Community Rehabilitation and Treatment (CRT) and 2 more...less...

CRT Employment

Mental Health CRT Community Support Services (16)

% of working age CRT clients who are employed

22%SFY 2020

Line Bar Comparison
Story Behind the Curve

Successful employment is the most powerful catalyst for recovery and change, especially for individuals living with a mental illness.[1] Working helps further recovery more than any other single intervention – more than therapy, case management or medication alone. Research also demonstrates that unemployment is extremely bad for one’s overall health.[2]  However, returning to work after unemployment improves health by as much as unemployment damages it.[3]

People do want to work; 60-70% of individuals receiving public mental health services nationwide desire competitive employment, yet only 10-15% find employment.[4] [5]  Extensive and rigorous research (25 randomized controlled trials) demonstrates that the Individual Placement and Support (IPS) practice is the most effective approach for helping people with mental illness obtain competitive employment of their choice.[6] When offered with high-fidelity, IPS supported employment services help 50-60% of job seekers achieve employment, higher wages, and job longevity.

Nationally, less than 2 percent of adults living with mental illness receive access to IPS supported employment services.[7] Vermont currently provides IPS services to 15% of CRT enrollees and of those individuals, 52% find and/or successfully maintain employment.

Vermont was the first state to implement IPS statewide and witnessed its access to IPS supported employment increase from 0% in FY1999 to 24% in 2005. At that time, Vermont stood out for its high employment rate. Due to the commitment of Vocational Rehabilitation and DMH leadership to increase 

the focus on supported employment statewide, Vermont witnessed close to a 200% increase in CRT employment rates (from 16% in FY1999 to 30% in FY2001). Vermont maintained these higher rates until 2005 when a slow, gradual decline began. The recession in 2008 exacerbated the decline. Since FY12 the employment rate has remained steady at 22%. The access rate to supported employment services also remained steady until FY2015 when it began to decline to 15% in FY17.

Part of the reason for the decline in access to supported employment services is the decrease in supported employment staff at the community mental health centers. In FY2015, Vocational Rehabilitation ended its 30+ years of supported employment grant-funding to the CRT programs due to federal funding cuts. CRT programs came to rely on VR funding to hire supported employment staff.

How has the CRT employment rate remained the same over the last several years despite a decrease in access to IPS supported employment services? One reason is the IPS services have increased in quality; of those with access to IPS services the employment success rate has increased from 47% in FY14 to 52% in FY17. People are maintaining their jobs longer and/or developing careers with support. The community mental health centers have remained committed to providing IPS services with its existing flexible case rate funding. Lastly, some mental health centers have begun to hire more staff with lived experience of mental health challenges to work as peer support staff or in other agency positions.

One potential reason for the decreased employment rate from 30% to the current 22% over the years is that several individuals who were working experienced an increased level of independence and recovery and no longer chose to receive CRT services. A reduced target rate may be another reason. The employment target rate was set at 35% in FY2012 based on past performance history. In FY2015, the state reduced the target rate to “maintain or improve current employment rate” due to providers’ requests as part of Master Grant negotiations.

Measuring access to supported employment, monitoring fidelity to the IPS practice, and tracking the employment rate of people enrolled in CRT all contribute to Vermont’s knowledge of who is better off.

 

[1] IPS Employment Center: Evidence for IPS (2018). Retrieved on 5/30/18 from https://ipsworks.org/index.php/evidence-for-ips/

[2] Mathers, C. and Schofield, D. (1998).  The health consequences of unemployment: The evidence. Medical Journal of Australia, 168 (4) 178–82.

   Libby, A. M., V. Ghushchyan, et al. (2010). Economic Grand Rounds: Psychological Distress and Depression Associated with Job Loss and Gain; the Social Costs of Job Instability.  Psychiatric Services 61(12): 1178-1180.

   Dance, A. (2011).  The unemployment crisis. American Psychological Association Monitor, 42(3).

   Warr, P. (1987). Work, unemployment, and mental health. Oxford: Oxford University Press.

