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Enhancing employment outcomes for individuals with serious and persistent mental illnesses.

In an attempt to improve services to people with serious and persistent mental illnesses, we examined the role of the mental health rehabilitation facility and its relationship with Missouri Division of Vocational Rehabilitation (DVR). We noted that a substantial number of our participants who achieved employment had indeed been former vocational rehabilitation (VR) consumers but that the VR effort was often not properly acknowledged. This occurred frequently because, in many instances, the individual's case had been closed prior to the achievement of employment. The other side of this coin is that a significant number of VR consumers with serious and persistent mental illnesses for whom competitive work was the expected outcome failed to achieve it within the VR contract time period.

Since the Indepence Center in St. Louis opened in 1981, its members and staff have sought ways to promote employment and simplify the path for those who seek it. Many of us have suspected that systemic changes as well as individual program improvements would be needed to positively influence the achievement of employment.

With respect to program improvements, the center structured its services so that access to employment was an integral part of the milieu. Paid work experiences in regular places of businesses were made easily accessible for participants through an expanded transitional employment program. A significant detour from traditional vocational program design was taken by assuming that the participants willingness to try to work is the best indicator of readiness to work. This assumption, and the others outlined in the conceptual frame below, have far-reaching programmatic consequences. They affect daily programming and, more importantly, the relationships between the staff and the people served.

In addition, a substantial program improvement was made through a grant from the Missouri DVR, through which additional job development staff were hired to locate and capture job opportunities.

With respect to systemic concerns, we made certain assumptions about the people with whom we worked and the state-federal VR program system. Some individuals with long-term mental illnesses have special needs that complicate and frustrate the VR referral process. The ongoing and often volatile and labile nature of chronic mental illnesses requires, we posited, a special system that responds quickly to rehabilitation opportunities. The VR system, in contrast, is perceived by many consumers as cumbersome and/or unresponsive. This perception is, we believe, the result of dissonance between the system structure and the special needs of the target population.

The current VR system reimburses community rehabilitation programs on a person-by-person, fee-for-service basis. When a person with disability is authorized to attend a facility, the facility is paid only when that person attends and only as progress toward goals is positive. During the assessment (vocational evaluation) phase, the facility is paid to render a judgement about the participant's current and future needs. That judgement determines, in part, which, if any, services are to be provided.

Why question this system? As we have already noted, many competitively employed VR consumers do not pass the evaluation or drop out or otherwise fail to achieve employment within the VR contract period.

VR services are time limited and structured accordingly. The VR consumer must make use of and be able to benefit from the services purchased on his or her behalf within the contractual or extended contractual timeframe. Yet, the field's ability to accurately predict both if and when a person with this disability will benefit from vocational services appears to be problematic. For the most part, the field has attempted to resolve the problem by seeking ways to improve the professional's ability to predict the future more accurately. There are underlying assumptions to this structure: that each consumer's course is linear and that, for the employment-ready consumer, there is little fluctuation in the individual's level of functioning. These assumptions deserve investigation. If, in fact, the journey towards employment is not linear, but is better depicted as a sine wave-like line that gradually climbs the vertical axis and if, in fact, the level of functioning of consumers follows a similar pattern, then the programs we offer and the structure of the VR system that supports these programs can and should be examined.

An alternative demonstration was undertaken to examine what happens if a community rehabilitation program is compensated on a level of service (LOS) basis rather than on a consumer-by-consumer basis. A level of service system requires the provider to serve a minimum number of eligible individuals for a flat, annual fee. A provider serving more persons with disability than the minimum does so at its own expense, but can use the number served to request a higher level the following year (along with an increase in annual flat fee). Such a system would make it unnecessary to predict both if and when a particular person will benefit from VR services. Rather, it is based on predicting the future behavior of a group of consumers. Such a system would:

* enable the facility to provide services that better match the needs of a group of consumers,

* reduce the staff time spent in formulating predictions for individuals (and, therefore, increase rehabilitation time),

* permit a more accurate assessment over time, and

* permit participation by a broader range of persons with more severe disabilities.

Further, while time-limited vocational services would be provided to the group, individuals in the group should benefit from a more forgiving timeframe with cost saving benefits to VR. In order to justify this approach, VR must have a valid expectation of a predetermined minimum number of people with severe disabilities to be served, a minimum number of consumers with successful employment outcomes, and a predetermined, average cost per person.

A project was undertaken to determine if a level of service approach (concurrent with a psychosocial rehabilitation program support base) would enable the achievement of successful employment outcomes by individuals who had, heretofore, not been able to go to or sustain work.

Conceptual Frame

This project has three major suppositions upon which it is based.

1. That there is a window of opportunity for each person with a disability during which VR services will be most useful and effective.

As described above, the field's ability to predict when the window will be open is questionable. The flexibility and rapid response needed to offer appropriate vocational services when they will be most effective may be best achieved by designing services for groups of consumers. Individuals within the group will be able to take advantage of the services as their own individual situations warrant.

2. That the journey to employment is more successful with a series of "little steps."

By building a service system with a gradual rather than a "graduation" philosophy, more people are afforded the opportunity to experience work as a natural and integral part of their rehabilitation course. Feelings of competence and self-confidence can be obtained without the concomitant fear of failure from which so many persons with disabilities shrink.

3. That human progress is linear only from a distant perspective and that the rehabilitation course must permit intermittent lateral and circular moves for some consumers.

This belief is, perhaps, singularly important in understanding the intent of this project. It lies at the heart of the traditional friction between the worlds of vocational rehabilitation and mental health. Many mental health professionals view the VR system as rigid and inflexible. Many VR professionals cannot understand why mental health professionals view the VR system as rigid and inflexible. services that are not vocational. Providing services on a level of service basis should allow maximum flexibility to the individual's rehabilitation course, while, at the same time, assuring VR that employment is the outcome for which it is paying. Under such a system, a facility's LOS agreement would be adjusted periodically based on performance. That is, a facility that failed to demonstrate that it met the expected level of service to persons with severe disabilities and/or failed to achieve the requisite number of successful employment outcomes would have its financial contract reduced for the next period.

Such a system might also provide an incentive to community rehabilitation programs to increase the number of people with severe disabilities it serves.

The project's objectives are to:

* serve a minimum of 300 people severely disabled by psychiatric illnesses in a 3-year period,

* achieve successful employment outcomes for a minimum of 150 people,

* document the course of each project participant,

* demonstrate the rehabilitation efficacy of the level of service approach, and

* analyze the cost benefit of the level of service approach.

For purposes of this project, applicants at Independence Center who are willing to try to go to work are selected as participants. Each person's VR history is determined (i.e., never a consumer former consumer, etc.).

Project Results

The results of the first year's experience are presented in the tables accompanying this article. No final conclusions should be drawn, however, until a complete analysis is made. It is hoped that the data will be examined critically by wary and skeptical people.

Table I describes the categories and VR [status.sub.1] of persons served and their employment outcomes. Table ll presents the likely VR status under the existing fee-for-service system of the people served and their employment outcomes. Table Ill shows the estimated number of months in which VR services would have been consumed. (The numbers are estimates because there is no way of knowing with certainty if a VR counselor would have contracted for services for all available months.) Table IV estimates VR costs under the existing fee-for-service system for work adjustment evaluation (WAE). Table V describes the probable cost under the existing system for providing supported employment (SE) services. All clients with 4 weeks or more of project time available are assumed to have had a WAE. Only clients who have been placed for @ weeks or more are assumed to be funded for SE.

Table 4. VR Cost Estimates Under the Existing Fee-For Service
System for Work Adjustment Evaluation (WAE)

(The grantee's WAE is $395 for a 4-week period.)

Participants Status Cost

52 06 20,540
27 18 10,665
12 20 4,740
13 22 5,135
23 24 9,085
34 08 13,430
 9 28 3,555
41 26 16,195
TOTAL 211 $83,345


 The 211 participants who had 4 weeks available for WAE would have
cost the VR agency $83,345 under the fee-for-service system, had
they all been
accepted by VR.


Although only I year of data are available, it appears likely that statistically significant outcomes will be documented. A level of service funding approach may merit further investigation and testing. There are serious concerns, however, about such an approach. The facility and the VR agency must be able to agree upon reasonable and challenging goals. In comparing facility programs one against another, weightings for severity of disability must be established.

