particular with their policies and level of respect for individuals with disabilities. They should be flexible to accommodate their employees' special needs (such as therapy appointments) and be more understanding when employees disclose mental illness issues.

The current job market is "limiting" says a participant in recovery; there are more 3F (food, filth and filing) employment positions than competitive opportunities, which is not encouraging and does not provide a future. A greater proportion of these individuals have obtained some form of higher education or technical certification, making them over-qualified for many positions they are offered. However their lack of experience or gap in employment history is often a serious concern for potential employers. As a result, many are conflicted with the decision of whether or not to disclose their condition to employers and deal with the associated stigma. One participant stated that "people with disabilities are often more committed than other employees because they have been given a second chance after they had lost hope. We often do a better job than the other employees because we have genuine appreciation for the opportunity."

Some other participants proposed employer-organizational partnerships that would facilitate the employment process. These partnerships would provide opportunities for jobs with employers who are connected with peer organizations and are aware that many applicants may have mental illness issues, but are committed to working.

Finally, from a policy perspective, many participants mentioned the benefit of wrap-around services (housing, transportation, trainings, financial and tuition support, child care, etc), which would improve the likelihood of their success. Obtaining employment is multi-dimensional and incorporates many aspects of one's life. If getting a child to school conflicts with arriving at work on time, something is going to suffer, which tends to be the employment option. Another issue of concern is funding for "reasonable" jobs and adhering to reasonable accommodations once an individual is on the job according to the Americans with Disabilities Act. Current federal guidelines for Supplemental Security Income (SSI) and Social Security Disability Insurance (SSD) eligibility often perpetuate unemployment either because of the loss of benefits or incremental reductions. As a result, participants mentioned feeling unfulfilled because they are forced to stay at home, when they could otherwise be working and contributing to society.
Participants also mentioned the value in programs such as Fountain House for transitional employment services, Network Plus (Baltic Street) with building a résumé and computer skills, One Stop Centers, Howie the Harp, Community Access and Pathways to Housing.

Interviews with Disability Program Navigators

We had the opportunity to speak with DPNs or One Stop Center directors from the regions we conducted focus groups to develop an asset map of services actually available in the area. (See Appendix B for the regional asset maps.) These interviews provided more objective perspectives of service availability. In New York City, there is a DPN for each borough and they are all located in the respective One Stop Center. Our discussions with the DPNs informed us that a lot of services (i.e.: résumé building workshops, interview trainings, job coaches) are offered within the One Stop Center to "provide services in one place rather than trying to get them to other organizations" as one DPN noted. Although this navigator was doing her best to help individuals who come to her office, there is not much integration and collaboration with other organizations that may be able to further support and reinforce her efforts. As a result, her clients are unaware (as was she) of peer advocacy programs in the area that offer valuable services and contribute to underutilization of programs. This may be a contributing factor of this particular borough's low service provision (approximately 5%) to clients with psychiatric disabilities. However, she did mention that there is a ACCES-VR counselor on site in all of the One Stop Centers, indicating an interagency partnership. These Centers have their benefits, but there is only so much that any one can do. There is a need for more comprehensive and multi-faceted services.

In addition, the One Stop Centers have a very specific definition of job readiness. As a program with a focus on employment, possessing a résumé is an indicator for being "ready to work". If individuals are not ready to work according to this definition, there are resources for résumé building, interview training, empowerment trainings and job coaches through supported employment programs.

Limitations of the analysis

Unlike the meetings with providers and administrators that continually raised the same concerns, topics that were discussed during the focus groups produced very different perspectives on programs such as ACCES-VR and One Stop Centers. This may be due to our small sample size and selection bias of how participants were recruited, or simply because individuals are more likely to have different experiences based regional variations of service availability.

The focus groups were designed to be semi-structured, to allow for elaboration and probing. However, given these individuals' experience with support group and therapy sessions, the discussions during the focus groups strayed off topic more than expected despite the guiding questions prepared by the group facilitators and efforts to re-focus on the questions. Another issue of concern is the potential that the wording of the questions used for the focus groups were not clear, leading to subjective interpretations. Also, a short and general anonymous survey of the participants may have provided some valuable quantitative data about general demographics and overall perceptions and experiences.

Our sample of consumers was very small considering the diversity of people with psychiatric disabilities across the state, so the power is insufficient to have significant external validity. Therefore the data ought to be considered exploratory rather than statistically representative. Nevertheless, it provided in-depth information of the 3 populations (general individuals with psychiatric disabilities, individuals with homelessness experiences and individuals with co-occurring conditions of substance abuse or forensic involvement) who participated in the focus groups as participants were able to explain their perspectives in detail.

The sample was biased as participants were recruited through our partner organizations that have an active role in advocacy. It is likely that the individuals participating in these groups are more aware of systemic issues, have formed opinions about advocacy issues and are more aware of their needs. The participants were primarily individuals seeking employment, who may also have a very different perspective and experience as those who indeed achieve employment; therefore we cannot speak to those items that were perceived as facilitators of employment by people who do achieve employment.