[3] Schuring, M., Mackenback, J., Voorham, T., Burdorf, A. (2011). The effect of re-employment on perceived health. Journal of Epidemiology and Community Health, 65(7), 639-644.

  Waddell, G. & Burton, K. (2006).  Is work good for your health and wellbeing? The Stationary Office, Norwich, England.

[4] McQuilken, M., Zahniser, J.H., Novak, J., Starks, R.D., Olmos, A., & Bond, G.R. (2003). The Work Project Survey: Consumer perspectives on work. Journal of Vocational Rehabilitation, 18(1), 59-68.

[5]  Mental Illness: NAMI Report Deplores 80 Percent Unemployment Rate (2014). Retrieved on 5/30/18 from https://www.nami.org/Press-Media/Press-Releases/2014/Mental-Illness-NAMI-Report-Deplores-80-Percent-Une

[6] Marshall, T., Goldberg, R.W., Braude, L., Dougherty, R.H., Daniels, A.S., Ghose, S.S., et al. (2014). Supported employment: Assessing the evidence. Psychiatric Services, 65, 16-23.

[7] Bruns, E.J., Kerns, S.E., Pullmann, M.D., Hensley, S.W., Lutterman, T., & Hoagwood, K.E., (2016). Research, data, and evidence-based treatment use in state behavioral health systems, 2001-2012. Psychiatric Services, 67(5), 496-503.

 

Partners

DMH partners with the Community Rehabilitation and Treatment (CRT) programs and Pathways-Vermont, Vocational Rehabilitation (VR), VCPI, NAMI-VT, and the IPS International Learning Collaborative to achieve higher employment rates. DMH expects each CRT program to offer IPS supported employment services and offers free fidelity monitoring and technical assistance to achieve good fidelity to the practice. As part of good fidelity, each CRT program should have at least two full-time employment specialists focused entirely on IPS services. (Currently, each program has at least one employment specialist on its treatment team and four programs have at least two employment specialists.) Collaboration with VR is a core element of IPS services. Most CRT programs engage in coordinated supports with the local VR office to benefit the job seeker while DMH and VR collaborate at the state level. Six of the ten CRT programs submit quarterly employment data to the IPS International Learning Collaborative and DMH works closely with the IPS collaborative to increase its expertise around technical assistance.

What Works

Research indicates that programs with high adherence, or fidelity, to the evidence-based practice of IPS have higher employment rates[1]. DMH provides technical assistance, training, and program fidelity monitoring to help improve fidelity to the practice. The partnerships with the CRT programs, state and local stakeholders, and continuous quality improvement activities lead to more people achieving employment.

[1]Kim, S.J., Bond, G.R., Becker, D.R., Swanson, S.J., & Langfitt-Reese, S. (2015) Predictive validity of the Individual Placement and Support fidelity scale (IPS-25): A replication study. Journal of Vocational Rehabilitation 43, 209–216. 

Action Plan

DMH will continue to work closely with the CRT programs and their employment specialists to provide technical assistance, training, and oversight as needed and/or as requested. DMH will continue to conduct fidelity reviews biennially at each designated agency. DMH will continue to meet bi-monthly with Vocational Rehabilitation and monthly with the International IPS Learning Collaborative. Data will be collected for each agency and reviewed regularly on fidelity ratings, access to supported employment services, and employment rates for both the CRT program level and the employment program level. DMH will examine existing policies to determine if any need to be addressed to improve the  quantity and quality of employment services.

Notes on Methodology

This report is based on record linkage of the Vermont Department of Mental Health (DMH) and Department of Labor (DOL) databases. DMH client data are submitted by Community Programs in conformance with contractual requirements. DOL data are submitted by employers in conformance with state and federal laws. Workers who are excluded from DOL reporting are the self-employed, firm owners not incorporated and the following employee groups: elected officials, employees of nonprofit religious, charitable and educational organizations, unpaid family members, farm workers (with some exceptions), railroad employees, and individuals employed in neighboring states.

Numbers include Community Rehabilitation and Treatment (CRT) clients aged 18 - 64 who were active during each reporting year and includes all employment reported for each year.

Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy