Individual Placement & Support Model of Supported Employment

Individual Placement & Support Model of Supported Employment


Ann Williams: Hi everyone. I’m Ann Williams
of S-E-D-L or SEDL in Austin, Texas. I will be moderating today’s webcast entitled Individual
Placement and Support Model of Supported Employment: Translating Research for Vocational Rehabilitation
Practice. The webcast is offered through the Center on Knowledge Translation for Disability
and Rehabilitation Research or KTDRR, which is funded by the National Institute on Disability
and Rehabilitation Research or NIDRR. I also want to thank my colleague Joanne Starks for
her support on today’s webcast. Here’s our agenda for today, after an overview of
the webcast topic, I will introduce our presenters and we will have a facilitated discussion.
We will then wrap-up by letting you know how to become part of this discussion. The Center
on KTDRR has a sub-grant with the American Institutes for Research or AIR to develop
a series of webcasts and to establish a community of practice to help promote the understanding
in youth of evidence-based practices in the field of Vocational Rehabilitation or VR.
Cindy Cai is the Manager and she and her colleagues, Anestine Hector-Mason and Prekesha Mather
have been instrumental in the development of this webcast and the related community
of practice. In the first webcast, we discussed the issues surrounding the use of practice
guidelines in the VR field. Another recent webcast, focused on the evidence-based practice
of motivational interviewing. In today’s webcast, we will follow the same thread by
translating research to inform VR service delivery. We will have a dialogue with the
co-founder of the Individual Placement and Support or IPS model, a researcher and a VR
agency representative to discuss how research about IPS can be used to support VR practice
and how practice guidelines can be useful in supporting VR practitioners in implementing
IPS. In our dialogue today, we will discuss four central questions: first, what is the
individual placement in support for IPS models and its evidence base? How has IPS been used
in vocational rehabilitation practice or VR? How can research about IPS be translated to
support VR service delivery? Finally, what is the role of practice guidelines in the
implementing IPS to support VR service delivery? We’re happy to have our three panelists
with us today. Deborah Becker, MeD, CRC, is Associate Professor of Community and Family
Medicine and of Psychiatry at the Geisel School of Medicine at Dartmouth. Gary Bond, PhD,
is Professor of Psychiatry at Dartmouth Medical School and Senior Researcher at the Dartmouth
Psychiatric Research Center. Gene Oulvey, PhD, is a Coordinator of Evaluation and Psychiatric
Rehabilitiation services for the Illinois Department of Human Services – Division
of Rehabilitation Services or DRS. Deborah Becker will begin the presentation by defining
what the IPS model is and its characteristics and practice principles. Deborah, are you
ready to begin? Deborah Becker: Yes! Thanks very much, Ann. I appreciate being here today.
I’m going to spend the first few minutes describing what IPS supported employment is.
Again, IPS stands for Individual Placement and Support. I’ve been working in the field
of rehabilitation for 25 plus years and there’re really three main points that have really
stood out for me. One, most people with severe mental illness want to work. Two, the evidence
is very clear that most people with serious mental illness can work. Three, that IPS supported
employment helps people to find and keep jobs of they’re choosing. I usually start my
presentation with the words of people who have received these services and who are working
because it constantly reminds me why I do what I do. These are quotes from people who
have given their permission to use them, who are at work and – the first quote: “When
I am working, the noise in my head gets quieter.” The second quote, “Working gives me a reason
to get up in the morning and that is the best medicine.” Third, “In the past, people
might have used labels to describe me such as ‘homeless,’ ‘mentally ill,’ and
‘welfare mother.’ Now, my titles are ‘financial administrator,’ ‘college student,’ and
working mom.’” In the past, 5, 10, 15, 20 years ago, these people might not have
been eligible for this kind of employment service and they wouldn’t be working at
all. What we’ve learned by studying and understanding IPS supported employment that
lots of people can and do go to work, and that work helps with recovery. We’re not
waiting for people to recover and then help them with work. Instead, work is what helps
them with recovery. Next, I’d like to define terms because I think we often use these terms
but may mean different things when we use them. The first one is, supported employment
and of course that was defined pretty generally in the Rehabilitation Act Amendment and it
was defined for people who, as you know, had typically been screened out of getting services.
Evidence-based supported employment is really equivalent to the term IPS supported employment,
Individual Placement and Support and we have come to use the term IPS more regularly just
to distinguish it from supported employment. This really is the practice that has the evidence
behind it and that was initially studied and researched for people with severe mental illness.