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Appendix 6: Descriptive Inventory of Employment Services

The following is a summary of the most important employment services available within the NYS Department of Labor, Office of Mental Health, Office of Vocation and Educational Services for Individuals with Disabilities (ACCES-VR) and the Social Security Administration

Table 4: Number of programs/sites across NYS and individuals served by state/federal agency

Name of Program

Total number of programs/sites
in New York State

Number of individuals served

NYS-DOL

 

 

One Stop Center

83

 

Disability Program Navigators

48

 

NYS-OMH

 

 

Assisted Competitive Employment

89

1,142

Ongoing Integrated Supported Employment Services

140

1,303

Transitional Employment Placement (TEP)

34

208

Enclave in Industry

10

97

Affirmative Business/Industry

29

310

Work Program

31

445

Sheltered Workshop/Satellite Sheltered Workshop

56

1,199

Vocational Services-Child & Family

23

 

ACCES-VR

 

 

Adult Vocational Rehabilitation Services

15 (District offices)

IndependentLiving Services (ILS)

52

 

SSA

 

 

Work Incentives Planning and Assistance(WIPA)/ Community Work Incentives Coordinators(CWIC)

10

 

Department of Labor

One Stop Centers: The primary objective of is to help jobseekers access the skills they need to obtain employment while linking qualified jobseekers to hiring employers. To accomplish this goal, One Stop Centers offer an array of services from skill trainings to career counseling and assistance with updating résumés. All One Stop Centers offer services at no cost.

Disability Program Navigators (DPN): Disability Program Navigators serve as disability resource specialists to help individuals with disabilities "navigate" through available programs and services in the local One Stop system. The Disability Program Navigators work to increase employment opportunities and the self-sufficiency of persons with disabilities by linking them to employers to achieve successful entry or re-entry into the workforce.

Office of Mental Health

Assisted Competitive Employment (ACE): The objective is to assist individuals in choosing, finding and maintaining satisfying jobs in the competitive employment market at minimum wage or higher. When appropriate, ACE provides these individuals with job related skills training as well as long-term supervision and support services, both at the work site and off-site.

Ongoing Integrated Supported Employment Services: These funds are intended for ongoing job maintenance services including job coaching, employer consultation and other relevant supports needed to assist an individual in maintaining a job placement. These services are intended to complement ACCES-VR time-limited supported employment services.

Transitional Employment Placement (TEP): The objective is to strengthen the individual's work record and work skills toward the goal of achieving assisted or unassisted competitive employment at or above the minimum wage paid by the competitive sector employer. TEPs provide time-limited employment and on-the-job training in one or more integrated employment settings as an integral part of the individual's vocational rehabilitation growth.

Enclave in Industry: The objective is to provide vocational assessment, training and transitional or long-term paid work for individuals with severe disabilities in an integrated employment environment. An enclave consists of a small group of approximately 5-8 individuals who work in an industrial or other economic enterprise either as individuals or as a crew. Individuals in enclaves are provided with training, supervision and ongoing support by a job coach or supervisor assigned to the work site by the rehabilitation service agency.

Affirmative Business/Industry: The objective is to provide vocational assessment, training, transitional or long-term paid employment, and support services for persons disabled by mental illness in a less restrictive/more integrated employment setting than sheltered workshops. Affirmative programs may include mobile contract services, small retail or wholesale outlets and manufacturing and service oriented businesses.

Work Program: The objective is to provide vocational assessment, training and transitional or long-term paid work in institutional or community job sites for individuals disabled by mental illness. Individuals are paid by the vocational services provider.

Sheltered Workshop/Satellite Sheltered Workshop: The objective is to provide vocational assessment, training and paid work in a protective and non-integrated work environment for individuals disabled by mental illness. Services are provided according to wage and hour requirements specified in the Fair Labor Standards Act administered by the Department of Labor.

Vocational Services Children and Family: The Vocational Program for Adolescents was designed to provide work training and clinical support services for those older adolescents with poor academic performance and social adjustment in regular day treatment programs. The program identifies 5 goals on which to focus: Goal 1: Help youth identify problem areas and learn ongoing coping skills (i.e., involvement in support groups, recognizing need for relaxation and medication management); Goal 2: Provide Vocational Assessment and on-the-job training and experience; Goal 3: Improve Social Skills; Goal 4: Improve Educational Functions; and Goal 5: Provide Family Education and Support.

Department of Education-Vocational and Educational Services for Individuals with Disabilities

Adult Vocational Rehabilitation Services:Vocational rehabilitation services are provided to eligible individuals to prepare them for suitable jobs. In addition, it helps people with disabilities that are having difficulty keeping their jobs. Individuals in this program receive: a vocational assessment; a physical and/or psychological examination; guidance and counseling; referrals to help with problems; vocational counseling; career planning; short-term medical intervention; training to learn the skills required for desired job; transition services; driver evaluation and training; services that may assist individuals during assessment or training; books, tools and equipment needed for training or employment; rehabilitation technology; telecommunication aids and adaptive devices needed for rehabilitation assistance with some costs of modifications needed for employment; training in job-seeking skills; occupational licenses, tools, initial stock and supplies for a small business; job placement services; follow-up services; referral to independent living services; and assistance in working with agencies.

Independent Living Services (ILS): Independent Living Centers (ILCs) provide an array of services that assist New Yorkers with disabilities to live integrated and self-directed lives.  ILCs assist with living, learning and earning and work to remove barriers to full participation in to the local community and beyond.  ILCs are private, not-for-profit organizations, governed by a majority of people with disabilities and staffed primarily by people with disabilities.  ILCs are resource centers that do not run residential programs or operate places where people live.  The philosophy of independent living is to maximize opportunities for choices and growth through peer driven supports and self-help.  ILCs are the voice of people with disabilities and the disability rights movement in local communities across New York State.