Finally, a careful look at the project suggests that the role of the VR counselor may require re-evaluation. Because the rehabilitation facilities will be assuming some of the roles previously played by the VR counselor, the counselor is free to invent and discover new roles. The author has believed for some time that many rehabilitation facilities across the country would benefit from knowledgeable VR consultants who would:

* monitor levels and quality of service vice;

* consult on the Americans with Disabilities Act and other regulatory issues;

* assist small facilities with budgeting and fiscal reports

* suggest program modifications if employment or other targets are not met;

* become principle advocates for persons with disabilities; and

* become a resource for facility management.

These are only a few of the new roles VR counselors might assume. If these thoughts have merit, the curriculum for training of rehabilitation counselors in the future will require modification and expansion.

The author wishes to acknowledge the efforts of Timothy G. Lalk, MA, who compiled the data, and Sara Asmussen, Ph.D., who made it comprehensible.


l. Status classifications in the rehabilitation caseload system, coded in even numbers, signify progress and decisions points in the VR process. The caseload statuses, if fully applied, are as follows:

Status 02 - Applicant: As soon as an individual signs a document requesting VR services, he or she is placed into Status 02, and is designated as an applicant. While in Status 02, sufficient information is developed to make a determination of eligibility (Status 10) or ineligibility (Status 08) for VR services, or a decision is made to place the individual in extended evaluation (Status 06) prior to making this determination.

Status 06 - Extended evaluation: An applicant is placed into this status when a rehabilitation counselor certifies the need to provide certain services to help in determining whether the individual can benefit from the full range of rehabilitation services in terms of an employment outcome. Applicants leaving this status will be moved to Status 10 (eligible for VR, services will begin without delay) or closed from Status 08 (not eligible/not accepted for VR) within the 18-month period allowed to complete the eligibility determination.

Status 08 - Closed not accepted/ineligible for VR: This status is used to identify persons determined ineligible or who are otherwise not accepted for VR services, whether closed from the applicant status (Status 02) or extended evaluation (Status 06).

Status 10 -lndividualized Written Rehabilitation Program (IWRP) development: While in this status, an assessment of the rehabilitation needs of the individual is completed to provide a basis for the formulation of the RM. The individual remains in this status until the rehabilitation program is written and approved.

Status 12 - IWRP completed: After the IWRP has been written and approved, the applicant is placed into Status 12 until services have been actually initiated.

Status 14 - Counseling and guidance only: This status is used for those individuals having an approved program which outlines counseling, guidance, and placement as the only services required to prepare the individual for employment.

Status 16 - Physical or mental restoration: Individuals receiving any physical or mental restoration services (e.g., surgery, psychiatric treatment, fitted with an artificial appliance) are placed into this status until services are completed or terminated.

Status 18 - Training: This status is used to identify persons who are receiving academic, business, vocational, on-the-job, or personal and vocational adjustment training.

Status 20 - Ready for employment: A case is placed into this status when the individual has completed preparation for employment and is ready to accept a job, or has been placed into, but has not yet begun, employment.

Status 22 - In employment: When an individual has been prepared for, placed in, and begun employment, his or her case is placed into Status 22. The person must be observed in this status for a minimum of 60 days before the case can be closed rehabilitated (Status 26).

Status 24 - Service interrupted: A case is placed in this status if services are interrupted while the individual is in Status 14, 16, 18, 20, or 22.

Status 26 - Rehabilitated: Cases closed as rehabilitated must, as a minimum, (1) have been declared eligible for services, (2) have received appropriate diagnostic and related services, (3) have had a program for VR services formulated, (4) have completed the program, (5) have been provided counseling, and (6) have been determined to be suitably employed for a minimum of 60 days.

Status 28 - Closed for other reasons after an IWRP is initiated: Cases closed into this category from Statuses 14 through 24 must have met criteria (1), (2), and (3) of Status 26 (above); and at least one of the services provided for by the IWRP must have been initiated, but, for some reason, one or more of criteria and (6) in Status 26 were not met.

Status 30 - Closed other reasons before IWRP initiated: Cases placed into Status 30 are those which, although accepted for VR services, did not progress to the point that rehabilitation services were actually initiated under a rehabilitation plan (closures from Statuses 10 and 12).
COPYRIGHT 1994 U.S. Rehabilitation Services Administration
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1994, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

Article Details
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Author:Harvey, Robert B.
Publication:American Rehabilitation
Date:Jun 22, 1994
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