It has clear guidelines so we know what it is and it can be replicated. So, here are
some general characteristics of IPS supported employment. It’s evidence-based, so there’s
research behind it showing that it works. We’ve seen overtime that it’s important
for all practitioners to really focus on people’s strength and what they like to do. So, it’s
not based on deficits, what they can’t do, but really a positive approach and we have
seen that through this approach work really promotes recovery and wellness. IPS is best
implemented with the partnership of State Vocational Rehabilitation and as I go through
the principles, I’ll try to highlight how it’s consistent with VR, vocational rehabilitation,
and the role there. The mental health system hasn’t always embraced work as part of recovery
and promoting wellness the way the VR system does. IPS has really helped to change how
services are delivered in the mental health system. I’m often asked, “What type of
jobs are we talking about here?” Really there are all kinds of jobs because all types
of people are getting into these services so I just took a list of job titles from a
project actually that we did in Rhode Island a while ago, and you can see that they are
very different jobs and that’s because the jobs in IPS are really focused on what the
person wants to do, what skills they have, and what experiences they have. They’re
not all going to be in food service or clerical work. Let me go through eight principles that
are defined IPS-supported employment and, as I said before, try to relate them to your
work. The first principle is that these services are open to everyone who wants to work. Anyone
with severe mental illness who wants to work regardless of what their diagnosis is; or
the severity of symptoms that they are experiencing; or their work history; or other problems like
substance use in cognitive impairment. What has been found is that motivation to work
is a significant predictor of success and oftentimes outweighs other factors. People
can work with the right supports. Mental health agencies overtime developed a culture of work
so everyone embraces these principles. It hasn’t come naturally to everyone because
most of us have been trained to think that people have to get ready to work and that
not everyone actually will be able to work but that just isn’t true. For VR this is
consistent with the Federal Rehabilitation Act, which has the assumption of the ability
to benefit irrespective of severity of the disability. It’s also consistent with VR
as eligibility of having a physical or mental disability that impedes employment and that
the individual will benefit from full range of VR services. The second principle is the
focus – is on competitive employment. Competitive employment is defined as paying at least minimum
wage and the wage others receive performing the same work. These are jobs in regular community
settings alongside others without disabilities, it’s not reserved for people with disabilities.
These jobs don’t have time limits that are imposed by the employment program. One person
said, she started employment services, IPS, and got a job that when she got up in the
morning now, she said, “I’m an ordinary person.” She was going to a regular job.
This idea, focused on competitive employment, is completely consistent with VR’s mission
of work which is defined as competitive employment. The third principle is that it’s a rapid
job search approach. Employment specialists help clients seek jobs directly rather than
providing extensive pre-employment assessment and training or intermediate work experiences.
They’re not asking clients to participate in situational assessment, trial work experiences,
job tryouts, job shadowing or traditional vocational evaluations, or work adjustment
programs and training programs that focus on good work behaviors prior to receiving
help with job placement. So how this works is the employment specialist and/or the consumer,
the customer, the client will start connecting with employers within 30 days of starting
the program. Now to be clear here, this isn’t a rapid job placement approach. The timing
of this really goes by what is right for the individual. Somebody may not get a job for
a number of days. People vary as they enter IPS programs and knowing exactly what they
want to do. Some people are very clear and others are not and so the employment specialist
may spend time with individual who’s not just learning about jobs and the employer
community by visiting jobs. In terms of VR, rapid determination of eligibility and movement
into job development service is an important part of rapid job search. IPS programs and
VR counselors work together to gather the documentation that VR counselors need – the
medical and eligibility documentation at intake. Some programs have joint initial meetings
with the employment specialists and VR counselors. The IPS team could start/begin job searching
with the person before the VR plan is written but when VR counselors participate in initial
intake meetings and IPS meetings regularly, they’re going to know who’s getting ready
for VR referral. The fourth principle is that it’s a – systematic job development is a
key part of what employment specialists do and they develop relationships with employers
based on their clients’ work preferences, skills, and past work experiences. The rationale
behind this is that employers prefer to work with employment specialists who understand
their business needs and by understanding their business needs, they can make good recommendations
on people for the employers to interview. They might not have anybody as it turns out
once they get to know what the specific business needs are of that employer. Employment specialists
are asked to make at least six in-person contacts a week with hiring managers and business owners
and they keep track of these contacts. They then make return visits to these employers
to develop their relationships and understand more their hiring practices. For VR, you have
lots of information about the employer community and VR counselors introduce employment specialists
to employers they know. VR counselors can ask for documentations of these contacts as
part of the monthly written report to increase accountability for this process. All right,
now the fifth principle is that client preferences guide decisions. The IPS services are based
on client preferences and choices regarding the job type, work location, type of job supports
whether the individual is going to disclose to the employer that they have a disability.
People who find jobs that match their preferences stay at these jobs longer than those people
who are in jobs that really aren’t consistent with what they want to do. This principle
is similar to VR’s focus on an informed choice. The sixth principle is that individualized
long-term supports are provided and they are provided by the IPS team, as well as the mental
health team as long as the individual wants and needs these supports. To give examples
of these job supports, they’re really very different based on who the individual is and
what they’re going to benefit from but it could be simple encouragement, some people
that may be helping to ask for accommodations, for another person it may be helping to learn
the bus route, problem solving, role-playing different approaches to interpersonal issues.