Social Security Administration

Work Incentives Planning and Assistance (WIPA)/ Community Work Incentives Coordinators (CWIC): The WIPA projects were funded to assist Social Security Administration's (SSA) disability beneficiaries with information about work incentives, benefits planning and making good choices about work. By working with a WIPA, SSA beneficiaries will be better equipped to make informed choices about work.  Each WIPA is staffed with Community Work Incentive Coordinators (CWICs) to: provide work incentives planning and assistance; help beneficiaries and their families determine eligibility for Federal or State work incentives programs; refer beneficiaries with disabilities to appropriate Employment Networks or State vocational rehabilitation agencies based on an individual's needs and impairment types; provide general information about potential employer-based or federally subsidized health benefits coverage available to beneficiaries once they enter the workforce; and inform beneficiaries with disabilities of further protection and advocacy services available to them. WIPAs are authorized to serve all SSA beneficiaries with disabilities, including transition-to-work aged youth, providing benefits planning and assistance services on request and as resources permit.

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Appendix 7: Summary of state policies, procedures and MOUs

Table 5: Agency Procedures and Policies

Service Eligibility


Agency

Criteria

Sources

Office of Mental Health (OMH)

Screening instruments:

  • Modified Simple Screening Instrument for Substance Abuse (MSSI-SA), CAGE-AID and ASSIST

Personalized Recovery-Oriented Services (PROS)

  • >18
  • Designated mental illness diagnosis
  • Functional disability
  • Recommended for admission by licensed practitioner
  • Verify Medicaid eligibility

Vocational and Educational Services for Individuals with Disabilities (ACCES-VR)

  • Physical or mental impairment that is a substantial impairment to employment
  • Can benefit by achieving employment specific to individual
  • Requires vocational rehabilitation services that are conducive to employment
  • Non-citizens must be legally allowed to work in the US
  • Individual receiving SSI or SSDI benefits
  • Eligibility must be determined within 60 days of application

NYC Department of Health and Mental Hygiene
(NYC DOHMH)

  • Disability eligibility:
    • Categorical and derivative eligibility
  • Disability determination for clients <21 yrs
  • Individualized functional assessment

Office of Alcoholism and Substance Abuse Services (OASAS)

Screening instruments:

  • Modified Mini Screen (MMS), Mental Health Screening Form II (MHSF-III), K-6 (Kessler)

 

Reimbursement Structure


Agency

Criteria

Sources

Office of Mental Health (OMH)

PROS reimbursement only for individuals who are:

  • Pre-admission/pre-registration status
  • Currently in PROS program
  • Collaterals

Also:

  • FFS for individuals in Medicaid managed care
  • Maximize funding from ACCES-VR
  • PROS service available to individuals at their workplace can only be used on 1:1 basis

See Finance Chapter pdf of PROS Provider Handbook for more details on comprehensive and specialized additional programs

Vocational and Educational Services for Individuals with Disabilities (ACCES-VR)

  • Assistance with transportation to participate in VR at a cost of <$200/week, $7000/year or $15000 for the life of the case
  • Based on the number of total direct service hours rendered

 

NYC Department of Health and Mental Hygiene
(NYC DOHMH)

 

 

Office of Alcoholism and Substance Abuse Services (OASAS)

 

 

Interagency agreements


Agency

Agreements

Sources

Office of Mental Health (OMH)

  • Collaborate as much as possible with ACCES-VR to reimburse for PROS program

Vocational and Educational Services for Individuals with Disabilities (ACCES-VR)

  • See "Referral from ACCES-VR to Mental Health System" section for collaboration with OMH
  • Merger of DAAA and DSAS to collaborate with ACCES-VR to provide comprehensive, coordinated and integrated services
    • Referred individuals must meet minimum functional criteria (see MOU between ACCES-VR and OASAS)
  • Interagency MOU for supported employment with CBVH, OMRDD and OMH

NYC Department of Health and Mental Hygiene
(NYC DOHMH)

 

 

Office of Alcoholism and Substance Abuse Services (OASAS)

Statutes of mention from OMH/OASAS MOA:

  • Majority of co-occurring disorders can be treated at either OMH or OASAS sites (#1)
  • OMH and OASAS agree to work together to facilitate the provision of an integrated treatment model (#3)
  • Identification of a diagnosis or functional characteristics of a co-occurring chemical dependence or mental health disorder shall be made utilizing Screening Instruments and Assessment tools approved by both OMH and OASAS (#5)

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Appendix 8: 2009 MISCC employment data of selected agencies
(Selected agencies) (*)

Agency

Type of Day/Employment Program

Program Description

Number of Individuals Served

Length of Stay

Funding Appropriated SFY 2009-10

Funding Source

Level of Integration

DDPC

Peer Mentoring & Supports

Demonstrates how the provision of peer mentoring and supports in the vocational rehabilitation process can improve the ability of people with developmental and other disabilities to obtain and maintain employment.

115
Employed YTD

 

$110,000

MOU through ACCES-VR

High

DDPC

Youth Leadership

Implements a "Youth Partners" curriculum that develops and sustains self-advocacy, self-determination and leadership competencies and skills for youth with developmental disabilities.

