REPORT ON THE ROLE OF SUPPORTED EMPLOYMENT AND CLUBHOUSES IN CREATING VOCATIONAL PATHWAYS FOR PEOPLE IN RECOVERY

A Project of the North Central Regional Mental Health Board

Site Visits Conducted May 2013 – May 2014

Respectfully Submitted Marcia DuFore, Executive Director Quyen Truong, Review & Evaluation Staff Susan Coogan, Review & Evaluation Chair

North Central Regional Mental Health Board 367 Russell Road Newington CT 06111 860-667-6388 Final Report – September 2014

Report on the Role of Supported Employment and Clubhouses in Creating Vocational Pathways for People in Recovery North Central Regional Mental Health Board September 19, 2014

TABLE OF CONTENTS

Section

Page Number

I.

Executive Summary……………………………………………..……2

II.

Overall Recommendations.…………….………………………..…..4

III.

Methods of Collecting Data..……………………..……..………..….8

IV.

CAC 15 – CHR Work Source & We Can…………………...……...10

V.

CAC 16 – InterCommunity & Common Ground…………………...20

VI.

CAC 17 – CHR Enfield & Second Wind……………………….…...32

VII.

CAC 18 – Chrysalis & Phoenix Club………………………………..42

VIII.

CAC 19 – CMHA & Team Time……………………………………..45

IX.

CAC 23………….…………………………………………….…….....55 a. Easter Seals, Choices II, EARN…………………………………55 b. Recovery and Empowerment Center (REC)…………………...58 c. CMRHC’s Peer Support and Recovery Resource Center……59

X.

Town Personnel Comments…………………………………………61

XI.

Other Models of Supported Employment……………………….….63

XII.

Appendices…………………………………………………………….66

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Report on the Role of Supported Employment and Clubhouses in Creating Vocational Pathways for People in Recovery North Central Regional Mental Health Board August 15, 2014 Members of North Central Regional Mental Health Board wish to thank its six Catchment Area Councils, the Local Mental Health Authorities (LMHAs) in Region IV, agencies providing clubhouse and resource center services, their staff, and persons in recovery who participated in the discussions held during this review. We hope that all the participants see this report as their opportunity to convey to the Department of Mental Health and Addiction Services their perceptions and recommendations.

I. Executive Summary In FY 2013-14, the North Central Regional Mental Health Board (NCRMHB) conducted a review of DMHAS funded Supported Employment (SE) and clubhouse vocational programming in Region IV to achieve the following objectives: 1. Understand the particular Supported Employment models and vocational programming currently available in the region 2. Document how each program has implemented Supported Employment principles and practices; and 3. Assess the effectiveness of clubhouses and SE programs in creating vocational pathways for people in recovery. To do this work, NCRMHB coordinated efforts with the Connecticut Department of Mental Health and Addiction Services (DMHAS) in a series of fidelity reviews with agencies in Region IV that offer Supported Employment programs. Additional site visits were scheduled at psychosocial rehabilitation programs (Clubhouses) operated by those same agencies. Finally, NCRMHB facilitated Catchment Area Council (CAC) discussions in order to gain a full picture of how Supported Employment and vocational programs in clubhouses impact Region IV. We looked at the role they play in helping people in recovery attain the confidence, skills, and ability to obtain and retain jobs, and the challenges and obstacles they faced. In our review of Supported Employment programs, we found the relationship between Supported Employment and the local Clubhouses to be an important area of study and found an interesting range of connections between those programs. While all of our Clubhouse Reviews were conducted by our Review and Evaluation team, the SE Reviews were done in conjunction with DMHAS reviewers, using the Dartmouth model and evaluation tools. 2

DMHAS Supported Employment contracts are similar to, but distinct from the Dartmouth model of Individual Placement and Support (IPS). We want to note that our SE programs were diligent about compliance with their DMHAS contract, but also separately with the Dartmouth IPS model. The nimbleness of juggling both DMHAS and IPS requirements highlighted the agility and strength of our Region’s SE programs. All of our Region IV SE programs scored well within the range of “Good Fidelity” on the Dartmouth IPS scale. This means that even though each organization’s scores varied a little, Region IV’s SE programs are all projected to have “Good Outcomes.” This is a big accomplishment and something to take pride in because “Good Fidelity” scores are not consistent statewide. We want to be clear that we neither subscribe to nor object to the Dartmouth IPS model as the best way to help individuals attain paid employment in the community. The Dartmouth evaluations offer a specific lens through which we can understand each SE Program’s success, but they do not provide the full picture of how helpful a program can be to people in recovery in our communities. The Dartmouth model offers specific guidelines to create effective and efficient SE programs, but currently those programs only reach 8% of the total DMHAS population in Connecticut. While this number is remarkable in light of the nation average, which is 2%,1 nonetheless, the limits of the IPS model are something to consider as we examine the worth of clubhouses and their role in people’s recovery efforts through meaningful opportunities. This report focuses on issues that arose from site visits and interviewing administration, staff, and persons in recovery with each of the organizations listed below throughout FY 2013-14:    

Catchment Area Council 15: o Community Health Resources (CHR): Work Source (SE) & We Can Clubhouse Catchment Area Council 16: o InterCommunity (SE) & Common Ground Clubhouse Catchment Area Council 17: o CHR-Enfield (SE) & Second Wind Clubhouse Catchment Area Council 18: o Chrysalis Center (SE) & Recovery Empowerment Center (REC) Clubhouse & Phoenix Club

“Only 2.1% of people with severe mental illness in the U.S. public mental health system received supported employment in 2009.” (SAMHSA. http://www.samhsa.gov/dataoutcomes/urs/urs2009.aspx, 2009) 1

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 

Catchment Area Council 19: o Community Mental Health Affiliates (CMHA – SE) & Team Time Clubhouse Catchment Area Council 23: o Capital Region Mental Health Center (CRMHC – Choices II, EARN, Easter Seals SE programs), Chrysalis Center’s REC & CRMHC – Peer Support and Recovery Resource Center

A total of 12 NCRMHB volunteers participated in the reviews as interviewers. Review teams were comprised of NCRMHB staff, NCRMHB Review and Evaluation Committee members, and CAC members that included persons in recovery, family members, provider members, and concerned citizens. Review teams also collaborated with and supported DMHAS staff during their fidelity reviews. What follows are 1) major recommendations based on observations and findings over all of the SE and Clubhouse programs; 2) a description of our methods of collecting information, and 3) a description of each organization’s activities and accomplishments, our findings, and recommendations specific to that organization. This level of detail is offered so that our findings, along with those from the DMHAS fidelity reviews, can be further discussed, researched, and/or acted upon. Broad overviews of each Supported Employment and clubhouse program are offered first. Then we share Review Team Findings, which are mostly organized by strengths, issues to consider, and recommendations. We hope that our review efforts will stimulate further discussion among the region’s Supported Employment programs, the agencies that provide vocational supports services, DMHAS, and our various community partners, so that systemwide and cross sector improvements can be made to broaden the impact and increase the effectiveness of Supported Employment programs in our region.

OVERALL RECOMMENDATIONS Recommendation #1: Increase Collaboration between Region IV Clubhouses & Supported Employment Programs Outreach to people who might benefit from Supported Employment services is greatly enhanced when a strong collaborative relationship exists between Supported Employment and Clubhouse programs. Our review team observed that Employment Specialists who were embedded in the clubhouse’s daily activities as program leaders, facilitators, or mentors were able to establish relationships and create buy-in from clubhouse members, thus influencing people to work towards committing to employment as part of their recovery efforts.

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Recommendation #2: Develop Employer Relationships and Job Opportunities that Respond to Diverse Needs Each clubhouse and Supported Employment Program must respond to the diverse needs of members in its specific catchment area. Although this was an important component of fidelity reviews, many Supported Employment programs did not offer sufficient diversity in the types of jobs developed in response to the unique skills, interests, and abilities of people seeking employment. Different people in recovery need different kinds of challenges and supports in seeking employment. Having a variety of job offerings can help people feel that employment is worthwhile and for them. Several people we interviewed expressed concern that their educational background and skills were discounted in favor of entry-level employment – as if that was all they were capable of as a person with mental illness. Recommendation #3: Enhance Skill Building and Training Opportunities in Clubhouse and Supported Employment Programs Ensure that adequate support for structured employment skills development within the clubhouse and educational pursuits outside the DMHAS system are encouraged and available. Seek out resources for childcare and/or transportation so that parents can seek careers rather than settle for dead-end part-time jobs. Invite speakers from HUD, Social Security, and the EPIC education program, as well as benefits counselors. Make use of Connect-Ability training via the EPIC program. Develop a more structured approach to teaching skills – use curriculum, tools, role plays, and “take-aways.” Identify more opportunities for members to take on the duties of running and maintaining the clubhouse. Train staff to approach individuals (one-on-one) about personal, educational, and professional goals; to explore this topic in depth; and to check in on club members regularly. Recommendation #4: Offer Alternative Models to Earn a Living People we interviewed did not believe that any of the agencies included in this review would hire them for a job. Part of the problem is there are limited openings at these agencies for job seekers. The IPS model is also limiting, and supporting efforts to volunteer, intern, start an enterprise, or work in transitional employment offers additional options. Alternatives for people who haven’t been well supported in traditional jobs will open more opportunities and, as described by one clubhouse director, “build up work muscle.” In particular, entrepreneurial work seems an appropriate venue for some people. Entrepreneurial work not only allows people to determine their own work schedules, it can help people identify their strengths and focus on developing skills for the economy that makes sense for them. While difficulties exist for small entrepreneurs, connecting people with internships, apprenticeships, or mentors who provide models for entrepreneurial work can inspire people in recovery. Pursuing pilot program funding will be important for this work to transpire, as will fostering appropriate partnerships.

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Recommendation #5: Education at the Community Level Educate the broader public on mental health and addiction issues. Educate employers. Create a community where people in recovery can be welcomed to live and work via advocacy and education efforts. Connecting with the towns to enhance awareness of SE programs is important to their sustainability. When NCRMHB reached out to this region’s Social Services directors to inquire whether they knew about SE services, the numbers indicated that more outreach and marketing efforts must be made. Of 11 towns that responded, five towns or 45% of the sample had no knowledge of SE services in the region. In terms of outreach, one SE program reached out to 3 towns last year, while the rest of the towns had no contact or nominal contact from years ago. Only 30% of towns were contacted to encourage SE referrals. CHR was scheduled to come to Manchester, but the staff said it’s an “intimidating organization to access.” To increase the 8% reach of the SE programs, we must involve towns in the process of engaging people in recovery. Recommendation #6: Encourage Referrals to Benefits Counselors Be sensitive to the limits of Employment Specialist (ES)s’ knowledge about benefits. Facilitate opportunities for ES to make appropriate referrals to BRStrained benefits counselors. Provide ongoing training for Community Support staff, ES, and BRS to share information and resources on benefits issues that present barriers to employment, in order to improve referral pathways. Recommendation #7: Strengthen Relationship with BRS Vocational Services: Multiple agencies admitted that their relationship with BRS Vocational Services was weak. Efforts from both sides must be made to strengthen this relationship, which will open additional opportunities for people seeking job opportunities. Recommendation #8: Focus on Job Development in a Different Way All of the Supported Employment programs should continue to examine how they can increase regional community involvement and leverage community partnerships to develop multifaceted job leads. DMHAS offers job development training on a program by program basis. Additionally the DMHAS Education and Training Division offers courses at CVH to address job development skills and employment strategies for clients with co-occurring disorders, and strategies to work with clients with criminal records. Nonetheless, to push back on the Dartmouth IPS model, we propose a different way to consider job development. Instead of individually developing jobs for clients, another strategy is to allocate that responsibility to one experienced job developer, or to a small team of dedicated job developers. Employment Specialists may be excellent at helping people gain confidence, create resumes, and acquire job skills, but those skills do not always translate to

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being good job developers. Each SE specialist approaches job development with different levels of understanding and knowledge about how to effectively pursue job leads. If ES could focus on developing people’s skills and confidence, then Job Developers could find employment for those people. Job Developers can focus on building business relationships, marketing the SE programs to local employers, and coordinating job opportunity offerings for SE specialists. Recommendation #9: Address Supported Employment needs in all Region IV Catchment areas. Ensure that there’s a balance of services for West Hartford and the Farmington Valley. Currently, Easter Seals is the only Supported Employment program serving people in CAC 18, but it is located in East Hartford and serves people from CAC 23 as well. Easter Seals has limited capacity to conduct outreach or increase service availability in the area. (For more information on this issue please refer to the sections for CAC 18 and 23 on pages 37 and 49) Recommendation #10: Consider Ways to Acknowledge and Support Innovative Supported Employment Models Programs require more resources to do their work. Some SE programs choose to create innovative programming in order to fit their communities’ needs. Unfortunately, they lose points on the IPS fidelity scoring because extra programming occupies SE staff time in activities that are not part of the IPS model. In this way, the IPS model constrains the flexibility of SE programs to respond to the diverse needs of their community. Alternatives for people outside the SE Program are enriching, and deserve more credit. Some programs see a need to foster vocational skill development and prefer to focus on long-term career opportunities rather than try to attain shortterm jobs to score high employment numbers for the quarter. Some programs recognize that employers will not hire people with an inconsistent work history, and choose to offer skills training, transitional employment and opportunities for people to become entrepreneurs. However, lack of staff can mean that ES often wear multiple hats in an agency, and this can negatively affect SE programs’ scores, which may impact their funding and credibility. We need to support those programs by acknowledging the value of offering alternatives. It is important to understand and appreciate these programs’ impact within the larger context of regional economic development. Recommendation #11: Enhance Opportunities for People to Celebrate Work Stories Staff and agency leadership should be involved as much as possible in helping people share and celebrate their work stories. Prominently displayed written postings about supported employment in the lobby and other offices, where outcomes of competitive employment rates are shared at least quarterly, would contribute to an environment where employment is highly valued and encouraged. Pizza nights and field trips like camping trips or amusement parks

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would help people celebrate successes and incentivize them to work towards their goals, as well as give them social opportunities to share their triumphs. Newsletters and sharing on social media are other places to highlight people’s successes. CONCLUSION This report aims to provide an opportunity for a rich exchange of ideas among Supported Employment and clubhouse leaders. Throughout the review and evaluation process, all the Supported Employment programs and clubhouses provided evidence of thoughtful vocational activities, continuing efforts to improve programs, and a committed dedication to support recovery via vocational supports. We see this report as a snapshot of our Region’s activities, and want to note that some of our findings may be outdated, due to the long duration of this review. The review team is excited that our report has already had an impact as we are aware of changes and improvements have occurred since our visits that are not reflected in the body of this report. These will be shared with their respective Catchment Area Councils (CACs) for follow-up in the coming year.