It’s all varied. The goal, obviously, is to help the person to work as independently
as possible. In addition to supports by the IPS team and mental health team that there
may also be natural support such as from family members or co-workers that could be available
over time. The VR counselors and the employment specialists and client talk about possible
job supports right from the job start and will include recommendations and ideas from
the mental health teams as well as family members. Seventh principle is that – this
is an approach that integrates IPS employment services with mental health treatment and
employment specialists are members of multi-disciplinary treatment teams that meet regularly, usually
weekly, to review client progress and members of these teams typically are case workers,
may have nurses on the team, psychiatrists, housing specialists, people who are substance
abuse, specialists but they work together to try to put information together that’s
going to really promote functional recovery for individuals. The VR counselors are also
part of this process. Many of them are meeting regularly with IPS team members but they also
– some VR counselors meet with the mental health team and in this way they can hear
up to date information about client progress such as changes in medication, housing changes,
and of course VR counselors can provide information about physical disabilities, about employers
in the community – in this way, the VR counselors and the employment specialists and the mental
health practitioners really work together. The last principle is that benefits counseling
is included and this actually happens early in the process so clients/customers get accurate
information about what’s the impact of certain wages and hours at jobs on their package of
benefits which may include social security and Medicaid and other government entitlements
in relation to their earned income. As you probably know, fear of losing benefits is
the main reason people with serious mental illness are ambivalent about going to work
and so it’s really key that they have good information to make good decisions. People
who provide work incentives – counseling need to be specially trained to have this information
and the VR counselors can help with accessing this service. I know that some VR agencies
have the benefits planners, work incentive counselors on site. Some mental health agencies
invest in having these positions at the agency and it’s sometimes a hard resource to get
but it’s very important. All right so I’ve described to you the principles of supported
employment and there is a fidelity scale that outlines the 25 key ingredients to this approach.
It’s a scale that has these items scored on a one to five response format, five being
fully implemented and one not being implemented. If you are interested in looking at this scale,
you can find it on our website which is www.dartmouthips.org. That’s spelled D-A-R-T-M-O-U-T-H ips.org.
We also have lots of other information on that website as well. Lastly, I would just
like to highlight how IPS has been implemented through the partnership of Mental Health and
Vocational Rehabilitation for many years now but it’s also formed into IPS learning collaborative
also by the name of Johnson & Johnson Dartmouth Community Mental Health Program that includes
16 states and regions in the United States and three European countries. In these programs,
at a local level, IPS Programs connect with the VR counselors, typically one or two VR
counselors will connect with an IPS program to work together on their shared client. The
mental health program overtime provides the long-term support. We track outcomes in this
learning collaborative in all of these IPS teams across these different states and regions.
Typically in these programs about 42% of the people in any quarter in a year become employed.
So, I’m going to let Gary Bond go over the research with you but hopefully you will look
at our website and you’ll be able to find more information about this. Ann Williams:
Well, thank you very much, Deborah. Like what you said, we’re going to turn over to Dr.
Gary Bond who will comment on the research and quality of evidence base related to IPS.
Gary? Gary Bond: Thank you, Ann. I am happy to be here today. I have been doing research
on vocational programs for about 30 years and it’s been my great pleasure to have
the opportunity to collaborate with Debbie and with Bob Drake for about 20 of those years.
Also, so much shorter period of time with Gene Oulvey who will be speaking next. This
next segment of the presentation is about the evidence. We talked about IPS as being
an evidence-based practice. Well, what is actually the evidence? As Debbie indicated,
most clients with severe mental illness really want to work. This is a basic aspiration that
all of us have, most of us have anyway and it holds true for people with psychiatric
disorders as well but the truth of the matter is that in many surveys we find that only
a fraction of those who would want to work and could benefit from help are actually employed
– somewhere around 10% to 15% in various surveys. In my early work, I studied a variety
of employment programs and concluded that none of these other models up until the current
development of IPS were effective for helping clients achieve stable competitive employment.
I’m going to talk about two major strands of research that we use to say that IPS is
an evidence-based practice. The first of these two is the studies that looked at converting
day treatment programs in mental health centers to IPS and this actually dates back to the
original evaluation study of the IPS model that Debbie Becker and Bob Drake did in
the 1980s. Day treatment services in mental
health centers back then and in many places still today offer opportunities for clients
to socialize, to have recreational activities, to have skills training groups, and to spend
structured time during the day. Day treatment programs often say – advertise themselves
as offering an opportunity for people to gain experiences so that they can go to work but
the research has not been very impressive in terms of the success of day treatment programs
in doing that. In the original study in New Hampshire, the clinicians and staff at the
agency, of which Becker and Drake were part of the staff at that time, discontinued the
day treatment program after a process of discussing it with the staff and tried out their new
model, their IPS model, to replace the services that have been offered to the clients and
at the same time providing support in terms of case management support for those who were
not interested in working. This particular study done in New Hampshire was later repeated
in a number of other sites and as all these works has been reported in the research literature.
In the sites that discontinued their day treatment services and converted over to IPS, the increase
of employment went from 13% of those who were working before the conversion to almost triple
that amount, 38% in the period of time after the conversion. These sites had comparison
sites as well. There were a number of other programs that did not convert over to IPS
and in those sites the day treatment services continued and as you can see the employment
rate remained almost the same or went from 12% to 5%. This was a dramatic illustration
that if you replace day treatment services with IPS services, a significant portion of
clients went to work. Now, in the addition to the increase in the competitive employment
rates, these studies also showed that there were no negative outcomes. There was a lot
of worry among the clinicians that by closing down the treatment programs, that people would
drop out of services there would be re-hospitalizations, and other adverse outcomes. In fact, this
didn’t happen at all. In fact in one of the studies, the employment – the hospitalization
rate actually declined for people who were in the group that converted over to IPS. After
the conversions, the clients, the families and the clinical staff, all were pretty unanimous
in saying that this was a positive change. They were very enthusiastic by and large – even
though some of them were pretty nervous before the switch. Also, another interesting finding
was that among the clients who said they were not interested in working – what happened
to them when they closed down the day treatment program? It turned out that many of them spend
more time in the community using health centers and exercise clubs and spending time in community
activities rather at the day treatment program so that was another indication that there
was greater community integration. Overall the conversions also resulted in cost savings.