368 youth
Participating YTD

 

$234,000
To 5 community based organizations

Federal Developmental Disability Assistance and Bill of Rights Act

High

DOH-AIDS Institute

Housing Works, Inc., Job Training Program

Prepares formerly homeless and low-income individuals living with HIV/AIDS for employment opportunities. The program guarantees full time jobs at Housing Works to all who graduate.

55

6-12 Months

$393,175

AI / NYSDOH / MSA (State - BCBS)

High

NYSOFA

Senior Community Service Employment Program

Helps job seekers improve their skills, obtain training and find a job. SCSEP is funded by a grant from the U.S. Department of Labor.

1,067 individuals from 7/1/08 to 6/30/09

36 Months

$7,510,656

Older Americans Act Title V - Federal Program

High

OASAS

Civic Association Serving Harlem, Inc
Job Placement & Employment Retention

Provides work readiness counseling, job development, job placement, retention counseling, GED Prep, and computer training.

90

 

$535,697

 

High

OASAS

Correctional Educational Consortium (NYC)
Vocational Service Model, Job Placement & Retention

Provides vocational case management, career development assessment, job development, and job placement and retention services.

120

 

$516,656

 

High

OASAS

Kings County - Educational Vocational Rehabilitation Job Placement & Retention

Provides job development and work retention assistance.

49

 

$253,277

 

High

OASAS

Employment Program for Recovered Alcoholics, Inc (NYC)- Job Placement & Retention

Provides diagnostic vocational evaluation, situational assessment, job readiness training, job placement and work retention assistance.

96

 

$620,199

 

High

OASAS

National Association of Drug Abuse Problems, Inc (NYC)- Comprehensive Employment Services

Provides work readiness counseling, computer classes, job development, job placement and work retention counseling.

160

 

$1,119,132

 

High

OASAS

Nassau County Mental Health, Chemical Dependency, & Developmental Disabilities-Job Placement & Retention

Provides work readiness counseling, job development, job placement and work retention follow up.

42

 

$239,251

 

High

OASAS

Gateway Communities Industries Vocational Transition Center- (Ulster)
Job Placement & Retention

Provides work readiness, direct job placement and work retention follow up.

15

 

$71,615

 

High

OASAS

North East Career Planning (Schenectady)- Comprehensive Employment Services

Provides work readiness, direct job placement and work retention follow up.

51

 

$265,248.00

 

High

OASAS

Horizon Health Services (Erie)-
Employment Services

Provides work readiness, job placement and work retention follow up.

36

 

$130,000

 

High

OCFS-CBVH

Vocational Rehabilitation

Prepares individuals to enter, reenter or retain competitive employment in an integrated setting.

3,875

$31,000,000

Federal government under the Rehabilitation Act of 1973

High

OCFS- OWD

Work Experience (OJT)

Enables youth the opportunity to experience the steps of the job search process. The OJT experience simulates real job demands and expectations.

200-250 at any given time

 

$125,000

 

Low

OCFS-
OWD

Work Readiness

OCFS mandated curriculum is used in all facilities. Every youth placed in a facility receives at least one semester of Career and Financial Management. The curriculum includes job readiness, budgeting, workplace communication & job searching.

Approx. 250

 

$50,000

 

Low

OCFS-
OWD

Vocational Certifications:
CMI
Serv Safe
NCCER
Weatherization

OCFS offers certificates in the vocational areas of food service, property management, building trades and weatherization.

40

 

$25,000

 

 

Medium
Medium
Low
High

OMH

Ongoing Integrated Supported Employment (OISE)

For job maintenance services including job coaching, employer consultation and other relevant supports needed to assist an individual in maintaining a job placement.

 

 

$10,448,446

 

High

 

Personalized Recovery Oriented Services (PROS)

Integrated services for individuals with SPMI Services include community rehabilitation and support, intensive rehabilitation, vocational support and clinical treatment.

 

 

$919,160 (this funding will increase as the numbers registered in PROS increase statewide)

 

High

OMH

Assisted Competitive Employment (ACE)

Assists individuals in choosing, finding and maintaining satisfying jobs in the competitive employment market.

 

 

$7,531,547

 

High

OMH

Temporary Employment Program (TEP)

Strengthens an individual's work record and skills toward achieving competitive employment. TEP provides time limited employment and on the job training in integrated settings.

 

 

$2,624,431

 

High

OMH

Affirmative Business Initiative (ABI)

Provides vocational assessment, training, transitional or long-term paid employment and support services in a less restrictive/more integrated setting than sheltered workshops.

 

 

$2,946,543

 

Medium

OMH

Enclave in Industry

Provides vocational assessment, training, and transitional or long term paid work in an integrated environment.

 

 

$417,323

 

Low

OMH

Work Programs (Mobile Work Crews)

Provides vocational assessment, training and transitional or long-term paid work in institutional or community job sites.

 

 

$1,491,198

 

Low

OMH

Sheltered Employment

Provides vocational assessment, training, and paid work in a protective and non integrated work environment.