PROVIDER RESPONSES One SE Supervisor pointed out that fidelity standards and the DMHAS contract have different requirements. The supervisor wants to understand why the two are not aligned. Another issue to consider is that the fidelity model encourages integrated teams. However, if the priority is to have integrated teams, then the vocational teams are not together. This can be a challenge when it comes to job development, problem solving, or trouble-shooting together. In CAC 19, the SE Supervisor found that vocational team meetings were immensely productive, educational, and generative.

II. Methods of Collecting Information To evaluate Supported Employment programs, R & E members participated with DMHAS in Supported Employment Fidelity reviews using the Supported Employment Fidelity Scale. The scale is used to rate the organization’s fidelity to the Individual Placement and Support (IPS) model in the areas of staffing, organization, and services. Scoring is drawn from individual questions which rate the organization on a 5-point Likert scale, ranging from 1 = no implementation to 5 = full implementation. Reviewers also supplemented the scoring with notes and recommendations. For the purposes of this report, we will focus on drawing from

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these notes to articulate a vision of how each Supported Employment program achieved its outcomes. To evaluate Clubhouses, the review teams attended morning and program meetings and interviewed clubhouse members, staff, and directors. The notes drawn from these loosely structured visits inform the analysis of clubhouses for the sections that follow and help us highlight some best practices. To gain a perspective about the effectiveness of each SE program’s outreach into its respective communities, we conducted surveys and interviews with Social Services staff in each of the Region IV Catchment areas. We were surprised to learn that very few social services staff from the towns were aware of or made referrals to the Local Mental Health providers for services like Supported Employment services. While it is important to note that a person must be using DMHAS services in order to access SE programs, it also points to why the penetration rate (8%) for SE services is so low across Connecticut. This speaks to a need for more outreach from Supported Employment programs to share information about their services with the community. The report is organized by Catchment Area Councils (CACs) and then subdivided into Supported Employment programs and Clubhouses. We share perspectives of CAC members, clubhouse members, staff, directors, and reviewers.

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CAC 15 I.

Supported Employment Program – Community Health Resources (CHR) “Work Source”:

CAC 15’s Supported Employment program is CHR/Work Source. The program served 87 people with 4 Employment Specialists in the April – June 2014 quarter. This equated to about 22 people per caseload. Work Source reported 53% of people employed during this time, the highest in the region. Moreover, they reported 17% who successfully transitioned off their Supported Employment caseload – another highest percentage in the region.

STRENGTHS: In terms of SE fidelity, Work Source met fidelity across many of the standards. Among their strengths, the organization kept to a limit of 20 people per caseload, which allowed them to provide good individual attention and comprehensive services to each. Reviewers received glowing remarks regarding the relationship between Bureau of Rehabilitation Services (BRS) Counselors and Employment Specialists. They noted remarks such as “great communication,” on the same page,” and “working well together.” Employment Specialists were savvy about making employer contacts based on the diversity of their people. There was no “cookie-cutter” approach for job development for all people on their caseload, Employment Specialists provided information about various job options throughout the community, maintained face-to-face contact at the beginning of a job, and continued support as needed. Once people established themselves and felt comfortable, support was decreased gradually. Furthermore, staff participated in CHR multidisciplinary team meetings in order to encourage Supported Employment referrals for people in recovery. Work Source is unique in that the program is operated by the Eastern Connecticut Hospital Network (ECHN) Manchester Hospital, under contract with CHR. The hospital setting provides a whole other set of multidisciplinary relationships that connect people with mental health issues to opportunities for employment. In fact, according to the Work Source Director, it is not unusual for the hospital inpatient unit Psychiatrist to walk into her office with a referral for Supported Employment for one of his patients, prior to discharging him/her from the hospital.

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In addition to having communicative staff, SE program supervisors were strong leaders willing to share their time, talents, and expertise in order to build a strong and effective employment team.

ISSUES TO CONSIDER: Some aspects of the program deserving consideration include the fact that initial intake was being done by an Employment Supervisor, which might have been more efficient, but detracted points from fidelity to the IPS model and may have excluded individuals based on Work Source’s eligibility criteria. The review team also felt that Work Source could be more integrated with the mental health treatment team, and recommended that Employment Specialists (ES) attend weekly team meetings and multi-disciplinary meetings at CHR to encourage consideration and strategize employment options for people not yet referred. The review team also found that Work Source’s employment services documentation wasn’t integrated into each individual’s mental health treatment record, and the ES offices were far away, in a separate agency, from the clinical team members. Work Source had a mediocre score on the Zero Exclusion Criteria, a principal that outlines the need to allow anyone who’s interested to be accepted into Supported Employment services. In an IPS program, members cannot be turned away for anything, including their diagnosis, symptoms, treatment choices, work history, substance abuse, missed appointments, prior hospitalizations, or history of legal problems. At Work Source – reviewers noted that CHR Community Support Staff who were interviewed made multiple references to more people being referred to the Clubhouse than to Work Source for various reasons, including substance use and mental health issues. In reviewing the Work Source Client Eligibility Criteria for Referral, we see that referrals require “the client’s history, risk assessment and medications.” While some of this information might be used to determine DMHAS eligibility (for referrals that come from sources other than CHR), it might also be used to discourage people from the Supported Employment program until they are deemed ready. This can exacerbate misconceptions about job readiness and undermine the importance of adhering to the zero exclusion principal. In terms of celebrating achievements, reviewers couldn’t find a place where people shared their work stories, and no evidence of the rate of competitive employment was shared with agency leadership and staff. Publicly noting employment achievements promotes a culture of support and goal-setting for people, which helps in their recovery process.

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A place where Work Source scored low was on Executive Team Support for Supported Employment. The agency’s top leadership displayed limited knowledge about the SE program performance measures, and they knew little about peoples’ experiences in the CHR Supported Employment program. Reviewers perceived complacency towards the SE program on the part of the executive team. One theory is that since Employment Supervisors were extremely competent, the executive team did not feel the need to be more “hands on.” Employment Specialists lacked a tracking system for following up on employer contacts. Based on numbers submitted, SE staff was averaging an appropriate number of six employer contacts each week, but because they did not have a process for tracking, they got a low fidelity score. This is notable because it highlighted the importance of tracking in fidelity scoring. Documentation is important not only because it is an IPS fidelity and a DMHAS contractual requirement, it also helps with continuity of care. Work Source needs help with documentation. The issue of documentation affected Work Source in other arenas. In individualized follow-along supports, in order to increase their fidelity score, CHR needed to improve documentation of these individualized services in their charts and contact notes. One reviewer noted that copying and pasting was taking place and causing some inaccuracies in people’s records. These practices perpetuate inaccuracies and lack of individualization as concerns. While Employment Specialists assisted people in obtaining different types of employment 70-84% of the time, this could be improved by engaging area businesses and examining the jobs offered. Moreover, Employment Specialists could assist people in learning about the range of jobs available, familiarize themselves with community resources and job listings that could be shared with people, and improve job development activities. One of the DMHAS contractual requirements for SE providers is that the work should be done primarily in the community. Work Source Employment Specialists spent only about 55% of their time in the community. However, it should be noted that this was in response to the preferences of people on their caseloads who cited confidentiality as an issue when meeting in the community. Work Source also allowed service termination based on missed appointments. While it isn’t feasible to keep everyone on the caseload who are missing appointments, some modification to this rule is important for fidelity. Additionally, clinical integration to involve other members of the team to assist with follow-up in this area is one of the key tenets of Supported Employment. On a measure of assertive engagement and outreach by an integrated team, reviewers found that Work Source lacked clinical integration. This means Work

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Source didn’t involve all members of the team in strategizing, outreach and engagement. One of the biggest challenges for CHR/Work Source is to fully integrate the IPS model into the provided clinical services. There have been great strides recently in this area. The implementation of electronic records may bring more improvements to integration. However, since Work Source is located in a completely separate building across town from the clinical services, integration will continue to prove a challenge.

RECOMMENDATIONS: Our primary recommendation for CHR/Work Source is to continue its excellent work. One point to address is the need for education regarding the Zero Exclusion criteria, and the importance of using motivational interviewing techniques to encourage employment as a means of promoting recovery. Particular attention should be paid to case management and community support staff. It is unclear whether Work Source’s inconsistent adherence to the Zero Exclusion criteria contributes to their high employment rate. Perhaps by being selective about who can join the SE program, Work Source is empowering only those who they deem might best find employment to acquire the services that should be equally offered to everyone. This is something to consider when we examine the outstanding outcome numbers of Work Source. Another place to improve is in the provision of opportunities for people to share work stories, such that staff and agency leadership are involved as much as possible. Prominently displayed written postings about supported employment in the lobby and other offices, where outcomes of competitive employment rates are shared at least quarterly, would contribute to an environment where employment is highly valued and encouraged. Pizza nights and field trips like camping trips or amusement parks would help people celebrate successes and incentivize them to work towards their goals, as well as give them social opportunities to share their triumphs. Newsletters and sharing on social media are other places to highlight people’s successes. Job developers’ logs should be kept in order to determine if job development is being done by all employment specialists. The lack of job development logs also means that reviewers cannot determine the quality of employer contacts. Overall, we find that Work Source is a program with strong numbers for outcomes, but needs to improve in the realms of Zero Exclusion, sharing work stories, and job development documentation.

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II.

Clubhouse – Community Health Resources (CHR) Manchester, “We Can”:

The CHR We Can Clubhouse operates based on the philosophy that individuals who suffer from prolonged mental illness may require a period of learning and/or relearning basic life skills necessary to live, work, learn and socialize in the community environment of their choice. Vocational and Prevocational work units, supported educational counseling and employment supports, create an atmosphere conducive to learning new skills with other program participants. The CHR We Can Clubhouse provides a supportive recovery-oriented, memberfocused program that encourages esteem building through activities that promote opportunities for successful community integration. The program model is a hybrid of a work-ordered day where members are encouraged to engage in a variety of activities that promote skill building and self-esteem. Skills and Support = Success = Rehabilitation/Recovery.