It looked pretty much like a win-win all the way around. The next strand of research I
want to talk about consist of the set of studies of IPS that were done in a Randomized Controlled
Trial. A Randomized Controlled Trial is a study in which you decide by a flip of a coin
whether someone receives the treatment that you’re interested in evaluating versus a
comparison group. In drug research, the Federal Food and Drug Administration requires that
pharmaceutical companies first test out the effectiveness of the drug in Randomized Controlled
Trials where one group would receive the new medication and the control group would receive
the standard medication. That’s basically the logic behind Randomized Controlled Trials
for IPS or for any psycho-socio intervention. Randomized Controlled Trials, RCTs, are considered
the gold standard in medical research. So in the last 20 years, there have been actually
22 of these Randomized Controlled Trials and the next slide shows a graph of the employment
outcomes in these studies – the competitive employment rates. This is a pretty complicated
slide so let me give you a little bit of an orientation to it. So the 22 slides are labeled
by the year in which the project was done and the location of where it was done. The
very first study was done in New Hampshire in 1996, published in 1996. The next one was
done in 2012 in Alabama, the third study in Illinois and so forth and so on. The bars
represent the employment rate during the follow-up period and the black bar represents IPS and
the red or orange bar – there is one study that had two controls groups but the red bar
and the orange bar represent a comparison group. The comparison group varies from study
to study. In some studies it was a career counseling approach. In other studies it was
traditional vocational rehabilitation referral to a shelter workshop. There were a number
of different competitors in these different studies. As you look at this graph, you can
see that the IPS group had a higher employment rate in every single one of these studies.
In most cases twice as much as the comparison group. In fact in all 22 of these studies
you’ll see that – well it turns out in every single study the competitive employment rate
was significantly higher than the control group. These studies, by the way, have been
done in a lot of different types of communities. They’ve been done in big cities like Chicago
and Washington DC, and rural communities like in rural South Carolina. They’ve been done
all across the country from the East Coast in Baltimore, Maryland and the West Coast,
several in California. They’ve been done internationally, too. There was a large study
in Europe that included a number of different European countries. It’s been done in Canada,
Sweden, Japan, the Netherlands, Australia, and United Kingdom. In every one of these
studies, the IPS program has had better employment outcomes. If you look at the main competitive
employment rates across these studies, the average is 56% for IPS and only half that
rate for the comparison group. I’d like to mention that the employment rate is higher
in the US studies probably because in European countries, in particular, the labor laws and
their disability laws probably affect the success that employment specialists have in
engaging employers in hiring people with disabilities but that’s something that we need to investigate
further. The
graph that I’ve shown you looks at the employment rate defined as someone working at any time
during the follow-up period, obviously that’s not the only thing we’re interested in.
We’re interested in people actually working to sustain a period of time, making a wage
that will lead to more income and a better quality of life. We’ve looked at those measures
as well in a number of studies and to summarize across all those studies by a margin, the
IPS is significantly more effective than the approaches used in the traditional vocational
rehabilitation – the outcomes from those other programs. In this particular slide, we have
examined four of the randomized trials that I just described and combined the data from
that to look at some of these employment measures to give you a sense of the strength of the
findings. Job acquisition refers to getting a job and in this set of four studies, over
an 18-month period, 70% of the people on IPS got a job and you can see that 24% in the
comparison conditions got a job. In terms of working 20 hours or more a week, you can
see that 40% or less than half of the people in IPS got a job working 20 hours a week.
The comparison group was much lower. The time to the first job was shorter for IPS. The
total hours they worked over this 18-month period was four times as much as the control
group for IPS did and the wages were significantly higher as well. We’ve also, in a couple
of studies, looked at how long people hold their jobs. In IPS, the goal is to help people
work and develop an identity as a worker and there is of course an interest in helping
people sustain a job once they get it but more importantly the goal is that people continue
to work and if someone has a succession in their jobs before they find one that really
suits them, well fine. The IPS model doesn’t say that’s a negative that the first job
that you try isn’t a good fit for you. The goal is to find one that really suits you.
We looked at the tenure in the longest held job in a couple of studies, one was a two-year
follow-up study and the average length in the longest held job was 10 months. There
are recently was a study done out in Switzerland that had a longer follow-up period, five years.
In the Hoffman study in Switzerland, they found that the longest held job averaged two
years, which is pretty darn impressive. For the participants receiving usual vocational
services, you can see it was only eight months so it was only a third as much. Now perhaps
the most important outcome from IPS is not whether you helped somebody get their first
job, although that’s certainly a wonderful outcome, but it’s rather over the lifetime
that people develop a direction in their life that is towards working on a regular basis.