 

 

$46,041,318

 

Low

SED/
ACCES-VR

Vocational Rehabilitation VRTitle I
Services are provided to eligible individuals through an individualized plan for employment (IPE) leading to integrated employment outcome consistent with the individual's strengths, preferences and abilities. These services include assessment, vocational training, including higher education, maintenance and transportation, personal assistance services, rehabilitation technology, vehicle modification, job placement, post employment services and supported employment

59,016

On average 2 years

$182 Million
Federal - $127M federal, Title I (Section 110) plus $15M ARRA
State - $54M case services (Required Match and Maintenance of Effort)
Plus $5M in mostly Federal Social Security Reimbursements and a small portion of State Workers Compensation.

High - *** Federal regulations for the VR Program require employment outcomes, by definition, to be in an integrated setting.

 

 

Supported Employment Intensive

14,800

On average 2 years

$25 Million
State - $15.1 Million of which $5.1 M is allocated to intensive.
Federal -
($18.6M taken from above Section 110) and
Title VIb ($1.3M)

High

 

 

Supported Employment Extended

3,801

Most individuals- extended services between 3 and 10 years.

$10 Million
State - $10 M (earmarked from the above $15.1 M State Supported Employment Appropriation)

High

(*) The complete report includes employment programs within OMRDD and other state agencies. We have included in this Appendix the programs that appear most relevant to individuals with psychiatric disabilities.

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Appendix 9: ACCES-VR VR Participation of Individuals with Mental Health Disability

Preliminary Draft of Findings - September 2009

In 2006, at the request of the New York Association of Psychiatric Rehabilitation Services (NYAPRS), ACCES-VR conducted an analysis of the VR services to individuals who have identified a mental illness as a primary disability. This analysis was shared with the NYAPRS Employment Committee at that time. The initial analysis was updated and described in the FFY 2008 VR State Plan Comprehensive Statewide Needs Assessment. Since that initial assessment, the VR Program has annually updated and tracked our progress in serving this population each year. The most recent data was summarized in the FFY 2010 VR State Plan Comprehensive Statewide Needs Assessment.

A summary of some of the key findings based on FFY 2008 data includes:

Data Definition: For the purposes of this assessment, the VR Program used the following set of impairments and causes to designate mental health-related disability: cognitive, psychosocial or other mental impairment due to anxiety disorder, depressive or other mood disorder, eating disorder, personality disorder, schizophrenia or other psychotic disorder, or mental illness.

Table 7- Total number of individuals served

 

FFY 2003

FFY 2004

FFY 2005

FFY 2006

FFY 2007

FFY2008

Total served

108,478

102,246

97,981

93,314

93,124

100,454

mental health

20,175

18978

18,527

17,717

18,143

19,026

percent

19%

19%

19%

19%

19%

19%

 

 

 

 

 

 

 

ssi/ssdi served

29,615

28,809

28,284

27,505

27,165

27,613

mental health

9,927

9,535

9,424

9,042

9,017

9,065

percent

34%

33%

33%

33%

33%

33%

 

 

 

 

 

 

 

new applicants since 10/1

42,170

39,620

37,937

38,220

39,991

 

46,180

mental health

7,235

6,980

6,909

7,010

7,518

8,136

percent

17%

18%

18%

18%

19%

18%

 

 

 

 

 

 

 

reached eligibility since 10/1

35,839

32,985

31,820

31,872

34,277

 

38,619

mental health

7,289

7,000

6,896

6,930

7,357

7,752

percent

20%

21%

22%

22%

21%

20%

 

 

 

 

 

 

 

active caseload
(10 - 24)

57,077

54,582

49,940

47,982

49,142

 

55,064

mental health

10,964

10,613

9,724

9,693

9,959

10,743

percent

19%

19%

19%

20%

20%

20%

SSI/SSDI

Table 8- Case closures

 

FFY 2003

FFY 2004

FFY 2005

FFY 2006

FFY 2007

FFY
2008

employment outcomes (26)

15,010

13,826

13,292

12,956

13,198

 

13,236

mental health

2,534

2,346

2,376

2,289

2,443

2,436

percent

17%

17%

18%

18%

19%

18%

 

 

 

 

 

 

 

closed without employment after plan initiated (28)

11,023

10,830

11,197

9,730

9,379

 

8,900

mental health

2,557

2,440

2,685

2,258

2,249

2,217

percent

23%

23%

24%

23%

24%

25%

 

 

 

 

 

 

 

closed without employment before plan initiated (30)

12,522

10,993

11,979

11,162

10,557

 

10,569

mental health

3,025

2,609

2,734

2,439

2,422

2,339

percent

24%

24%

23%

22%

23%

22%

 

 

 

 

 

 

 

closed from applicant or pre-eligibility (08)*

7,505

6,559

6,440

6,357

5,725

6,409

mental health

574

471

472

497

538

631

percent

8%

7%

7%

8%

9%

10%

* (includes unknown impairment)

 

 

 

 

 

 

Closures

Mental health consumers make up 18% of successful closures. As a group, they make up 24% of ACCES-VR's unsuccessful closures (Status 28). This higher percentage may reflect the unique challenges experienced by individuals with psychiatric disabilities in maintaining employment and having those supports that can accommodate or overcome the impact of their disability.

In reviewing Status 26 closures for youth (consumers who were under age 22 at application), are significantly under represented and make up only 8% of successful closures. (It would be interesting to see if the Cornell MTP data can account for this).