REVIEW TEAM FINDINGS: The review team attended a morning meeting, and afterwards interviewed clubhouse members, staff, and the Director of We Can. During the morning meeting, members discussed tasks for the day. Discussion focused on securing people to do everything from wiping down tables and chairs, serving as head chef and helpers, watering plants, taking care of trash, unloading the Food Share, assembling birthday cards, and finding current events. Clubhouse members discussed jobs they have held in the past, ranging from fast food work at places like Wendy’s, to doing food prep and washing dishes, to stocking and filing medical records and doing road services. Over 69% of the members we spoke to (9 out of 13) worked in the past. Now, the members work cleaning computers, taking care of garbage, watering plants, serving lunches; one member works on an online freelance website. Most only work at the clubhouse now, and several indicated they were not impressed with Work Source. Two of the members said that no one from We Can had spoken with them about their interest in paid work in the community, and some said that they did not yet get the referrals for jobs that they wanted. However, one member admitted she was referred to ECHN for work, one shared that someone tried to help him find a job but it wasn’t in line with his skills and interests, and one confirmed that no one at the clubhouse has helped him with the employment search, even though he did try a GED course. In regards to education, a member knew that the State of CT will help pay for their education, and one person originally got ill at MCC, but then took a noncredit course with one of the staff supporting her, but she stopped because

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she was older than her peers and struggled with bad memories. Another deterrent was that BRS wouldn’t pay for her education. A negative relationship with BRS seems to persist. One member said BRS told him he shouldn’t go back into the computer field and they wouldn’t pay for it, but he felt that he was capable of holding a job in the field, and that he struggled more with stress than skills. Members wanted to learn a range of skills to better prepare themselves for gaining employment in the community. The skills included computer skills, running groups, doing a better job of cleaning, following instructions from a boss, working a cash register, using a calculator, and gaining cooking skills. People affirmed that their involvement in the clubhouse helped them with soft skills and practical skills. Examples included learning from mistakes, becoming less shy and talking to people, and also using a computer, writing grants, food prep, and running groups and meetings. Knowledge about what the SE staff does to help people find jobs was low. One member just knew that Horizons has an unemployment office. One person said he is off the SE list now because he has a job. Nonetheless, the support for employment at We Can was high. Even though one member felt she shouldn’t work outside the clubhouse because of where she lives, and due to stress, staff never suggested that she wasn’t ready for work. It seemed that members were timid and fearful of taking the risk to gain employment – one person shared that they had bad memory, had a problem working with others and selling themselves, and that they were fearful of bosses/coworkers, or not knowing how to do the job. Quelling these concerns and affirming the clubhouse members’ skills and experiences seemed to be an important part of the work to get people ready for Supported Employment. In terms of knowing about how benefits would be affected by getting a job in the community – one person stated that they were allowed to work up to $1200/month and still qualify. This member seemed to be aware of the costs and benefits of employment, but it’s unclear whether the majority of members shared this knowledge or understanding.

STRENGTHS: Overall, the We Can members affirmed that the clubhouse cared about them, that a kind environment and an enjoyable work-ordered day were provided, and that they know they’re in a safe place with gentle staff when they enter the clubhouse. Members said that it feels like family, that it’s good here, and they’re happy to get out of the house to come to the clubhouse. In terms of working towards employment, members stated that the clubhouse helps them to feel independent and have their own responsibilities.

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We Can staff and directors talked about the abundance of volunteer jobs at We Can – including but not limited to cleaning crew, computer tech, drivers, Part time, kitchen, and reception. The Director at We Can thought the members were learning many skills at the clubhouse that can lead to employment. She saw a gain in confidence of people’s abilities, less resistance to trying tasks once people saw what they can do (which were encouraged with praise, help teaching, etc.), and an improvement in social skills. Everything is related to employment, in her opinion. We Can does not offer stipends for volunteer work performed at the clubhouse, although, at the time of our visit, was in the process of developing a stipend program for volunteer work performed in the community. With the advent of the work-ordered day, some of the stipends for volunteer duties were eliminated from the program, but there was an effort to celebrate volunteers and keep up motivation with an incentive program using stickers. It appeared that We Can’s move to a work-ordered day will be helpful for developing supports for SE. People were trying work that they never tried before. The We Can space was conducive to having multiple activities, and a portion of the day continued to be reserved for social and recovery support groups. The staff said members needed less support over time, and that they worked with groups to address everything from recovery from addiction (alcohol, substance abuse, and food), to leadership, public speaking, and interview skills. People who have never been involved in anything start to participate more. Opportunities to learn new skills, like computer, are offered, and soft skills like coping, learning autonomy, and individual empowerment, were cultivated. People were encouraged to set goals by having that be a requirement in the intake meetings. When a positive pattern emerged, it was supported and fostered. Staff also fostered positive growth and self-esteem, and allowed the members to grow at their own pace. At We Can, there was a “big tent” approach, where it was acknowledged that some people will not want Supported Employment, and that was acceptable. To refer people for SE services, the Director said she used Work Source and BRS. Staff claimed it’s harder to get into BRS (which is another source of job coaching). A special feature of We Can was their extended hours and open hours case management once per week for people who did not have a case manager. We Can’s longer hours enabled more time for Open Hours Case Management. In that role, We Can staff had more frequent opportunities to make referrals for SE and other community services and, as a result, had more practical experience with a variety of resources, which may be helpful to employment. We Can staff appeared to be very familiar with needed resources and how to connect people with resources for housing, assistance with benefits, and employment.

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ISSUES TO CONSIDER: Staff reported that many people have been referred to SE but they needed to have a certain level of motivation, and are not just looking for a “quick fix.” This language brought up the question of whether the staff were familiar with the Zero Exclusion criteria. Another concern is the fact that clubhouse staff did not maintain contact with the SE staff after a referral had been made. Follow-up contact by SE staff only occurred if the job placements were not successful. It seemed precarious to develop a strong relationship with a member, refer that person to a new program, and then not maintain a connection with a staff of the new program to provide continuity of care. Perhaps time was a constraint, but programmatic policies can be put in place to promote interagency staff communication. The Director of We Can described the biggest barriers to people finding employment in the community as lack of experience, fear of losing benefits, limited education, and insecurities regarding skill sets. However she believed that coming to the clubhouse helped build people’s confidence and skills. She also thought that people needed to improve their hygiene, soft skills, communication, and following the rules. Staff thought that transportation and work hours were key concerns. Staff confirmed that many members were fearful about loss of benefits and had other insecurities. Staff noted that mental health issues could flare up, and affect attendance and performance. The Director said that there was a benefits counselor who came in once a year to present on the topic of benefits specifically. Staff would usually refer members to DSS or the case manager for individual benefits counseling, because everyone’s case was very different and unique. Clubhouse staff completed paperwork and referrals, but they just didn’t want to be responsible for relaying false information. Moreover – many members already had case workers – so staff felt comfortable delegating this responsibility. This effort to emphasize referrals to BRS-trained benefits counselors, instead of having staff share potentially incorrect or outdated benefits information, should be commended. The Director of We Can stated that if given more funding, they would like to implement more activities to expose members to useful experiences – such as learning to make change and working a cash register. She would also create an ethics committee to handle any potential indiscretions, such as hygiene issues, functioning in a group, and following rules.

III.

Relationship between “Work Source” and “We Can”:

It seemed that while We Can’s programming directly supported skill-building and confidence that translate well to Work Source’s SE program, the two

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organizations could do a better job of improving their connection. Several members indicated they would like more opportunities for job training and support for obtaining employment outside the clubhouse, but they didn’t seem to understand the clubhouse’s connection to Work Source.

ISSUES RAISED BY CAC 15 MEMBERS: In our Catchment Area Council (CAC) 15 meetings, people discussed how staying in the comfort zone of the clubhouse can be limiting in the long run, and ultimately isolating. We find it a positive step that We Can is looking to develop a stipend program for volunteer positions in the community rather than in the clubhouse. Another CAC 15 discussion involved the importance of community education to address stigma and employment discrimination. People need to be encouraged to present themselves in terms of their skills rather than their illness. Often people do not want to acknowledge their illness with employers due to stigma associated with mental health diagnoses. Moreover, they do not want supportive services at the job site because it makes them stand out as someone with a disability. Sometimes individuals with co-occurring disorders would rather be known as recovering from addiction than as a person in recovery from a mental illness. This points out to a need for education about the limits of stigma, and advocacy for folks in recovery, both within the clubhouse and in the community.

PROVIDER RESPONSE: We acknowledge that due to the long duration of this review, many practices have changed within the agency. In response to the comment about how the Employment Supervisor had been doing initial intake, providers stated that “For the past year, Employment staff have been doing their own intakes.” In terms of SE being potentially more integrated with the mental health treatment team, Work Source responded that “staff have been attending weekly multidisciplinary team meetings at CHR.” In addition, WS asserts that they also attend supervision/team meetings in the MMH out-patient department. WS believes that integration has been achieved. Since the review team found that WS’s employment services documentation wasn’t integrated, the agency has worked to create a “seamless system of mental health treatment bridging in-patient care to all out-patient services in the Manchester community including vocational services.”

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While Work Source had a mediocre score (3) on the Zero Exclusion Criteria, WS asserted they “work closely with the Clubhouse to ensure smooth transitions to competitive employment.” Staff clarified, “we do not turn people away but rather work with all community supports to give consumers what they need/want to achieve their vocational goals.” During fidelity scoring, reviewers couldn’t find a place where people shared their work stories. Now, WS said “each month an “Employee of the Month” is selected. That person’s picture and bio is displayed in the Work Source/Out-Pt corridor as well as at the CHR. At our CHR Vocational Planning meets, program stats are distributed. Agency leadership often attends these meetings.” In response to the reviewers’ comments about the lack of tracking system for following up on employer contacts, WS assured us that “since the review, we have been keeping written records of employer contacts.” As for following the Zero Exclusion criteria, WS stated, “The issue here seems to have been (1 year ago) poor communication and significant turnover of CHR case managers. The director of the Work Source, as well as some Employment Specialists, continue to educate CHR staff regarding the supported employment program. We do NOT selectively screen clients to skew outcomes as this report implies. All referrals from CHR are accepted and in some cases, collaboration with other programs is recommended. (clubhouse, out-patient, CT Works, etc.)”

CLUBHOUSE: At the clubhouse, staff asserted that regardless of people’s experiences or perceptions, a benefits counselor did come to the clubhouse to do a presentation on benefits and work. Many materials were handed out, and members had the opportunity to meet with the benefits counselor to provide one-on-one consultations. The agency also talked about a connection between the SE program and clubhouse, saying that “many, if not all, of the members that are referred to the Work Source still receive services at CHR (clinic, clubhouse, CSP, etc.) so the connection still exists between CHR and Work Source.” Moreover, “Work Source and We Can Clubhouse are working side by side with individuals who need prevocational skills. Once the individual feels they are ready for competitive employment, they are then transferred back to Work Source.” Finally, in response to issues raised by CAC 15 members, Work Source believes that “developing the volunteer unit outside the comfort of the clubhouse will help promote and educate others about individuals in recovery from Mental Illness. This is a small stepping stone but with the success of all the volunteers who will participate in this unit will help with the stigma of mental illness.”

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CAC 16 I.

Supported Employment Program - InterCommunity, Inc.:

InterCommunity (IC)’s Supported Employment program had a total of 85 people on its caseload, spread across 4 Employment Specialists, in the report period of April – June 2014. This means that each Employment Specialist served a caseload of 21 people (a positive shift toward smaller caseloads compared to when we first reviewed IC). During this time, the program had 39 people working, which is 46% of the total caseload. This is especially impressive since InterCommunity also has a Young Adult Program attached to its existing caseload. InterCommunity also had the highest percentage of people enrolled in education programs – 7% of their total caseload.

STRENGTHS: Some strengths to note include the fact that IC employment services coordinate with the Urban League. IC also has an employment program focused on young adults. All young adults served by IC have an employment track. Training experiences are offered at IC, and there’s an entrepreneurial emphasis. IC’s vocational unit helps people who want to go to school. At the time of the review, 10 people on their caseload were enrolled in educational programs. Other strengths included the fact that InterCommunity managed the high demand for their SE program well. Their caseload size was large at the time of our visit (average of 30 while the ideal for fidelity is 20). However, it is clear that IC still needs more resources for SE. Staff outside of employment services all seemed to be interested in supporting employment. Some employment staff worked on other agency projects related to vocational programming in addition to their supported employment responsibilities. InterCommunity also scored well on rapid job search for a competitive job, and individualized job search. InterCommunity scored especially well on individualized follow-along supports, time-unlimited follow-along supports, and assertive engagement and outreach by integrated treatment teams.

OPEN SUPPORTED EMPLOYMENT HOURS: Our review team visited IC’s Employment Open Hours, and observed that while only a handful of people came, everyone got one-on-one time with the employment specialist at the end. Moreover, the Open Hours enabled people who just needed a bit of help, or people being introduced to SE, or people on the waitlist for SE to get started on the employment process.

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The ES asked questions about work history, and current interests, and explained that they didn’t have jobs to give out. Rather, they build skills around job search. The ES also stated clearly that the goal is to not need SE long-term. In efforts towards resume building, the ES emphasized volunteer work, and filling up gaps on the resume; she also explained cover letters. The ES highlighted qualities that the employer may be looking for, including 3 past job references. She also described how to use personal references. Among services offered, the ES said she could offer a laptop to complete job searches and complete applications on-line, and accompany people to potential job sites, job interviews, or stay in the car and just offer transportation. People discussed transportation barriers, and she offered to drive bus routes to see places where people can go. The ES also offered help with interviewing skills. People then shared some school aspirations, to which she responded that she could help fill out applications or the FAFSA form for financial aid. She recommended visiting schools, researching what schools have to offer, and walking around campus together to deal with anxieties. Finally, she offered use of computers in the ES office or at Common Ground. Tools availed to the group included sample cover letters, a cheat sheet with information that one would need to put on application, and sample resumes. At the end, there was a check-in with each of the people about where they are at, and what interests them (what they used to do). The ES distributed an informational packet and held open hours to help people prepare for employment until they get off wait list. Overall, open hours seem to be about introduction to services, and on-the-spot one-on-one resume help/job search as needed. The ES seemed to have a script for Open Hours. Regardless, the ES was very good listener – she was inquisitive about people’ past work history, needs, and current interests. She helped people one-on-one with job search and was affirming; she typed in personal information for one person’s job application, and helped with cover letter and resume. She used packets as a reference guide, and offered people opportunities to ask questions and engage with the process. Overall, Open Hours offered a viable alternative for promoting employment to people new to IC services or on the waiting list for the SE program. The resources and skills development offered, as well as the group and one-on-one attention given to people seemed relevant and targeted. This alternative program was a thoughtful way for InterCommunity to offer SE on a limited basis to more people.