We have used this idea of a study worker. A study worker is defined as working at least
half a period of time. Study worker over a 10-year period would be someone who worked
at least five years during those 10 years not necessarily in the same job but over any
job. So we have three studies that have looked at a follow-up period of five years or more.
The employment rate that is a study worker rate across those three studies is almost
half, almost half, 49% of those people who enrolled in IPS were study workers over a
five or 10 year period. If you recall that the employment rate in the general population
of people with severe mental illness in mental health centers is about 10% or 15%, something
like that, 49% is a phenomenal change in people’s lives. IPS, I believe is really affecting
in touching people’s lives very fundamentally. In this Hoffman’s study – Swiss study
you can see that there were data for the control group and the study employment rate was only
11%, only one-fourth as much as in the IPS group. Finally, I just want to mention that
IPS seems to be a very flexible model that makes sense not only for people with a particular
set of characteristics but it seems to work for people who have many backgrounds. We haven’t
actually found any sub-group where IPS was less effective than some other vocational
approach. It has been demonstrated as effective in populations of veterans with post-traumatic
stress disorder, among people who are frequently hospitalized in many, many different groups
as you can see in this slide. Just in conclusion, I would say that IPS seems to be a very flexible
and effective model. With that, I will turn the presentation over to Gene Oulvey. Eugene
Oulvey: Thank you, Gary. It’s a pleasure to be with you today and it’s an honor to
share the stage with my colleagues and friends, Debbie and Gary. You’ve just heard an eloquent
presentation of the relevance of IPS Supported Employment to the Vocational Rehabilitation
System and the evidence-based for that effective VR model for serving really a range of persons
with disabilities. I’ve worked in the human service system for over 40 years in Illinois.
I served as Illinois VR’s Lead on mental health services for 22 of those years. I’ve
seen the guest work that has often gone into what is the best approach, the best practice
for serving a particular individual or a particular group. In 2005, Illinois made a statewide
commitment to IPS supported employment. The certainty and the structure and strength of
that model allowed us to not only enhance our services to persons with psychiatric disabilities
but to I think really move things to a new level of best practice. There are particular
characteristics of both the VR system and of the IPS support employment system in greater
community that fantastic learning community that stretch it across the country and across
the globe, that lend itself to this partnership. To the long-term relationship building that
is a key feature of IPS, long-term relationship building among team members of which the VR
counselor is an integrated member with the people that are served by the team and with
employers and other members of the community, which again has given Illinois VR the opportunity
to dramatically expand the reach of this service as we judiciously look at applying it to other
disability population. So IPS is among in my experience of the vocational models that
I’ve worked with is uniquely well described. There is an amazing fidelity scale which very
clearly defines the role conjunctions of community mental health agencies and give strong guidelines
to VR staff and how to work within that context and with those teams and with those agencies.
The VR system brings to that mix a number of strengths including a knowledge of accommodation
for a person with multiple disabilities. I am part of the Illinois technical assistance
team. We do the two-day fidelity reviews. I’ve done over a hundred of those reviews.
It’s been my experience that within the population a person served by mental health
agencies, all other disability groups are represented. So VR’s expertise in helping
people to overcome issues pertaining to hearing, seeing, listing, dealing with the range of
cognitive disabilities has proven to be an incredibly valued part and contribution to
those teams. So what does IPS offer to VR? Why is IPS a good investment for VR? As you’ve
heard, it’s an evidence based practice, so we can know the certainty that with the
population upon which it’s been tested, it is the best option. Therefore, it is a
good expenditure of resources, a good investment. It features that team approach that Debbie
so aptly described with well-defined roles, particularly of community mental health agency
staff, which allows the VR counselor to develop their role, their functions within that context.