Mental health consumers are also over represented with 23% of the cases closed as eligible but prior to plan development in Status 30. This number is similar to Status 28 closures and may represent, at least to some degree, the cyclical nature of disability and its impact on engaging in vocational rehabilitation activities. It may indicate the need to develop natural or other supports; individuals can benefit from family, peer or clinical supports when engaging with the VR system. These supports may need to be more deliberately activated by the individual as part of the VR process.


Table 9 - RSA Performance Indicators

 

FFY 2003

FFY 2004

FFY 2005

FFY 2006

FFY 2007

FFY 2008

Ind.1.1 change in employment outcomes (current minus previous year)

436

-1,184

-534

-336

242

38

mental health

61

-188

30

-87

154

-7

 

 

 

 

 

 

 

Ind.1.2 percent of employment outcomes 26/(26+28)

57.7%

56.1%

54.3%

57.1%

58.5%

59.8%

mental health

49.8%

49.0%

46.9%

50.3%

52.1%

52.4%

 

 

 

 

 

 

 

Ind.1.3 percent of competitive employment outcomes

92.4%

94.0%

94.8%

95.1%

94.4%

94.7%

mental health

93.3%

93.2%

94.7%

95.4%

94.1%

93.8%

minimum wage

5.15

5.15

5.15

6.00

6.75

7.15

 

 

 

 

 

 

 

Ind.1.4 percent of competitive employment outcomes with significant disabilities

96.7%

96.8%

97.3%

97.6%

98.0%

98.4%

mental health

98.6%

99.0%

99.3%

99.3%

99.5%

99.3%

 

 

 

 

 

 

 

Ind.1.5 ratio of average VR wage to average State wage

0.42

0.40

0.39

0.38

0.37

0.37

mental health

0.40

0.38

0.38

0.37

0.36

0.36

average state wage

22.71

23.66

24.81

26.29

28.29

28.75

 

 

 

 

 

 

 

Ind.1.6 difference between self-support at application and closure

63.7

63.5

63.8

64.8

63.7

63.0

mental health

53.4

51.7

55.0

54.7

54.1

54.3

 

 

 

 

 

 

 

 

0.89

0.92

0.90

0.87

0.87

 

Ind.2.1 ratio of minority service rate

0.89

mental health

0.83

0.91

0.87

0.87

0.87

0.86

RSA Performance Indicators

Change in employment outcomes and percent of successful closures has paralleled ACCES-VR's overall performance. 58.5% of all individuals closed after participating in an individual plan for employment (IPE) achieve an employment outcome, while 52.1 % of individuals with an MH disability achieve an employment outcome after participating in an IPE. In FFY 2007, it is noteworthy that individuals with psychiatric disabilities accounted for 154 of the total increase of 242 individuals achieving an employment outcome.

Competitive employment rates are the same for both ACCES-VR overall and the individuals with mental health disabilities at 94%. Ratio of average VR wage to average state wage is also essentially the same for both groups at .36. ACCES-VR does not meet the RSA Standard for this indicator, which is .52 of the average state wage. Keep in mind that NYS has the highest average wage of any state in the country.

The difference between self-support at application and closure evidences a bigger difference. Approximately 64% of ACCES-VR consumers are self-supporting upon closure while only 54% of mental health consumers are. This again may reflect their need to maintain necessary benefits.

Public Input: Youth Focus Group and Special Forum in NYC

ACCES-VR conducted a focus group and a public forum to gather input on how to better serve individuals with psychiatric disabilities. The first May 28, 2009 was focused on youth and included representatives from the MHANYS, OMH and ACCES-VR Special Education. The second was a special forum in NYC on July 30 in cooperation with Community Access and NYAPRS. The findings from these forums will be added to this report at a later time.

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Appendix 10: Personalized Recovery Oriented Services (PROS) and the Implementation of the Evidence-Based Practice of Individual Placement and Support (IPS) Model of Supported Employment

At a request of the research team preparing this report, the NYS Office of Mental Health provided a description of the roll out of Personalized Recovery Oriented Services (PROS) and implementation plan of the Individual Placement and Support (IPS) model of Supported Employment within the NYS public mental health system. OMH has conceived PROS as a "robust rehabilitation program developed to assist individuals in their recovery from mental illness." According to the program design of PROS, this program provides services within four distinct components:

The Office of Mental Health provides technical assistance with PROS agencies that are actively pursuing a PROS license. These trainings are provided in the following areas:

There are currently 21 licensed PROS programs in NYS. It is anticipated that approximately 20 additional programs will be licensed through the first half of year 2010. PROS programs are funded by a combination of Medicaid and State Aid funding. Medicaid pays for services to help individuals overcome barriers due to their mental illness that are preventing them from achieving their life goals, including the goal of employment. State aid funding was added to the model in the FY 2009/10 budget for programs to pay for staff and services required by the IPS model that cannot be funded by Medicaid (e.g. job development). State aid was added to the PROS program in an effort to sharpen the focus on supporting individuals in getting and retaining employment. It is too early to determine the effects on employment outcomes as the state aid described above was received by the PROS providers at dates after April 1, 2009.