ISSUES TO CONSIDER: Like many agencies, the tracking system at IC needed improvement, which affected the fidelity scoring in that there wasn’t enough detail in the logs or

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information in the records to determine strength of practices. While IC had quality employer contacts, the inconsistent records meant that job development activities were not well recorded. It was moreover noted that there was not enough data for supervisors to review current individual outcomes with employment specialists in order to set goals for program performance improvements on a quarterly basis. The inconsistent tracking also meant that there wasn’t enough evidence to discern efforts on disclosure. A DMHAS reviewer recommended that InterCommunity pursue efforts to at least scan intake forms, so that employment services documentation could be more easily integrated into people’s mental health treatment records. Another issue was that InterCommunity didn’t have regular contacts with BRS. However, they had a strong, supportive vocational unit. Their work could be further improved if they had a steering committee, comprised of a diverse group of stakeholders charged with reviewing fidelity, and if executive team support for SE was strengthened.

II.

Clubhouse – “Common Ground”:

Common Ground is a psychosocial rehabilitation program whose is mission is to support people in recovery. Each active member is assigned a Primary Counselor (PC), who partners with the member to develop rehabilitation goals and a plan to accomplish these goals. Each goal is individual and personcentered; every quarter counselors and members meet to reassess these goals and the progress being made toward them. These goals have resulted in the implementation of various new programs, groups, activities and trainings for staff and members.

REVIEW TEAM FINDINGS: CAC 16 has employment groups within and outside of the clubhouse. The clubhouse provides a strong bridge to the SE unit. The clubhouse is a “big tent” that can meet the needs of people interested or not interested in employment. In our interview of a random sampling of 12 people at the clubhouse, we learned that many have worked in service industries in the past, but that very few currently earn a living. Past jobs for folks include volunteer child care, dishwashing, bagging groceries, bakery, maintenance, grill cooking, landscaping, cashier at TJ Max, line cook, custodial, shopping & receiving, driver, tree service, hostess, sales associate, CNA work, bakery work, bank teller and medical records. Currently, many people either have no jobs or work at the clubhouse. One person worked at the clubhouse in clerical, taking mail upstairs; another worked in the store; another woman did data entry. A man who worked at the snack bar was told by his attorney to stop working or even volunteering, because

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he was trying to get disability benefits. There was only one person we spoke with who worked in the community at a bakery, as a paid baker. Our conversations confirmed that Common Ground did talk to people about their interest in paid work in the community. However, 4 out of 12 people said they hadn’t been approached about their interest in paid work. For others, the result was mixed; the conversations seemed to be mostly a starting point for future referrals. The results ranged from learning clerical work and developing a resume for one woman, to just considering the possibilities for most others. One person decided to just do the job search on her own – she sought seasonal work at the mall. Many felt they weren’t ready to work, due to physical or mental health issues. When asked what they needed to learn or get better at in order to get a paid job in the community, people talked about a range of skills. One person wanted interpersonal skills; another wanted to learn clerical tasks; a couple wanted to get a diploma. Two people were interested in cooking skills, and one wanted flashback therapy. Some people didn’t know what they wanted specifically, but just wanted new skills in general. Through their involvement with the clubhouse, people felt they were gaining many skills useful to their personal development, and a few skills helpful for employment. These skills varied from watercolor painting, to cooking and cleaning, to leading groups. Soft skills like self-advocacy, communication, and social skills were taught in groups. One person noted that he learned to say “Thank You” when people complimented him. Several talked about an improvement in communication. Overall, it seemed that Common Ground offered groups that catered to people’s interests in self-development and to employable skills. The clubhouse also encouraged people to lead meetings and take leadership in groups to build social skills and soft skills. In terms of goals, people wanted everything from a high school diploma to a job. Some people wanted to make friends, be able to speak louder, work more efficiently, and others were interested in becoming a whole person. One talked about getting better at a volunteer job. Another wanted to take an enrichment course in meteorology. And one had no goals yet. Two people offered to help a woman find a job in the community. They helped specifically with the resume, and seemed to be keeping in mind her work skills, history and educational background. Another woman articulated that she was offered help finding a job “when she’s ready.” More people were offered help finding a school or course to further their education. One person went to Manchester Community College (MCC) for educational counseling; another actually enrolled in MCC for computer data, and earned a Dean’s List scholarship. A third person is attempting to get high her

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school diploma on line. The last person wanted to be a therapist, and was one semester from graduating Central Connecticut State University as a psychology major before her illness hit her, and she is thinking about returning.

STRENGTHS: When asked about what the supported employment staff at InterCommunity did to help people prepare for and find jobs in the community, people seemed aware of the role of SE specialists. One woman worked with an Employment Specialist (ES) to complete her resume. Another said the ES helped you find a job by filling out applications, offering support with work attire; and asking good questions about interests. They also helped with interviewing skills. A man shared that ES gave people applications to fill out and take people to interviews. Even people who haven’t accessed the services hear positive reviews about InterCommunity ES services. No one has ever suggested that people are not ready for work outside the clubhouse. One woman was given a trial period to assess whether she could take on responsibilities, and another stated that she felt supported by Common Ground staff when her therapist and she agreed she wasn’t yet ready for work. A clubhouse member asserted that staff was respectful and waited until she was ready. Common Ground seemed to do a good job at empowering people where they’re at. In terms of benefits, people seemed to either know about or be comfortable with how getting a job would affect them. One woman knew that starting out part time meant she would not lose her benefits. Another woman wasn’t on disability, so she wasn’t concerned. A third woman knew she could only work a certain number of hours on disabilities, and stated that her case manager goes over benefits assistance with her. Several people talked about how they met with staff at InterCommunity who provided supported employment services to discuss goals, past work history, and resume development. A woman shared that the Career Opportunities Office in another building also offered employment help; while she currently did not have a case manager, she felt comfortable going to different staff. One woman said that her case worker will talk to her about employment services, or that she will go to the job center when she’s ready. The meeting resulted in an ES helping one woman look for job sites, develop her resumes, complete her applications, and look at transportation options. Another member expected his ES to look for jobs for him, since she used to be his case worker. Overall, people seemed to be loyal to and passionate about Common Ground. One woman had volunteered there for 11 years, and asserts that it’s a great

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place. Another said she wanted to work soon to make money. A third woman said she enjoyed the structure, and that Common Ground is a good place. STAFF INTERVIEWS: The review team visited Common Ground and asked the staff a few questions about the clubhouse. Staff shared that all the jobs offered to clubhouse members were volunteer positions. People earn “hours” towards fun activities; for example, one must earn 100 – 125 hours to go on the annual camping trip to Acadia. People want to earn the privilege of going on the trip – so they learn skills and build confidence along the way, gaining a sense of accomplishment. There were 2 work units: culinary and clerical. Units get people to be active; the core is the team. In the clerical unit, there were 10 active people, with 40 signed up. Jobs ranged from data entry, to sorting, making fliers, greeters, front office work, newsletter, work orders in-house, and figuring out trip logistics. In the culinary unit, there were 10 active people who cook lunch for 20 people (10-15 of whom buy lunch), and do preparation and cleanup. There were two each day working on fresh versus frozen plan menus. A store existed, supervised by staff, and was starting back up again. Three days a week, a volunteer offered computer help. One person did maintenance (bathrooms); another watered flowers and cleaned up around the agency; there were greeters, someone who made coffee in the morning; and odd jobs like closet maintenance and picking up the paper. It seemed that there were tasks aplenty to be responsible for at Common Ground. In addition, staff brought people to Manchester Community College, and connected people with volunteer jobs outside of Clubhouse. Some places where clubhouse folks volunteer included St. Mary’s, United Way, a local 5K race, and at the “Day of Giving” in Trinity Episcopal (preparing flower beds). Staff believed that learning and practicing soft skills, like teamwork, can lead to employment. Other valued skills collaboration, responsibility, being on time, self esteem, sharing responsibilities and resources, and problem-solving. Inculcating a sense of belonging is key. Common Ground encouraged members to teach each other, which imbued their learning with a sense of importance and meaning. This also got people active, and helped reinforce the staff mantra, “if you want something, work for it.” Currently, staff and clubhouse members are working on developing a collaborative cookbook. To complement the emphasis on soft skills, staff offered opportunities for members to learn hard skills. These include computer navigation, fax machine use, and use of resource room. Jobs offered include work at the Senior Center culinary unit, Computers, Maintenance, and Bakery.

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Staff took note of people’s skills, and reached out to consumers and encourage them to step up. Some people were reticent to volunteer, so staff tried to find comfortable opportunities for new people. One staff member stated, “Once they state an interest in developing a skill for employment, the ball gets rolling.” The strategy is to always recruit from both units, talk to everyone, and talk to people about resumes and how to handle stress. In addition, Common Ground supported education interests by inviting college speakers. Finally, staff organized coffee nights, where people could perform. People are encouraged to set goals for themselves by concentrating on their strengths. Staff ask members to set quarterly measurable goals: for example – lose 5lbs in 3 months. Recognizing that it is important to have something to move towards, staff talk about goals that are manageable. They consider both employment and life goals. Common Ground also offered a Recovery Resources group. This group broke down recovery into manageable pieces. The purpose was to show people that there is a big world out there. Finally, the clubhouse created exciting events to look forward to, including but not limited to weekly Friday night activities, the camping trip, coffee houses, dinner, and movies. Camping trips and big field trips showed people there is something exciting to work towards, and they must earn the opportunity.

CONNECTION TO SUPPORTED EMPLOYMENT: People were referred for supported employment services by clubhouse staff via an electronic list on the shared server. All staff could refer to it and know the length of the waitlist. A staff could also call the SE director and get them on the list. Staff asserted, “All the person needs to say is that they want to work.” Communication among the staff, Director, and counselors got people in the program more quickly. Alternatively, staff could also send people to SE open hours; staff preferred to do this rather than open up the folder and put them on a waitlist. The Director of Common Ground was also intimately involved with members’ recovery. He often took the time to speak with people one-on-one, and let people tell him what level of support they needed and triage appropriately. Staff who put people on the SE waitlist also continued to work with them to help achieve goals. The Director of Common Ground wanted to get club members to help each other in a peer support specialist role with an employment focus; however, no funding existed to create the position. Many people were referred to the SE program at InterCommunity, and they either got on the waitlist or into the program. About 20 people were referred in the past year. SE staff went on camping trips with Common Ground to build team rapport; members even had nicknames for them – there was a clear easygoing relationship with the three Employment Specialists (ES). These ES also each

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coordinated a program at Common Ground – “working through recovery,” art treatment, and organizing the store and the camping trip. There was a fluid exchange of people and helping each other with people between InterCommunity and Common Ground. The Director of Common Ground stated that there are “no silos” between the organizations. The key was to help first, and communicate with the person’s case manager later. In our conversation with the Director of Common Ground, we heard that the greatest barriers for people to find and succeed at employment in the community were “stigma and the system.” The Director stated, “We work really hard to tell people they’re disabled; we work really hard to get people on benefits, so people get rigid. If they’re constantly told they need to be careful, people will not take risks since they’re afraid they’ll end up at the hospital.” This was a valid concern for many people in recovery and for the folks trying to encourage people to take risks to work towards self-sufficiency. The Director explained that people often say, “It’s poverty, but it’s what I know.” People get stuck and have a difficult time letting go of what’s comfortable, even if that comfort is mired in poverty. One consumer had all the tools but not the mindset to pursue employment; the Director asserted, “60% get over mental illness but only 10% get off disability.” After a healing process, people get comfortable, so the question is, “How do you get them moving again without traumatizing them?” The majority of people didn’t see work in their future, because the fear of crashing and burning persisted.

ISSUES TO CONSIDER: People felt that they were walking on a tightrope. They had gaps in employment and gaps in their resume, and the ES worked diligently to find ways to fill in gaps. Many folks grappled with self-esteem issues and anxiety. A lot of people felt like they were wearing a “scarlet letter.” Common Ground staff helped them get over these trepidations by engaging people in ice-breaker exercises, focusing on strengths, and promoting recognition. Staff also taught people how to write thank you cards. In general, people struggled because it was a tough economy; many are older adults; and they needed help staying on the treatment course when they’re doing well. Folks also needed help adjusting the treatment schedule, with transition, and continuing with therapy to keep feeling good. Transitioning and maintenance were important for long-term stability and employability. Common Ground has a Benefits/Entitlements group which is held every week for walk-ins, and is run by a Community Support Specialist. On top of that, they have an Employment Specialist that specializes in how benefits will be affected by employment status, and that is held by appointment. The concern is that ES cannot know all the complexities of benefits counseling that a BRS-trained benefits counselor do. Referrals to BRS is highly recommended. However, to the

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extent that these benefits groups help people understand the benefits of getting a job, so that they can be prepared to talk to BRS, these programs are valuable. Nonetheless, it is important to be clear that only specialized BRS counselors can give up-to-date and accurate information about benefits, and/or to have a BRStrained counselor at these meetings.