It features the IPS support and employment fidelity scale, which is a predictive measurement
tool. One can predict with confidence, all things being equal that agencies will have
certain levels of outcomes over a given period of time, which in my experience is unique
in the VR system. As Debbie described, there is that amazing learning collaborative that
spans the nation and increasingly the globe, that gives VR staff and professionals and
agencies the ability to gather information about practices approaches, resources that
allow us to enhance our own practices within states and within programs. What does VR offer
to IPS? VR staff have unique expertise. Among other things they again have a range of knowledge
about how to assess, identify, develop work accommodations for and access resource or
either by purchasing or arranging for accommodations for multiple disabilities. There is a consistency
within the VR system. In Illinois, VR funding does not fluctuate to anywhere than the extent
that other human service systems’ funding fluctuates. There is the ability and VR staff
tend to stay in place for extended periods of times, so sometimes years, sometimes decades
in a community. That base in stability, that consistency both allows community agencies
to take the risk of starting IPS programs with the understanding that the funding will
be in place for the long-term. It also enables the recipients of the services to take the
risk that go along with looking for employment, particularly where an individual may have
had a history of disappointments and a sense of failure that again the resources, the staff
will be in place for the long-term so that they can make those decisions and take those
risks with the understanding that they will be supported throughout. In Illinois, we expect
our VR counselors to be accessible to both the IPS team. Debbie mentioned that the regularly
scheduled meetings with the community mental health team is an expectations and accessible
to consumers of the IPS services. We have 43 offices. VR counselors are available throughout
the state. We’ve also quantified that accessibility and instead of guidelines and regulations
which I’ll talk about on the next slide. Taking it to another level, there’s increasing
signs that a higher level of integration has occurred across the state. In many agencies,
VR counselors are co-located with IPS teams. That is have office space, they’re there
twice a month, every week, sometimes multiple times in a week, and that makes them available
both the IPS team and to the consumers of the agency. It also allows for shared activities
such as sharing and developing relationships with employers for the long-term, a key feature
of IPS. IPS in our experience, is not as Debbie said a job placement approach, it’s an approach
to cultivating employers and understanding employers’ needs so that when they are hiring,
they think of the IPS team first. We’ve had a number of examples of employers where
the higher the person that was referred to the employer just did not work out sometimes
because of flaring up of symptoms or for a number of reasons. The employers were more
than willing to work with the IPS team in the placement of another individual because
they knew that the team not only had the consumers back, the team also had the employers back
and that support would be for the long-term. VR staff have access to resources that other
members of human service systems do not, again, those pertaining to the range of disability
issues. Here are some quotes from a study we did in Illinois in 2009 and 2010. In effort
to look at how to enhance our practice of IPS, we did 22 focus groups that included
members of a community agency, IPS team of the treatment parts of a community agency
teams, VR staff and VR administrators, and most importantly, included the consumers of
services. These are some of the quotes that we got from those focus groups in that study.
Expertise: The VR counselor helped because helped because he had all the inside track
on really most of the businesses here. He probably saved a lot of time and effort, just
knowing where to go, and where we might not be. So it’s successful. Accessibility: The
VR counselor’s door is always open. I could make an appointment with him and go talk to
him and I know he would listen to me, what’s going on with me so I can make a better employee
and not have mental blocks and insecurities. Accessibility – we heard this over and over
again in these focus groups and I’ve heard it in doing the fidelity reviews and the number
of other context, that because that long-term relationship of trust has been built with
an individual that begins, so they know that the VR counselor and the rest of the IPS team
will support them throughout, they’re much more open to taking like the unpleasant criticisms
or a strong urging to continue the job search even when it’s unpleasant. Again, I think
a strong indicator of using this approach how those bonds of trust can be built over
the long-term. That level of integration – this came from one of the focus groups and one
of our most rural areas in Southern Illinois, where among other things, the VR counselor
and the IPS team members grew up together and also grew up with most of the employers
in the area. So they had formed the relationship of working together so that as the quote says,
“I don’t think the consumers really noticed a difference between the IPS team members
and the VR counselor. I think they see us as working together as a team. So when you
say VR, they say it’s us.” We’ve codified the advantage of IPS and the guidelines for
VR counselors in Illinois. Because IPS has been such a good investment for us, we’ve
advantaged IPS case that we’ve allowed for certain things in IPS cases that are not allowed
in other VR cases. So whereas the VR counselor has in a regular VR case up to five or six
months to determine eligibility and to develop the individual plan for employment the rehabilitation
plan with IPS, our counselors have 10 days from the time of the referral to determine
eligibility and to develop the rehabilitation plan. Now that of course only works in this
team context where there is frequent ongoing communication, there’s this bond of knowledge
and trust that has been develop so the VR counselor can presume that the other members
of the IPS team will provide them with all the information they need in a format that
they need, to make this quick eligibility determination and to develop a plan. The monthly
team meetings that are part of the IPS fidelity scale are mandated in our guidelines, but
again, there is a lot of evidence that VR counselors across the state are meeting with
the teams on much more frequent basis. Our counselors are allowed to mandate up to 21
days when an individual makes an application in support of that rapid job search approach.
That is not allowed with any other case, but again, IPS is fluent to be a good investment
for Illinois. Again, there is an assumption that the IPS team will provide the counselor
with the information and the resources they need to make those quick determination. We
have a milestone payment system approach. When an individual goes to work, there is
a payment to the IPS agency at 15, at 45, and at 90 days post to that start of employment.
Among other things that facilitates the ongoing communication between the IPS team and the
VR counselor member of the team. It’s not a black box where an individual is sent and
you get a report at 90 days of what’s going on with the individual. At least at 15, 45,
and 90 days, there will be a clear communication about where things are in terms of the individual’s
progress. Again, because of that higher level of integration, it’s frequently much more
common that communications that’s occurring on an ongoing basis. Alone among types of
cases in Illinois, we pay for ongoing supports post to 90 days. There are two additional
payments in support of the ongoing support principle of IPS services. Again, we tested
this out over two or three years and found that it’s a good investment, that putting
additional money into IPS services has really paid off for us so that our rehabilitation
rates of IPS cases and the individual serves for IPS had been far above the average rate
for a person with disability served by Illinois VR and historically high above the rate of
person with psychiatric disability served by Illinois VR. We’ve also, to enable the
rapid determination, used the IPS guidelines as an opportunity to expand the range of life
and diagnostic providers. Let me illustrate how in terms of all of the features that the
VR counselor and VR system brings the IPS, how that has shown itself in I think a fairly
interesting way. We have 17 soon-to-be 20 new teams starting in Illinois in the past
few months. We did a series of five kickoffs in different parts of the state to introduce
the new team to the more longstanding teams and to allow them to dialogue and begin to
develop ways of working together. In those kickoffs, there were consistent teams that
appeared and one was, in Illinois, staff turnover of community mental health agencies has been
at a crisis level for several years. It’s the case that usually IPS team in our state
are in a constant rebuilding process, that new team members are coming in often the whole
team leave within a short period of each other. Agencies that were represented on these panels
talked about the important role that many of our VR counselors played in helping new
team members to understand more about what IPS is, what is the best practice in applying
IPS to link them with resources and persons in the communities like employers, because
they had those longstanding relationships and longstanding tenure in those communities.