The Evidence-Based Practice Technical Assistance Center (EBP-TAC) is operated by the New York State Psychiatric Institute at Columbia University and has been funded to provide technical assistance in order to move evidence-based practices into real clinical practice in the programs OMH funds. Within the EBP-TAC, OMH has implemented a Supported Employment Technical Assistance Center. This Center has hired a senior trainer with multiple years of experience in providing IPS to individuals and supervising others in the practice. A second IPS trainer will be brought on board during calendar year 2010. A senior consultant has been contracted to assist in designing the rollout of the IPS model throughout NYS. The senior consultant also has a wealth of experience working in other states on the collaborative relationship between state mental health and state vocational rehabilitation. It is expected that OMH will take advantage of these experiences to build a stronger coalition with Vocational and Educational Service for Individuals with Disabilities (ACCES-VR) NYS's vocational rehabilitation agency.

OMH will begin implementing IPS in the personalized recovery oriented services program (PROS). The process will be kicked off by holding several regional IPS forums to introduce the IPS staff from the EBP-TAC to licensed and soon to be licensed PROS programs. The rollout will include traditional mentoring to a small number of PROS programs and non-traditional use of distance learning systems in order to bring IPS to scale with the PROS programs.

OMH will measure the success of both the traditional and non-traditional methods to provide technical assistance to PROS programs initiating the IPS model.

Appendix 11: NYAPRS' Recovery-Orientation Transformation and Technical Assistance Framework

Implementation research provides strong evidence of what works and what does not work in improving program capacity. For instance, research shows that knowledge-based training does not necessarily change practitioners' competencies, and that training alone is not enough to effect changes at the programmatic level. Changes in administrative practices or organizational structures are often needed for significant change to occur (Fixsen and Naoom, 2005). Our experience in providing training and technical assistance to mental health providers confirms these observations. In our experience, the most effective transformation often occurs when five elements are present:
(1) new strategies or services are research-informed;
(2) a creative program-specific plan is devised;
(3) concrete changes or improvements in program structures are made;
(4) training approaches proven to develop competencies are utilized;
and (5) successful transformation experiences are shared.

An effective transformation framework must describe the principles and methodologies that are most likely to impact the implementation capacity of mental health programs. This framework must include the following principles and methodologies:

Assessing Programmatic Recovery Facilitation Capability : Program improvement efforts must be informed by an assessment of the recovery-facilitation capability of programs involved. This assessment aims to measure the capacity of mental health programs to facilitate recovery, that is, the ability of individuals served to live, work, learn and participate fully in their communities. Below are examples of domains and indicators that ought to explored and assessed as a baseline in program improvement efforts:

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Appendix 12: Summary of Policy and Programmatic Recommendations

Table 10: Summary of systemic barriers, recommendations and agency involvement for improving the employment outcomes of people with psychiatric disabilities in NYS

Area

SYSTEMIC BARRIER

POLICY / PROGRAM IMPROVEMENT RECOMMENDATION

AGENCIES INVOLVED

 

Policies

 

Employment of people with psychiatric disabilities has not been a systemic priority for New York State: (a) lack of policy mandates for the achievement of competitive employment as a clinical and service priority in the rehabilitation and recovery services; (b) the lack of an adequate service infrastructure to effectively support the employment and career goals of individuals; and (c) a predominant treatment and service orientation tolerant of idleness and unemployment.

Making employment a systemic priority and an essential component of rehabilitation and recovery services and supports for individuals with psychiatric disabilities by:
(1) establishing a state policy mandate for agencies and state-funded programs to prioritize employment;
(2) prioritizing the improvement of employment and economic integration outcomes and not solely the availability of evidence-based practices; and
(3) appointing a senior administrator within OMH to be responsible for coordinating the cross-agency Workforce System for People with Psychiatric Disabilities.

Governors' Office All state agencies
OMH
ACCES-VR
DOL
OASAS
DOH
DSS

Services and supports across agencies

Fragmented services and supports provided by
multiple state agencies with few and often weak
linkages amongst each other;

 

Overcome the fragmentation of services through enhanced and multi-agency memoranda of understanding,
cross-agency liaisons, and other mechanisms of coordination and collaboration;

OMH
ACCES-VR
DOL
DOH

 

Funding

A "silo" funding structure that appears to create a highly inefficient use of the resources available due to unnecessary duplication of services (e.g. assessments) and few initiatives for creating synergy;

Maximize funding and resources available by developing mechanisms for integrated funding (e.g. braided funding), eliminating duplication of services (e.g. repetitive assessments), creating joint assessment and eligibility determination (e.g. OMH/ACCES-VR), strengthening synergy with available state and federally funded programs (e.g. Work Incentives Planning Assistance- WIPA benefits advisors, DOL Disability Programs Navigators), providing technical assistance and support to programs to become Employment Networks and utilize SSA Ticket-to-Work funding, exploring ACCES-VR/OMH joint access to funding through unutilized streams (e.g. "service to groups" or Innovation Expansion modalities);

OMH
ACCES-VR
DOL
SSA

 

Data systems

Limited cross-agency data systems to assess the short-term and long-term outcomes of individuals towards achieving employment and economic integration (i.e., each agency has at best short-term outcome data for individuals served by its program/s);

Improving cross-agency data systems on employment and economic integration outcomes;

OMH
ACCES-VR
DOL

Accessibility to Services

Limited access to services available:

  • Heterogeneous and often complex application processes, and significant waiting times, for determining service eligibility, which seriously compromises accessibility;
  • A narrow definition of "job readiness" based on the "appropriateness" of an individual for a particular program or funding stream, which not only screens out individuals but sets the foundation for individuals deemed as "not ready" for a particular program to be "dropped" by the system;