RECOMMENDATIONS: At the end of our review, staff articulated a few suggestions to consider. First, they identified a problem with the transitional program. In it, people often ask, “why should I leave?” and staff don’t know how to manage this issue. People were worried about crashing and burning; there’s a fear of the “bottom falling out” and people were worried about being “safe.” The issue was inspiring people to take the next step. Staff acknowledged that it’s easier to talk one-on-one. People also needed transitions, or build up “work muscle,” before entering the work force. Going from zero to 40 hours of work a week was too much. Staff thought that it was important to have transitional employment opportunities. The system should offer opportunities and options to build work muscle and reintegrate work back into their lives. Moreover, the Director thought we needed to give people a decent wage in the Transitional Employment Program (TEP). He said that sheltered work didn’t offer a decent wage. Peer-run business and peer support were important components to work. The Director thought that as ethnic communities (like the Irish Americans) supported and created opportunities for themselves through oppression, prejudice, and economic hardship, so should our mental health communities. A staffer wanted to have “friend to friend” program – to match consumers to a member of the community who could support and mentor them. This program once existed, but now there are a lot of roadblocks and stigma, so the program no longer exists. Finally, there was a suggestion for education at the community level. One Common Ground staff went to local colleges to do education on mental illness and addiction. She felt that we needed to educate employers and society. More than 25% of people have suffered a mental health crisis in their lives, and most people with mental illness are victims rather than perpetrators of crime. Overall, it seemed that Common Ground was a place committed to offering work opportunities and supporting people’s efforts to take the risk towards employment in the community.

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III.

Relationship between SE Program and “Common Ground”:

The best way to discuss the relationship between the SE program and the clubhouse is to talk about the work of SE specialists who connected with Common Ground on a daily, programmatic basis. Intercommunity had three SE specialists who organized and led groups at Common Ground. This relationship between the two organizations helped staff from both become better acquainted, and help them understand and appreciate the recovery process of members. This also ensured a seamless transition from clubhouse to SE, and fostered a work-positive environment at Common Ground. To understand this relationship, the review team attended a Common Ground meeting, “Working Through Recovery.” This group seems to directly support the SE program at Intercommunity. The 6-week program met weekly, and was mandatory for people in the “secure” program, but open to all others. This was a popular group and had as many as 17 people at a time. The facilitator bantered with group members, and often said “hello” or “welcome.” He engaged people in leading the group, asking people to read a quote of the day on the board, and inquiring what people thought it meant. The thought-provoking quote for this day was by Thomas Edison: “We often miss opportunity because it’s dressed in overalls and looks like work.” To introduce the group, the facilitator asked each person to share their name, best asset, and skill to improve in an interview setting. People went around the circle and shared – no skipping was allowed; only one person walked out. Strengths shared include being a good driver, being a good cleaner, cooking, and baking. People talked about everything from job skills to triathlon training and art development. Sometimes the facilitator reframed answers to fit in the parameters of what was being asked. When someone was stuck, the facilitator asked other people to help him define what he’s good at. There was a discussion of how depression and other issues affect performance on the job, and about learning to cope with difficult co-workers. When asked to deconstruct the quote, people responded that what resonated was being “scared to change,” or feeling “too lazy to change” – they knew how much work was involved in change. The facilitator asked people how they felt about change – this gave them time to share feelings and past negative experiences. One person articulated a deeper meaning of the quote by comparing it to artwork. The facilitator then asked about how strengths can contribute to a job, and facilitated a discussion on challenges, change, and fears. He asked, “how long did it take you to do something about it?” Then they discussed coping mechanisms, like setting boundaries, taking a moment to talk to a boss or friend when triggered, being careful from saying things in the heat of the moment – “think before you speak.” He reminded people to be kind to others, because this gives you a good reputation at home. Another suggestion was stepping back – review what’s going on, stepping into someone’s shoes and being a good listener. The facilitator shared that most people who come to his office struggle

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with issues like age and health; these problems force people to change jobs and find new paths. The facilitator skillfully asked useful questions and offered affirmations, like whether personal strengths or weaknesses problems affect work, and if that made it any easier for people. He affirmed that folks “went through a lot and did their best to see it as best as you could.” Lastly, he found ways to use strengths and coping skills that help in personal life carry into work. In particular, they included how we treat people, boundaries, thinking before saying things, and listening to others’ point of view. Overall, the facilitator seemed to know the people at the clubhouse well. As an Intercommunity Employment Specialist who facilitated a group at Common Ground, he had insider knowledge in understanding the challenges that people faced. He earned the trust of the members, and he actively worked to develop strategies with people in the group to enter the SE program. Unlike the relationships between most SE programs and clubhouses, where staff worked independently and rarely (if ever) interact, this arrangement facilitated understanding and careful collaboration between the two agencies. The unusual collaboration served to empower people in preparing for employment regardless of whether they ever choose to join the SE program. ISSUES RAISED BY CAC 16 MEMBERS: When asked about SE programs and the clubhouse, Catchment Area Council (CAC) 16 members wondered how much emphasis was placed on employment skills and services at the clubhouse. They were also curious about how InterCommunity supported and encouraged people to step outside the perceived safety and security of the clubhouse. Catchment Area Council members inquired, “Is it important that the person has success with their first job? If we don’t consider whether the person is ‘ready,’ do we jeopardize their success?” Some CAC 16 members questioned how many people kept their jobs and for how long. Moreover, Dartmouth IPS fidelity standards require that 40% of the people in SE gain employment, and of those employed, 65-95% acquire competitive jobs. Some CAC members doubted whether this is realistic. Finally, CAC members wanted to know how the possibility of relapse was addressed. CAC 16 members also noted that valid, creative employment methods don’t always meet fidelity standards, so it is important to have opportunities for “push back” regarding the fidelity scale during reviews. Another discussion revolved around how some members felt that certain job training strategies are not competitive to begin with (i.e.: in-house job training at Common Goods Store, entrepreneurial activities). However, it should be noted that job training activities at clubhouses do not have to comply with SE standards. Nonetheless, clubhouse vocational activities were viewed by staff as important vehicles for engagement. CAC members wanted this to be acknowledged in the SE standards.

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Working closely with BRS was valued. CAC 16 members affirmed how BRS can provide funding for work evaluation, working interview, and interviewing preparedness. Members also wanted to develop a relapse-prevention plan as part of follow-along support.

PROVIDER COMMENTS: The provider commented positively on the review, and saw the process of the evaluation efforts and the final product in the report as useful means of informing their work.

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CAC 17 I.

Supported Employment Program – Community Health Resources (CHR) Enfield:

CAC 17’s Supported Employment program is run by CHR/Enfield. The program employed 5 Employment Specialists and served 78 people during the report period of April – June 2014. Each caseload was about 16 people. A total of 28 people or 36% worked; impressively, there were 16 job starts this quarter. This is even more noteworthy considering that CHR/Enfield had the highest number of new enrollees admitted to the IPS Supported Employment program during this reporting quarter, which was 27, or 35% of their caseload!

STRENGTHS: CHR/Enfield was a strong program that follows fidelity to the IPS model. Staff work with individuals in all phases of employment services; program intake, engagement, assessment, job development/placement, job coaching and followalong supports. This allows them to build a good working relationship, good job matches, and engage them in the process. CHR does an exemplary job of integrating the Employment Specialists (ES) into their mental health treatment teams and weekly team meetings. Employment Specialists attend weekly mental health treatment team meetings; they participate actively with shared-decision making, the integration of employment records with clinical records is well done through the electronic records. The Employment Specialists’ office is in close proximity to mental health treatment team members, which facilitates good communication and integration. Moreover, Employment Specialists help the team think about employment for people who haven’t yet been referred to Supported Employment services. Outside of the program, CHR has developed an excellent relationship with the BRS Counselors in their region. They have “great communication, are on the same page, and work well together.” SE staff meets on a weekly basis to discuss the progress or employment status of each individual on their caseloads. The groups work well together to strategize ways to work through challenging situations. They also share information about various job options throughout the community. Young Adult Services staff members are included in these team meetings so that their clientele can also benefit from the strategizing and employer contacts. In terms of leadership, the Supported Employment Supervisor played an integral role in moving the SE program forward. The SE program supervisor is a strong leader who is willing to share her time, talents, and expertise in order to build a strong and effective employment team. The Vocational Committee is

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made up of staff and people in recovery who are recipients of CHR services. Opportunities exist for people in recovery to share their experiences at meetings. A great deal of supervision/education is done around disclosure. Employment Specialists discuss disclosure on more than one occasion and emphasize individual choice. Within 30 days of referral to the SE program, ES staff is engaged with people assigned to them. The Employment Specialists make employer contacts based on the individual strengths and interests of people on their caseload. There is no “cookie-cutter” approach when it comes to job development. Employment is encouraged by sharing the success stories. An Employee of the Month posting is shared through public display and through the CHR Intranet, which is available to all staff, including agency leadership. Finally, the review team observed an exemplary strategizing done at the ES meeting by CHR/Enfield. Everyone worked together to address barriers. Reviewers were so impressed with the program’s vocational unit, they suggested that perhaps a part of the employment unit meeting could be used to train or assist others on the IPS model and job development.

RECOMMENDATIONS: While CHR/Enfield had many strengths, the organization also needed to focus on certain aspects of their program to create a more effective program. First, CHR/Enfield must resolve the imbalance in caseloads – at the time of the review, one Employment Specialist had 28 members while another had fewer than half that caseload. Efforts should be made to balance and maintain a maximum caseload of 20 people per caseload to allow them to provide good individual attention and comprehensive services to each. Similar to CHR/Work Source, the Enfield program needed to address staff understanding of the “Zero Exclusion” policy. This criterion was important in the IPS model because it ensured that no one was barred from the opportunity to pursue gainful employment, as long as they felt ready to work. However, at the CHR Supported Employment program, perceived “job readiness” issues might have played a role in referrals to the employment team. Although there was no evidence of exclusion, it was noted by reviewers that the clinical team may need some additional training or a “refresher” on the zero-exclusion criteria of the IPS model. Reviewers noted that while the rest of the organization enjoyed a strong relationship with BRS, the Young Adult Services Employment Specialists may need some assistance in building relationships with BRS. It should be noted however, that CHR/Enfield was one of the few programs reviewed that included Young Adult Services staff in their Employment Staff vocational 33

meetings – thus providing an opportunity for sharing of information and strategizing with staff who are not strictly members of the SE department but who provide similar services to their clientele. While the leadership was supportive of the CHR/Enfield SE program, at the time of the review, the agency’s top leadership displayed limited knowledge about the SE program performance measures, about CHR Supported Employment members, and about their employment experiences. The review team was assured that employment played a prominent role and was a focus for leadership meetings; however, reviewers perceived complacency toward the SE program on the part of top leadership. It was theorized by the team that because the Employment Supervisors are extremely competent in running their programs, the executive team did not feel the need to have a “hands on” approach. Therefore, the review team recommended that at least one member of the executive team should actively participate in supported employment leadership meetings every 6 months; the Executive Director should communicate how supported employment services support the mission of the agency and discuss clear and specific goals for competitive employment to all agency staff at least annually; SE Program Managers need to share information about implementation barriers with the executive team twice yearly; and the executive team needs to assist the Program Manager in identifying and implementing solutions to barriers. It was noted that Community Support Specialists needed additional training/information/resources on benefits issues that present barriers to employment. Moreover, programs must be mindful of copying and pasting and appropriate tracking in their service plans and records. When they noted repetition that suggested copying and pasting efforts, reviewers were concerned about the accuracy of entries in the records of individuals served by the program. Finally, most employer contacts were made by one Employment Specialist, while others fell behind on the 6 face-to-face goal of the IPS model. Employment Specialists should increase the number of weekly face-to-face employer contacts to 6 face-to-face employer contacts per week. Job development impacts client success. Perhaps staff should regularly review strategies and techniques at weekly supported employment meetings and discuss effective ways to build relationships with employers and other job developing techniques.

I.

Clubhouse – Community Health Resources (CHR) Enfield, “Second Wind”:

The CHR Second Wind Clubhouse operates based on the philosophy that individuals who suffer from prolonged mental illness may require a period of learning and/or relearning basic life skills necessary to live, work, learn and

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socialize in the community environment of their choice. Vocational and Prevocational work units, supported educational counseling and employment supports, create an atmosphere conducive to learning new skills with other program participants. The CHR Second Wind Clubhouse provides a supportive recovery-oriented, member-focused program that encourages esteem building through activities that promote opportunities for successful community integration. The program model is a hybrid of a work-ordered day where members are encouraged to engage in a variety of activities that promote skill building and self-esteem. Skills and Support = Success = Rehabilitation/Recovery.