That was repeated over and over again that that stability, that presence of VR was a
tremendous factor in helping these new teams and this new staff of these teams get up to
speed as quickly as possible. Illinois as I think you can see in this slide has decided
that IPS is such a good investment and it’s such a powerful tool for vocational rehabilitation
that we have had a substantial, some might say a dramatic expansion of teams over the
past few years. We’ve also expanded services, began to experiment with using the principles
and practices of IPS in service to other disability groups such as persons with a developmental
disabilities. Also, although we’ve always served, used a transition age youth, working
age youth with mental illness, we’re looking to refine our practice guidelines by focusing
on service to use. We have 11 teams that will specialize in serving persons in that age
range. We’ve also reached out to communities such as those that are the Asian and the Hispanic
communities in the Chicago area, with this stronger foundation to build the collaboration
to have a – we’ve struggled sometimes with making services to those communities
accessible culturally sensitive, but through this foundation and this focus of IPS and
the confidence that that practice builds, we found it’s become easier to build the
collaboration and to give those communities the sense that this is something that again
is they can take a risk with. We’ve used that strengths of the IPS model to among other
things enhance and identify the mentorship opportunities that come with the practices
that’s strong and that’s identifiable. So we’ve began to work to the new members
of the team in the Asian and Hispanic communities as mentors and how to provide culturally competent
services to persons from Asian and Hispanic backgrounds. We’ve also, in turn, the more
senior teams that began to mentor the new teams in how to provide best practice IPS
services. It’s also allowed us to begin to build partnerships with other systems in
Illinois such as developmental disabilities and with the business community. So in summary,
IPS has given us the opportunity and the strength of the practice and the good fit with VR has
given us the opportunity to learn much more about each other and in expanding set of services.
One way we found that’s particularly effective in helping the both new and longer standing
team members and teams to enhance their practice and also VR staff to understand and to enhance
their understanding of how to support IPS teams over the past few years we’ve, with
the permission of the agency, under the IPS fidelity review, we’ve begun to include
observers on those reviews. Through the lens of that 25-item fidelity scale, we’ve enabled
people to take a good look at how a team is practicing IPS and to contrast and compare
to borrow the forms and to adopt the forms that are being used by that team. We’ve
also included members from the VR system and from other systems as observers. We’ve had
universal feedback that this has been a uniquely effective way again to understand what IPS
is, the strength of the practice and how the individuals who are that been the observers
can enhance their practice roles and relative to supporting and providing IPS services.
VR system has a tremendous opportunity to modify regulations to facilitate this incredibly
powerful practice, to better define roles and to develop measurement tools to enhance
VR support in the accountability for IPS services. For example, in Illinois we’re having a
series of discussion about developing as to our web based case management system, a common
chase that would allow the IPS team members and the VR system and VR team members to add
access to a common case where information could be shared and where that it would really
facilitate that rapid decision and shared decision making and the rapid services in
support of helping the individual to achieve the employment and career goals they desire.
So I will stop at this point and turn the floor over to Ann. Ann Williams: Thank you
very much, Gene. Now we’re going to discuss the role of practice guidelines and implementing
IPS because one focus of our webcast series is on the potential application of practiced
guidelines and VR service delivery. I want to turn to our presenters. Do you believe
that practice guidelines will be a helpful tool for VR practitioners and support them
in beeping into finding the application of IPS? If so, what may be the benefits of having
practiced guidelines? Gary, why don’t you start off this conversation from a researcher’s
perspective? Gary Bond: Sure. Well as we have been saying during this webinar, we view the
IPS fidelity scale as a tool that provides a road map for not only the vocational counselors
but for the IPS team to move towards helping people get jobs which is of course the goal
here, the overriding goal of bulk rehab is to help people get jobs. I think that when
Gene described the team approach and that wonderful quote that says that, “In rural
Illinois, the IPS team and the counselors were working so closely together that the
clients didn’t see them as being separate. They saw them as part of the same team.”
That I think captured the spirit of this team approach and so we view the practice guidelines
as being synonymous with the fidelity scale which I should mention. I don’t know if
we’ve said it already but we have studies that show that when you are higher in IPS
fidelity, you can just – Fidelity scale, you get better outcomes. You get better competitive
employment outcome. So that in a nutshell is how I would view the role of the IPS fidelity
scale in providing guidance to all the stakeholders in this process. Ann Williams: Thank you,
Gary. Gene, what’s your perspective? Eugene Oulvey: I would second with Gary said. Again,
the unique advantages of the IPS model, the practices and principles and that again that
incredibly powerful tool of fidelity scale, I have made it easy for us in Illinois to
both have the communication that suggested and expected in the fidelity scale, but also
to enhance our understanding of our role in providing services about the persons with
psychiatric disability and to an increasing range of persons and other disability groups.