Improve the accessibility to services available by implementing No-Wrong-Door policies and procedures, broadening definition of readiness,
implementing a Zero- Exclusion principle at the system level (while allowing for the agency specific priorities or funding restrictions), improving the systemic capacity to support vocational outcomes of individuals at all stages of readiness, conducting a mapping of all services available at the community level across levels of readiness establishing partnerships with peer-run programs with experience engaging individuals with varying levels of readiness, and creating OMH/ACCES-VR joint and expedited eligibility;

ACCES-VR
OMH
DOL


 

Systemic Accountability

Lack of systemic accountability in relation to the employment outcomes of all individuals, that is, when a particular agency or program determines an individual as ineligible for their particular services there is not system in place to ensure that this individual becomes engaged in services that best suit her/his needs and is not "dropped" or "left behind" by the system;

Increase systemic accountability in relation to the employment outcomes of all individuals by implementing No-One-Left-Behind policies, establishing a Cross-agency Referral and Counter-Referral System to ensure no one individual is "dropped" or "left behind" by the system, but instead is referred to the appropriate agency/provider, and counter-referred for follow-up or reassessment if necessary;

OMH
ACCES-VR
DOL



 

Utilization of services available

Underutilization of programs and services available (e.g. Medicaid Buy-In, Ticket to Work);

Improving utilization of programs and services available (e.g. Medicaid Buy-In) by expanding cross-agency initiatives for deputizing of enrollment, improving information technology systems, etc;

DOH
SSA
OMH

 

Effectiveness of services

Limited availability of integrated and comprehensive care with coordinated clinical, vocational, and "wraparound" supports;

Improving effectiveness of services by increasing the systemic capacity to provide integrated and comprehensive services to support individuals obtain, maintain employment and pursue career advancements, clinical, vocational, "wraparound" supports, and other supports aimed at building their human, economic/material and social capital for employment;

OMH
ACCES-VR
DOL

Capacity of programs and
staff competencies

Limited capacity of programs to provide recovery-oriented employment services, while practitioners and staff possess compartmentalized knowledge and competencies with little proficiency in aspects not directly related to their particular services (e.g. mental health clinical or support staff lacking knowledge about work incentives, ACCES-VR counselors lacking competencies in engaging individuals with psychiatric disabilities); and

Improving programmatic capacity and competencies of practitioners and staff to provide recovery-oriented employment services; and

OMH
ACCES-VR
DOL

People with Psychiatric Disabilities

Predominant hopelessness and disbelief among people with psychiatric disabilities that achieving employment is possible, resulting from the collective experience of chronic and multiple systemic barriers and relative isolation of individuals to mental health services.

Increasing the involvement and participation of people with psychiatric disabilities through grassroots campaigns (e.g. WE Can Work) and consumer-input and feedback about policy and program improvement initiatives (e.g. ACCES-VR Consumer Councils).

OMH

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References

Eligibility for Services Policy from ACCES-VR:202.00 Eligibility Procedure
http://www.acces.nysed.gov/vr/current_provider_information/vocational_rehabilitation/policies_procedures/0202_eligibility_for_services/policy.htm#Eligibility_Outcomes

Interagency MOU between OMH and OASIS
http://www.omh.state.ny.us/omhweb/resources/providers/co_occurring/adult_services/moa.html

Letter to Clinic Directors, July 2008
http://www.omh.state.ny.us/omhweb/resources/providers/co_occurring/adult_services/20080731_ltr.html

Medicaid Disability Manual
http://www.health.state.ny.us/health_care/medicaid/reference/mdm/mdm-officialpolicy.pdf

MOA between OMH and OASAS
http://www.omh.state.ny.us/omhweb/resources/providers/co_occurring/adult_services/moa.pdf

MOU between ACCES-VR and OASAS
http://www.acces.nysed.gov/vr/current_provider_information/vocational_rehabilitation/memos_of_agreement_or_understanding/alcoholism_and_substance_abuse.htm

MOU between ACCES-VR and OMH, Section 4: Interagency Considerations
http://www.acces.nysed.gov/vr/current_provider_information/vocational_rehabilitation/memos_of_agreement_or_understanding/mental_health.htm

Office of Mental Health. PROS Provider Handbook (Finance Chapter)
http://www.omh.state.ny.us/omhweb/pros/finance.pdf

MOU between ACCES-VR and OMH Appendix A
http://www.acces.nysed.gov/vr/current_provider_information/vocational_rehabilitation/memos_of_agreement_or_understanding/mental_health.htm

 

Partnering Organizations
New York State Office of Mental Health
John Allen, Special Assistant to the Commissioner
44 Holland Avenue, 8th Floor
Albany, New York 12229
corajba@omh.state.ny.us
Tel. 518.473.6579

Burton Blatt Institute (Syracuse University)
Gary Shaheen, Managing Director, Program Development
Syracuse University Burton Blatt Institute
900 S. Crouse Avenue
Crouse-Hinds Hall, Suite 300
Syracuse, New York 13244
geshahee@law.syr.edu
Tel. 315.443.9818

Employment and Disability Institute (Cornell University)
Thomas P. Golden, Associate Director, Employment and Disability
ILR School-201 Dolgen Hall
Ithaca, New York 14853
tpg3@cornell.edu
Tel. 607.255.2731