REVIEW TEAM FINDINGS: The review team attended a morning meeting, and afterwards interviewed clubhouse members, staff, and the Director of Second Wind. The clubhouse seemed full of life, filled with activities, and offered a positive (although somewhat cramped) space in which members could work towards short term and long term goals. During the morning meeting, members discussed the word of the week, “character.” Announcements were made regarding transportation, upcoming field trips, staff absences, and more events to look forward to. Also presented were Jokes for the Day. Finally, there was discussion of the four task groups: Transportation, Operations, Culinary, and Wellness. The Operations Group offered an opportunity to sign up for trash, bathroom, vacuum, furniture, and reception. The Wellness Group needed people to plan healthy snacks, offer WRAP support, organize walks for fitness, and healthy living tips. When the review team sat down with clubhouse members, many were eager to share their experiences in a group or one-on-one in a cafeteria setting. The people with whom we spoke held entry-level jobs in the past that required a high school education. These jobs included cleaning, culinary, and canteen work. Other people worked as a secretary, a CHR administrative assistant, a Pratt & Whitney machinist, and a clerk at the bank. Some folks worked as a Stop & Shop porter, a companion, a housekeeper, at McDonald’s, and as a movie theater usher. Now, the folks currently employed did work at the clubhouse arranging furniture, vacuuming, cleaning the bathroom and kitchen. Outside of the clubhouse, one person worked at a McDonalds. We wondered whether anyone from Second Wind had talked to them about their interest in paid work in the community, and it seemed that conversations about employment took place. One client wanted to have the discussion but lacked a work history. Another wanted to teach painting or do picture framing, but did not know how to get business. One man will try to pursue a job at his parish on his

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own. People seemed to be independent about their desire to get a job, and while conversations around employment certainly happened in the clubhouse, it seemed that the opportunities to connect with a staff about how to get support around employment were lacking. In terms of skills people needed to learn or improve to gain employment in the community, people wanted to acquire cooking skills and computer skills, learn how to operate a phone, and manage transportation. As for soft skills, people wanted to learn how to cope with stress, work with others and improve their social skills, and work in a work-ordered day. When asked about current learning opportunities and improvements in skills through their involvement with the clubhouse, people said being at Second Wind helped them become more confident and outgoing. In addition, they were learning to cook, operate phones, and use computers to hone skills. People also stated that their involvement at the clubhouse helped them get used to a work-ordered day, to scheduling, and helped them adjust to different personalities. When asked whether anyone has offered to help them find a job, one person stated that CHR has offered on two occasions, and that associates at BRS also offered her opportunities. Members also affirmed that no one has ever suggested that they are not ready for work outside the clubhouse. Members didn’t seem to know how their benefits would be affected by getting a job in the community; they said no one talked to them about this issue, and that people just seemed to know. Some members knew that benefits wouldn’t be affected if they worked part-time or retired. One member had a temporary job at ECHN, and they said she did great but they didn’t help her get another job after that position ended in 3 months. Overall, members spoke positively about Second Wind. The clubhouse didn’t seem to challenge them to move towards their goals at a particular pace, but instead provided the space and staff support so that people could achieve shortterm personal development goals. People leaned on each other and on the scheduled activities to make sense out of their days as they worked toward recovery. The review team didn’t encounter anyone enrolled in or even interested in the Supported Employment program. It’s unclear whether this is because members didn’t know about the program, or didn’t feel ready to engage in Supported Employment. The few people who were working or looking for work were not involved in the SE program at CHR – Enfield. It was unclear what, if any, relation exists between Second Wind and CHR – Enfield. However, it was clear that Second Wind did an excellent job of affirming members and helping people think about next steps by offering opportunities to volunteer and work in the clubhouse, as they moved towards self-sufficiency. The review team also talked with the Director and staff of Second Wind about the clubhouse’s role in employment services. They shared that via clubhouse

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activities, members are learning soft skills to help them find employment; examples include proper working behavior, how to take instructions, and managing time. These skills include etiquette with phones, negotiating customers, budgeting, and preparing food. The staff affirms that working on tasks helps members take on more responsibility, cooperate, be less likely to bail on activities, and gives people practice to be prepared for employment. Skill building is done through in-house apprenticeships and opportunities with the work crew outside. According to the Director of Second Wind, the work is entirely volunteer-based, and members start with easier tasks to “get feet wet.” Staff members engage but don’t push; clubhouse members are often asked to buddy up on larger tasks; this builds social skills and provides a structure for people. Staff lets them know who will help; staff also offers coaching and teaching. Members often get anxious if pushed, and they are fearful about losing benefits, so supporting them in accomplishing these tasks is important to help members take first steps toward a better future. The goal is to foster a collective desire to keep the clubhouse running and thriving. For long-term planning, the Director wants to implement a process in which members write out their own progress notes to set goals for themselves. Staff members meet with people when they are first referred for an intake meeting, so that they can address goals and encourage involvement in certain classes/activities accordingly. These goal-setting activities help members with accountability, but it’s unclear to what extent staff uses the stated goals to encourage employment-orientated behavior in members.

II.

Relationship between the Supported Employment Program and “Second Wind”:

The Director of the Clubhouse is also the Director of Supported Employment, which facilitates coordination between the two. Second Wind staff viewed the Employment Specialists as experts in Supported Employment (SE) and was comfortable making referrals to them for clubhouse members who expressed interest in employment. Staff could make referrals and also encourage members to call, see, or write to the Director of the program for supported employment services. Staff asserted that members were always encouraged to work if the time is right. They shared that work support groups exist for members who were still learning the skills needed to maintain a job. The staff had evening and day work support groups to foster communication. People who had improved/developed their skills over many years (especially receptionists) were encouraged to transfer over to Supported Employment services, especially if someone indicated a willingness/interest in becoming more involved in the community (for example, coordinating the Magic Carpet bus). The

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Director preferred to separate volunteer duties from paid employment; she believed members should not receive a stipend for their work at the clubhouse, that in-house work offers a sense of ownership and responsibility for a memberrun program, and should not be considered employment.

ISSUES TO CONSIDER: At Second Wind, many barriers existed for people to find and succeed at employment in the community. First and foremost, members worried about social security and loss of benefits. Staff members said that when people desire to limit the number of hours they work in order to sustain benefits, this causes them to worry that they will have to disclose their illness; this posed a problem when members didn’t want to disclose for fear of discrimination. In response, the staff wanted to bring in BRS Work Incentives specialists to the clubhouse for seminars. Secondly, there is a big problem with transportation in Enfield. Public transportation is very limited and few members can drive. The cost of bus passes and independence issues are also cited as barriers. The clubhouse transportation unit might be able to help with this issue, and staff acknowledged that they needed to promote the relatively new Magic Carpet bus as a good option. A buddy system might be helpful to people who are nervous about using the new public transportation. Another issue to consider was the question, “To what extent does an overly protective and potentially enabling environment within the clubhouse prevent people from seeking employment?” Second Wind filled the day for members; the work-ordered day was still supportive, but staff were moving people towards being more proactive. Nonetheless, self-esteem and independence issues could be perpetuated at the clubhouse because it was a close-knit and protected environment, thus there was less desire from members to go out alone into the community. The Director added that the clubhouse was working with a tight budget because members didn’t have to pay dues, and that free lunches (with only a donation system as required by their use of Foodshare) exacerbated the enabling environment and strained the budget. Staff also cited clothing, and the difficult economy as barriers to employment. As we consider the model at Second Wind and CHR/Enfield, and think about how having a shared Director for both programs can facilitate Supported Employment, we should also investigate the outcomes numbers for the clubhouse. How many referrals are made quarterly or annually? How long does it take a typical member to access employment services, if ever? How many people at the clubhouse never seek out or follow up with SE? How does the organization promote the SE program, and to what extent do members know about its existence? We know that both the clubhouse and the SE program are

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committed to employment, but how can Second Wind create a supportively yet challenging program without enabling its members to succumb to complacency? We see that even a high-scoring Supported Employment program has issues beyond fidelity, since part of its success depends on clubhouse referrals where members struggle with transportation and motivation. Second Wind’s challenges extend into CHR/Enfield, just as the SE program’s struggles with job developments and inconsistent application of the Zero Exclusion Criteria can limit the success of referred clubhouse members.

ISSUES RAISED BY CAC 17 MEMBERS: When the review team talked to the members of CAC 17 about the IPS model and our SE fidelity reviews, they raised some issues to be considered. Some CAC members questioned the qualifications of staff that provided SE services. They also wondered what was discussed in the disclosure conversation, and how job success was measured. Another point of concern was why a discussion of ADA rights not included in the fidelity standards. Regarding the IPS model requirement for 6 employer contacts per week, CAC 17 members wondered whether these were all new contacts, and members acknowledged that this requirement seemed like a really difficult standard to meet, especially with everything else that was expected from staff. Some CAC members wondered whether it’s difficult for vocational staff to carry out all the responsibilities of the generalist role. Finally, there was a concern that volunteering was not included in the Dartmouth standards even though volunteerism could be an important vehicle for engagement, building job skills, resume, building confidence, a step to employment, and an opportunity for observation or assessment. These questions were good to keep in mind as we examined the SE program at CHR/Enfield.

PROVIDER COMMENTS: We acknowledge that due to the long duration of this review, much has changed since our evaluation. This report is meant to be a snapshot, and we want to affirm the efforts of CHR/Enfield in responding to our recommendations. In response to, the discrepancy in caseloads, the agency believes that this issue “may have been attributable to full time staff vs. part time staff.” In regards to the Zero Exclusion Principle, CHR/Enfield responded that “training has happened in this area before and is ongoing. Zero exclusion is quite a complicated concept and difficult to translate. There are lots of nuances.” When we highlighted that Young Adult Services Employment Specialists may need some assistance in building relationships with BRS, the agency stated

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that “YA staff has utilized BRS considerably and in some instances more than adult staff without any difficulties.” In regards to our observation that agency leadership displayed limited knowledge about the SE program performance measures, about CHR Supported Employment members, and about their employment experiences, the agency asserted that “this may have been a miscommunication at the time of the review.” The agency further clarified that “the senior staff most aware of Employment Services and activities would be the Senior Program Manager.” They felt that this person “could have addressed the specifics of the department more effectively if the format of the meeting had been designed differently at the time.” In terms of our suggestion for more training to Community Support Specialists on benefits issues related to employment, the agency reported that “training has happened via the Director of Employment Services by attending team meetings, etc.” When we noted that programs must be mindful of copying and pasting and have appropriate tracking in their service plans and records, the agency asserted that “staff makes every effort to design all treatment plans individually.” In terms of our comments around improving job development, the agency said that “the one staff in question (who got a lot of job developments) has more access to businesses in the Bloomfield/Hartford/West Hartford region. All staff has had the customary job development trainings including the Three Cups of Tea promoted by both Dartmouth and DMHAS.”

CLUBHOUSE: At the clubhouse, we stated that opportunities to connect with employment seemed lacking, based on interviews with people. The agency responded that “since the Director of the Clubhouse is also the Director of Employment Services employment opportunities are constantly discussed, presented and promoted. Quite a few clubhouse members have been working with Employment Specialists in Employment Services as well as with BRS resulting in competitive employment placements and retention.” When we shared that clubhouse members didn’t seem to know how their benefits would be affected by getting a job in the community, the agency said that “a benefits counselor came to the clubhouse to discuss how benefits would be affected by a competitive job and handed out materials as well as met with members one on one after the presentation.” While it is unclear how often this happens, the clubhouse does make an effort to provide benefits information. Overall, members spoke positively about Second Wind. The staff confirmed that “several members have become involved in Employment Services.”

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Even though the Director preferred to separate volunteer duties from paid employment, the agency asserts that “this should be considered more prevocational in nature and a stepping stone to competitive employment in the community.”

ISSUES TO CONSIDER: In regards to barriers for employment, the agency adds, “transportation is also a huge barrier. Magic Carpet now opens more opportunities but has not resolved this problem entirely.” In response to our suggestion that a buddy system might be helpful to people who are nervous about using the new public transportation, the agency responded, “a buddy system has been implemented in the transportation unit of the work ordered day.”

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CAC 18 I.

Supported Employment Program – Chrysalis Center:

*The Supported Employment Programs available to people living in CAC 18 operates under contract with CRMHC and are the same programs that serve people living in CAC 23. Please see the section on CAC 23 to learn about programs that members in CAC 18 can access.

II.