So I think practice guidelines and moving toward measurement tools and other sorts of
ways of helping VR to understand our roles and the whole as accountable are indispensable
parts of this practice and this service. Ann Williams: Excellent. How useful are practice
guidelines in helping VR counselors actually implement IPS? Gary and Gene? Eugene Oulvey:
I’ll go first. Our experience in Illinois is that the more guidelines upon which we
can place our confidence we have are the better the job we do, the better the investment of
tax payer dollars and the more people as Gary said, go to work and develop the careers that
they want and that they deserve. We are all in on developing guidelines to help us enhance
our role in this service. Gary Bond: Yes, I will just add that fidelity scale makes
it very concrete what people’s jobs are and how to implement the model. It really
does give a road map that is reduces the ambiguity. Debbie mentioned a couple of the specific
guidelines, the notion that you should start talking to our employers, you start that job
search within a month after coming to an employment program. That’s a very, very powerful guideline
because historically many, many vocational programs have not had that kind of guidelines
and people would spend months and years in pre-vocational activity, so that’s a very
powerful guideline. There’s an expectation that employment specialist may contact with
employers on a regular basis and having a concrete benchmark of six contacts per week.
That’s pretty specific and these kinds of criteria allow people to know if they’re
on track, if they’re doing the model. As I mentioned earlier, when these guidelines
are followed, you get better results. So it is a tool that fits very nicely with the implementation.
Eugene Oulvey: Yes, and just following up on what Gary said, it gives VR counselors
[Crosstalk] a unique monitoring tool that by which they can be assured that the quality
of the services are up to speed. That also has allowed us to better understanding to
find our roles in supporting the employer context, the rapid job search approach and
so forth. Again, what we’ve tried to incorporate into our IPS useful guidelines. Ann Williams:
Excellent. Because of the important role of practice guidelines in supporting VR counselors
and implementing IPS, what should be included in the practice guidelines and who should
be involved in developing these practice guidelines? Gene, would you like to start off? Eugene
Oulvey: Sure. Well, as I indicated, we think that everybody who has a stake in the success
of persons with disabilities getting the jobs they want and the careers they want should
be involved, so that minimum should include persons with disabilities and their family
members. Certainly VR should include partner systems like mental health, developmental
disabilities, work force development and so forth. Employers, I think employers particularly
since there’s a renewed emphasis in the reauthorization of the Rehabilitation Act
both on the youth and on enhancing the understanding of service to employers, I think they should
be involved. We believe that developing good practice guidelines for VR really is a whole
community effort. Gary Bond: I guess I’d like to add another point regarding what the
practice guideline should include. I think there is an advantage to having a fairly concise
list. We struggled a long time in deciding how many items should there be on the list
and 25 is what we came up with. When older scale had fewer items and there were some
gaps in giving people good direction in what to do. In 25, I don’t know if it’s the
ideal number but if the list gets too long, then the guidelines are not very workable
because it feels hopeless to try to do too long the list. The beauty of the fidelity
scale is that when you have one of these fidelity reviews, you can give concrete feedback to
the program saying, which of this area if you’re really doing really well and which
of these areas are things that you need to work on in order to get up the high fidelity?
That’s what we’re struggling for in a practice guideline is something that is concise
but complete in finding that golden mean is the real art. Ann Williams: All right. Gene,
would you like to add anything? Eugene Oulvey: I think Gary said it well. The fidelity scale
again gives VR the ability to both better define our understanding of the practice and
I think to enhance the practice through the contribution that we can provide and having
that specificity that Gary described that concreteness I think is just a tremendous
advantage. Ann Williams: Excellent. This concludes our discussion for today. Thank you very much
to our discussants. We hope that all the people listening to this webcast found this session
to be informative. I want to remind them that today’s event was one of a series of webcasts
on knowledge translation from vocational rehabilitation research to service delivery. Also, we intend
that these webcasts will foster the creation of a community of practice where this dialogue
among researchers, educators, practitioners, policy makers and all other stakeholders can
continue to inform and serve those dedicated to vocational rehabilitation and its goals.
To stimulate more discussion, we invite listeners to contact us to provide your input on today’s
webcast, to share your thoughts on future webcast topics and to participate in the community
of practice to continue this dialogue. We would like to hear from you because your views
can inform and shape our future work. You can contact us at the e-mail address shown
on the screen which is [email protected] We would appreciate your input about the webcast
by completing a brief evaluation which we’ll be sending to you. The link is here on the
last page of the PowerPoint file and everyone who registers will also receive it in an e-mail.
Once again, I would like to thank Cindy Cai and her colleagues at AIR from all of the
staff here at KTDRR. We also appreciate the support from NIDRR to carry out this webcast
and other activities. On this final note, I’d like to conclude this webcast and we
look forward to your participation in our next event.

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