Clubhouse – Phoenix Club:

The Phoenix Club is a social club that offers individuals in recovery from West Hartford and the Farmington Valley the opportunity to participate in social, educational and recreational activities each month. It strives to develop opportunities that enhance the quality of life of consumers of mental health services. The program focuses primarily on the social aspects of recovery. Phoenix Club began as a consumer run social club without walls in West Hartford. Chrysalis has provided administrative support for the last several years, first out of the Case Management office in West Hartford and most recently out of the Recovery and Empowerment Center (REC) in Hartford. In June 2011 the Phoenix Club was merged with the REC. This was to allow for Chrysalis to use their existing REC staff to support Phoenix Club activities; which up to that point had only a small operating budget ($16,000+ and no dollars for paid staff.) Phoenix Club members expressed dissatisfaction with this arrangement due to the fact that, during the first year of this transition, there were no activities occurring in West Hartford or the Farmington Valley and few of the members felt safe with transportation options for getting to the REC. Since then, Chrysalis has made arrangements to hold one evening activity per month in West Hartford and provided transportation for Phoenix members to participate in one evening activity per month at the REC center. Chrysalis continues to encourage Phoenix members to take advantage of the broader array of recovery based services offered at the REC, especially links to employment for those who are interested. There is still little or no participation from persons in recovery in the Farmington Valley outside of West Hartford.

III.

Relationship between SE Program and Clubhouse:

Currently, no relationship exists between the Phoenix club and its associated SE program, Easter Seals. However, Chrysalis offers some support to Phoenix Club members who attend the REC through its employment program funded by the Department of Corrections and located in close proximity to the REC.

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In addition Chrysalis encouraged Phoenix Club members to become involved in REC activities and offers transportation to the REC Center so that members can access additional resources and supports.

ISSUES RAISED BY CAC 18 MEMBERS: Two CAC 18 meetings were dedicated to the issues of Supported Employment. In the first, with SE staff from Chrysalis, issues raised about Supported Employment ranged from questioning the difficulties of stigma to pros and cons of sheltered employment. Many comments were made in the “A Day in the Life” report about trauma and discrimination experienced by people leading to reluctance to leave “the safety” inside the system. One person commented that this is about the system as a whole, and not just about vocational services. Members also commented on the importance of education with employers, as there is much stigma in the work place among employers. Members held differing opinions when they talked about the pros and cons of sheltered employment and why this is lacking in the mental health system, as compared to the developmental disabilities system. Members wondered whether SE staff ever work with employers to carve a job for someone – and whether they carve out specific aspects of a job that match the competitive skills sets of a person. Members also questioned whether we know how many people really want to be in a competitive work world; what number of people we are dealing with; how this is measured; and how does this compare with the number of successful placements. Other questions include how the difficulties of stigma and fear of loss of benefits affect this number; how competitive do people remain when they experience relapse, lose employment, and then seek employment again. At the end of this meeting, CAC members discovered that only people who receive their clinical services from CRMHC are eligible to receive SE services from Chrysalis. This is problematic because a large proportion of people who live in West Hartford and Farmington Valley towns go to UConn’s Talcott Notch program for their clinical services. It was at this point that we discovered that Easter Seals was the provider under contract with CRMHC to serve people referred by UConn. A second meeting was held with staff from Easter Seals. Their program is similar in nature but much smaller than Chrysalis’. Easter Seals also offers Supported Education Services. Unfortunately no one from CAC 18 was aware of the Easter Seals program. It was suggested that Easter Seals conduct greater outreach in the West Hartford and Farmington Valley towns to inform them of services available. The Easter Seals Director expressed concern over

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conducting outreach when she does not have the capacity to provide more services if referrals increased. This issue is just one of many that leaves residents of the Farmington Valley feeling as if Region IV services were not designed to address their needs.

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CAC 19 I. Supported Employment Program – Community Mental Health and Affiliates (CMHA): Community Mental Health Affiliates (CMHA) served 124 people with 6 Employment Specialists during the April – June 2014 quarter. This amounted to about 20 people per caseload. Of these folks, 50 people, or 40% of the caseload worked during this time – this was the highest working percentage achieved in the region during this period. CMHA also had 4 people in education programs during the quarter reported, 21 new job starts (one of the highest in the area), and 18 people or 15% of their caseload were new enrollees to their IPS program.

STRENGTHS: Community Mental Health Affiliates, Inc. is a private non-profit agency that delivers an array of clinical services as well as employment services. CMHA continues to demonstrate a very strong commitment to assisting people to find and keep employment, utilizing the evidence-based supported employment model. Employment Specialists function as a unit providing only employment services, and the Employment Supervisor has done an excellent job in providing support and management of her staff, juggling staff caseloads during some staff transition, and maintaining quality services while in the process of a physical move of the program and implementation of a new integrated team model. In addition, the staff spoke a diverse array of languages, including Polish, Italian, and Spanish to support local community members in recovery. CMHA has recently re-structured its Adult Services programs moving toward an integrated team model. Reviewers were complimentary of this approach asserting that this is only going to enhance the supported employment program. It should also be helpful in addressing the concern regarding time unlimited long term supports – finding ways to involve other members of the team to support individuals who are stable in their employment. DMHAS staff recommended taking a hard look at caseloads to identify possible people in recovery who could be stepped down to less intensive services in order to open up slots for peoples who need more intensive employment services. Reviewers were very impressed with the relationship that CMHA enjoys with BRS. Regular meetings were held and contacts are made as needed for people to receive individualized vocational/benefits counseling. Unfortunately this type of unhindered collaboration was not possible in all of our regions, so DMHAS commended CMHA on maintaining this type of relationship with BRS.

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ISSUES TO CONSIDER: The only area of concern was the diversity of jobs developed and obtained by people. Although there were some very unique job positions noted (telemarketing, counseling, librarian, school monitor), they were outweighed by the number of retail, restaurant and food, maintenance, and seasonal or temporary positions. This lack of diversity may be due to client choice, area demographics, or transportation. Nonetheless, Employment Specialists need to look more closely at long-term goals and a more detailed vocational assessment process with people in recovery in order to adjust the job search and ultimately meet those long-term goals. In addition, Employment Specialists need to do more “outside of the box” thinking to obtain more diversity in employment opportunities. Diversity of job developments helps create choices for people transitioning back to work, and also enables people to start new careers. During our review of the clubhouse, we discovered that they offered a CNA class that had stringent requirements for participation, which excluded certain people. The organization offering the CNA class had its own specific eligibility requirements for referrals that CMHA had to honor, therefore it will be important to consider connections to other educational programs with less stringent requirements for others. On a positive note, it was evident to all reviewers that “employment is everyone’s business” is not just a catch phrase, but this attitude permeated the entire atmosphere at CMHA. The support for the employment program comes from the top, throughout the executive team and filters throughout the agency staff and people in recovery alike. CMHA should be commended for this type of attitude and atmosphere. This support from leadership, management, and staff has resulted in exemplary fidelity at CMHA. II. Clubhouse – Team Time: The mission of the Team Time Clubhouse at Community Mental Health Affiliates focuses on assisting and supporting persons in recovery to define and work toward their individual goals while encouraging empowerment and teamwork between the members in a community based setting.

REVIEW TEAM FINDINGS: The review team met with Team Time members, staff, and director. When we discussed jobs people have had in the past, many mentioned work in the food service industry, but work ranging from paper route to grocery bagging were also noted. People worked at Friendly’s, Geoff’s Sandwiches, did

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cashiering, volunteered as a receptionist, helped at church, worked in security, stocked groceries at Stop and Shop, and did factory work. Now, people either help out at the clubhouse, or do nothing. One person recently graduated from the Advocates Program through Advocacy Unlimited, and will become a paid Advocate to protect mental health patients’ rights. Another was not interested in working anymore since he was 60 years old, and since getting on disability benefits in 2003. Two people cleaned bathrooms at the clubhouse, while another ran the food pantry. This required going on the computer and creating the order, picking up the order, shopping for foods one can’t get at Food Shelf, unpacking and stocking the shelves, helping people select their items, talking to people respectfully with proper tone, and teaching and supervising volunteer helpers. Two others provided help in the food pantry and the kitchen. One out of five people we spoke with affirmed that Team Time talked with them about their interest in paid work in the community. A member said that people used to come to teach them about how to get a job, but not anymore. Three others weren’t interested in work anyway; one was worried about losing benefits, another preferred to volunteer, and the third had an opportunity to work at Joanne Fabrics but never went to the job. The only person who discussed their interest in paid work was connected with the Advocates Program; once she completed the course, she got a job offer from CMHA without applying. To get a paid job in the community, people felt they needed to learn everything from math to group facilitation. One person wanted memorization for waitressing jobs; another needed to learn how to be comfortable with big crowds. A member acknowledged that Team Time and peer support helped him manage anxiety, so that now he no longer needed to take medications. People also wanted to learn how to be a “bigger voice for the little voice.” One person mentioned “Ticket to Work” – a program that allows people on disability to make up to $75K/yr. People were also interested in receptionist skills, and becoming a DJ at parties. Through their involvement with the clubhouse, people were learning a lot of useful interpersonal skills, and a few employment-related skills. Among those skills are anxiety management, helping people feel like they are stronger people by offering them opportunities to run for leadership roles like club representative, and giving them confidence. Via activities like making potholders and stuffed cloth hearts, people learned how to talk to and get along with others, they became less nervous about their abilities, and communicated better. Trips and outings provided additional positive experiences in social settings. The volunteer position as a receptionist enables people to gain phone skills. One clubhouse member stated, “I have come a long way from where I was to where I am now. But I haven’t changed who I am. When you have someone working with you, you get farther in life.” Finally, the clubhouse’s partnership with Advocacy Unlimited enabled members to take a class on how to be an advocate. This offered people future opportunities for employment as peer advocates.

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People’s goals varied from personal fitness ideals to acquiring better housing. Some goals included coming to the clubhouse daily, going to the YMCA more often to exercise, working at the clubhouse, and losing weight to overcome hypothyroidism. One person wanted to get an Associate’s Degree in Human Services, and several wanted to be advocates. Yet another wanted to return to school for music or business. One person would like to do something with his craft skills – either teach a group at Team Time or get a job at AC Moore. Most people in the clubhouse had been approached by staff about helping them find a job in the community. One person was offered a job by CMHA when they completed the advocates’ certification. Three were currently working with an ES, one to find another job after having lost the most recent one, and another has filled out multiple applications to fast food restaurants like McDonalds and Chucky Cheese’s. One person met with the SE Supervisor and was on the waiting list for an ES. All agreed that Employment Specialists seemed to be keeping in mind their work skills, history, and educational background. People were also offered help to find a school or course to further their education. One staff mentioned an advocacy course and convinced a husband and wife to complete it. Another person had an ES who helped her explore taking a refresher course for radio broadcasting; she had graduated from radio broadcasting school many years ago, but never got certified – she saw this new opportunity as part of her recovery journey. While the clubhouse staff at CMHA seemed helpful towards helping people prepare for and find jobs in the community, many didn’t know about the SE program, much less what they did. One clubhouse member couldn’t remember the role of Employment Specialists; another said that her therapist helped her, but no one from employment or vocational services offered assistance. Moreover, people reported that there was no SE specialist at the clubhouse, and that they knew of one in the past but that the person no longer works there. The one person who knew about the SE program said that vocational staff from the other side of the building helped her get a job at Price Rite, and helped get clothing for interviews; however, she had to go elsewhere to get these services because they were not available at Team Time. Based on the difficulty in accessing SE services at Team Time, it’s important to strengthen the connection between Team Time and the CMHA SE unit. Only one person reported being told that they were not ready for work outside the clubhouse. This was upsetting to that person, but then the staff tried to teach her how to get a job. Only one person reported that they shared with staff at Team Time that they didn’t feel ready to work outside the clubhouse. In response, staff said, “that’s ok, when you are ready, just tell us.” In terms of knowing how their benefits would be affected by getting a job in the community, people knew bits and pieces, but most distrusted what they were

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told. “They say I can work 20 hours without losing my benefits, but I don’t know if that’s true.” Another person said that her benefits are dependent on how much money she made a week; she also knew about the Ticket to Work program and its limitations, and that one must be on Disability to get that benefit and raise the earnings ceiling. However, many people felt dejected by the possibility of losing whatever stability they had on benefits. A member lamented, “I lose my benefits, my rent goes up and food stamps go down a lot, so why work?” The economic incentive just wasn’t there to work. Some people believed that they couldn’t work at a decent paying full time job or they will lose HUD housing. There was a troubling concern about losing subsidized housing when people start working and raising their income level. This area of benefits counseling needs to be addressed because neither clubhouse staff nor ES have up-to-date information about housing subsidies, nor are they comfortable sharing this information. This housing concern prevented some Team Time members from considering employment. Staff knowledge about how employment would affect peoples’ benefits was mixed. Some knew a bit about benefits, since the assistant rehabilitation staff were also former people in recovery and they knew how it affected their benefits. Staff understood that housing, health insurance, and monthly SSI income would be affected. At one time, staff brought in a speaker to talk with people about benefits.

STRENGTHS: When the review team spoke with staff, they confirmed that people took responsibility for a range of jobs at the clubhouse. These include working the Warm Line, cleaning the bathrooms and the kitchen, organizing the Food Pantry, serving as a receptionist, cooking, and being on kitchen duty (this position is paid). Skills people were learning at Team Time that might lead to employment vary from resume building to customer service. Other skills are communications, teamwork via a bowling league and softball, hygiene in the women’s and men’s groups, laundry, and overall building confidence. Staff asserted that vocational specialists help with employment skills or transportation, while clubhouse staff provided support, soft skills, and sometimes offers free clothing. To help people develop new skills or build on old skills, staff encouraged people to join clubs and groups, attend classes, and take on responsibilities. Staff also referred people to vocational services. Team Time offered one-on-one coaching for personal hygiene, laundry group, and tips on how to dress for an interview. Staff also encouraged people to run the groups, and speak in front of the group. Team Time staff looked for strengths and encourage people to volunteer for some of the duties running the club, such as organizing the

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pantry or serving as the receptionist. Finally, the clubhouse offered opportunities to go to the YMCA for exercise 3 times a week. To encourage people to set goals for themselves, staff organized groups and talked to people about their interests. They have discussion groups, genderspecific groups, relaxation group, and a WRAP group. A partnership with Advocacy Unlimited enabled Team Time to offer an Advocacy Class. Mainly, staff spent time talking and listening to members, asking them “where are you at right now” – and empowering them. Sometimes, staff asked people directly about how they felt about getting a job.

ISSUES TO CONSIDER: In terms of referring people for supported employment services, clubhouse staff didn’t generally make referrals because most people came into the clubhouse with vocational counselors already. The clubhouse director has referred some people in recovery, but usually, at intake, people are referred to vocational services before they come to clubhouse. Staff also wait for members to approach them about their employment interests, and assistant rehabilitation specialists don’t “bother” members “because they might be in a bad mood” or want space or simply don’t want to talk. The two rehabilitation staff admitted they do not make many referrals. While these practices may affect people’s initiative in engaging with the SE program, staff clearly care about respecting people where they’re at in their recovery. Team Time clubhouse staff interacted casually with CMHA supported employment staff. SE staff often came to the clubhouse to get something to eat or drink. SE staff also came to the clubhouse when they are looking for one of their people in recovery, or for help searching for someone who has missed appointments. However, no formal structures or collaborations exist between the two parts of the organization, and no incentives are in place to facilitate referrals or communications about employment opportunities. Staff believed that the greatest barrier for people to find and succeed at employment in the community was knowledge about what’s out there. There was a general lack of information about opportunities, or education about where to go and what to do to find a job. Folks in recovery also tended to be shy, affected by medications, and worried about losing benefits. Staff believed that more information is key, along with educating, encouraging, and reprogramming people, since they tend to be tough on themselves and don’t see themselves as capable. Once employed, people felt dependent on vocational counselors to come along to jobs for guidance. These beliefs pointed to a need for a more fluid exchange between the SE agency and the clubhouse. If employment specialists spent more time interacting with people at the clubhouse

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in a more intentional manner and on a more regular basis, information about job opportunities and how to prepare oneself for them would be more easily availed. Team Time was in the process of moving to a new renovated space. This will avail them more space for programming. The Director felt that he needed more point people, more training for everyone, and more fliers and information about the SE program. At the time of the review, he was lacking staff, and needed another rehabilitation counselor. The Director was genuinely open to learning from others, and has only been at the organization for one year, so he wanted to learn from other successful models and work on curriculum building. In addition to more staff, the Director felt that he needed more technology, a fax line, outdoor space, and tools and resources. Staff expressed a need for speakers to come from different places to address gaps in knowledge, especially from DSS, HUD, Disability, and Social Security. In terms of organizational culture, Team Time seemed to be focused on meeting people at their level of interest with employment. Staff admitted they usually wait for people to approach them, and stated that they want to give people space, because they’re moody. Staff were also focused on teaching people hygiene, how to carry themselves, and interviewing techniques. They needed more expertise to teach basic computer skills. Staff felt that they couldn’t depend on members to be consistent volunteers. There seemed to be few successful efforts at a partnership between clubhouse members and staff, perhaps due in part to the staff’s outlook on people in recovery.

RECOMMENDATIONS: Overall, it seemed that staff need to understand how to create a more supported but challenging environment for members. While Team Time has a very dynamic and strong consumer-led leadership team, those who are not a part of this group can fall through the cracks. Team Time is special and unique because of its consumer-led mentality, but this doesn’t mean that all members of the clubhouse are part of the leadership team, and they may need services that staff don’t yet offer. Team Time staff seem passionate about empowering the consumer-led leadership team, but the rest of the clubhouse can benefit from support, as well. Part of creating opportunities for all members is to develop a curriculum cultivating employable skills, and developing programming that gets people to talk about and consider employment. The internet program EPIC is a great free online tool to help people develop job skills. Moreover, staff can create training to motivate those not part of the leadership team. Earning opportunities to participate in field trips, special meals, or fun events can help people work towards a goal. The fact that staff worried that they couldn’t depend

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on members to be consistent volunteers is enabling – the clubhouse needs to be a more challenging environment if it wants to help people towards independence on their journey to recovery. With a new director, the clubhouse has an opportunity to shift its culture towards helping people reach self-sufficiency; a big part of this is believing that people in recovery are capable of more than they can articulate, and investing in developing the proper tools and programming to equip people with the confidence and skills to find work.

III. Relationship between SE Program and Clubhouse: CMHA and Team Time seemed to have a weak connection. Few clubhouse members reported knowing about or participating in SE services at CMHA. Each Thursday – one staff would visit vocational services to check out new job listings and bring them back to the front desk, but generally, clubhouse staff did not work with vocational specialists. While the two organizations were friendly – no formal structured partnership existed. The Director had more ongoing contact with CMHA, but he was new and the culture hasn’t yet shifted to a more collaborative relationship. Overall, the clubhouse was perceived by our review team as an “add-on” by the agency, and not integral to CMHA programming. However, the clubhouse Director seemed motivated to shift the culture and move towards integrating SE services and clubhouse activities. He hoped that Team Time’s move to a bigger location in the next few months would help. ISSUES RAISED BY CAC 19 MEMBERS: In our meeting with CAC 19 Vocational Staff, we discussed issues ranging from the value of volunteerism to caseload size. The concern was that volunteering is not included in the fidelity standards, even though it can be an important vehicle for engagement, building job skills, resume, building confidence, a step to employment, and an opportunity for observation and assessment. CMHA is unique in that it is able to consider in-house employment as competitive as long as the person does not receive clinical services from the agency. Another concern is the fact that the discussion of legal rights and reasonable accommodation is not included in the fidelity standards. Vocational staff feel that people need to know that they can stand up for themselves. A recent training offered by the Connecticut Legal Rights Project (CLRP) was too expensive for an individual to take advantage of; perhaps this is something that should be offered regularly by the agency via the use of attorney presenters. A third issue concerns caseload size as it relates to capacity, and the waiting list for people seeking employment services. To try and accommodate immediate needs of

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those waiting, CMHA offered weekly open hours. Beyond this, there was a general agreement that having a vocational generalist assures the person that they will be working with the same staff throughout the process. This builds trust and knowledge. Finally, the group agreed that a good relationship with BRS is a must.

PROVIDER COMMENT: The provider chose to address our report with a letter: “The leadership team at Community Mental Health Affiliates would like to thank you for the time and efforts that have been put into this comprehensive evaluation. We share in your assessment and vision of the direction that the agency would like to be moving in terms of developing our Supported Employment efforts and fully integrating our services with the interests of our clients in mind. Over the past 18 months, Community Mental Health Affiliates has undergone a comprehensive restructuring of our Adult Services with the ultimate goal of integrated treatment services to improve treatment/service accessibility, outcomes and client satisfaction. The efforts to break down silos of care and bring all providers together have changed the day to day functioning of our Adult Services. As a result the Supported Employment team members have been integrated into the clinical teams providing better access for clients and staff and also ensuring better communication. As stated above, we share in your vision to have increased integration of Supported Employment and the Team Time Social Club. In our efforts to integrate services, we have and will continue to improve the integration of our services into one comprehensive unit that will provide quality care in an efficient manner by doing the following: 

Surveying our clients’ needs and interests

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Involving them in the decision making process by including them in employment interest groups, and a drop in employment support center

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Providing a computer lab for clients to utilize/access the EPIC website

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We will continue to move forward with integrating Supported Employment into the Team time activities/environment. We will work to ensure that a representative from Supported Employment

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has a regular presence at our Team Time social club. (Including training for rehabilitation staff that work at the club). One issue that Community Mental Health Affiliates has challenged over the past 18 months has been the relevance of the Dartmouth model, although we strive to adhere to the fidelity standards, the model has not changed to meet the changing needs/demands of our clients. We will continue to utilize this model, however, we cannot continue to do so at the expense of marginalizing any member at Team Time. This is a barrier as it relates to restrictions associated with caseloads or numbers of clinicians to meet the needs of our clients. Your observations associated with one out of five members not being told about Supported Housing resources is an immediate priority. We will develop a client satisfaction survey to assist the members directly to participate in the resolution of this matter. Due to the move of our Team Time club a few weeks ago, members have much more space and the staff are already undergoing plan for activities. One area of clarification re: the review of CAC 19 is the fact that both Team Time and the Vocational team are both active programs that are run by Community Mental Health Affiliates, they are not two distinct organizations, nor are they considered “add-ons”. Although the communication and access are not perfect, it has improved and will continue to do so each day. Once again we would like to thank for your time and guidance and we look forward to implementing some of the changes stated above. This evaluation has provided us with a lot of very good and solid information, and some areas of improvement. As an organization we will continue to promote the safety and well-being of our clients.”

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CAC 23 I. Supported Employment Program – Capital Region Mental Health Center (CRMHC): Capital Region Mental Health Center (CRMHC) is a state agency that provides a comprehensive array of clinical and supportive services to individuals in Catchment Areas 18 and 23. CRMHC manages the DMHAS contracts for three non-profit organizations offering Supported Employment in the area. These three agencies are Easter Seals of Capitol Region and Eastern Connecticut, Mental Health Association of CT (CHOICES II), and Chrysalis Center (EARN Program). These three programs were reviewed on an individual basis and have received individual fidelity scores. A) EASTER SEALS: Easter Seals served 46 people with two Supported Employment Specialists. This means there were 23 people per caseload. In the quarter between April – June 2014, 17 people or 37% were employed. They had the highest percentage of new enrollees admitted to the IPS Supported Employment program during this quarter: 17%. The major criticism of Easter Seals was in regards to their capacity – the organization had enough staff to serve 40 people on its caseload, but the program didn’t meet capacity in practice. Easter Seal’s primary source of referrals was the Institute of Living (IOL) and Hartford Behavioral Health. As discussed in the section on CAC 18, very little has been done to reach out to people in recovery in in CAC 18, many of whom receive services at UConn Talcott Notch. Reviewers were impressed with the clinical staff at IOL and their collaboration with Easter Seals, despite the bi-location of services. Consumers indicated they were very happy with the employment services they were receiving and many were successful in obtaining employment. Reviewers indicated that the charts were extremely detailed and that from the team meeting observed and the chart review that services were highly individualized. Reviewers also praised the Quality Management (QM) staff, commenting that they were very knowledgeable, thorough and kept pristine documentation. Other than the fact that the Easter Seals Employment Office was in a totally different location, the only concrete recommendation for improvement that can be made at this time is to increase the opportunities for family involvement. There was a misunderstanding regarding benefits counseling from BRS, but to our DMHAS reviewer’s knowledge, that issue is now resolved.

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B) CHOICES II: Choices II focuses on serving individuals who are deaf or hard-of-hearing. Choices II is based at the Mental Health Association of CT. In the quarterly outcomes report for April – June 2014, Choices II served 24 people with one Employment Specialist. This amounted to 24 people per caseload, which was large (20 is ideal) and a shift from Choices II having the smallest caseload in the region in September 2013. Perhaps the agency lost one SE staff in the interim. Of those on the caseload, 14 were employed during this period, which equaled 58% of the caseload. While the program had no new enrollees nor job starts during the quarter, Choices II attained one of the highest employment rates among our regional Supported Employment Programs. Reviewers indicated that all staff appeared to be “on board” with employment services and were willing to offer any assistance necessary. Quality Management (QM) staff were knowledgeable regarding employment and did an excellent job in tracking the employment services. People served by the program were very pleased with the services they received and felt that they were well served. CHOICES II is doing a good job in working with the BRS benefits counselors and ensuring that their people are well informed. The Deaf and Hard of Hearing (DHOH) population being served by CHOICES II has added another whole dimension to this review. Employment specialists have additional responsibilities in serving this population; services must be much more individualized and must include more “thinking outside the box.” The Program Manager at CRMHC was emphatic in stating that that working with CHOICES II was great. One area to improve fidelity would be attention to the documentation. Reviewers had difficulty scoring in several areas due to incomplete documentation. The charts lacked history, which led reviewers to believe that not enough attention was paid to this particular area. C) EARN: EARN served 165 people with 7 Employment Specialists in the April – June 2014 quarter. This equated to 23 people per caseload. EARN reported 67 people, or 41% of the total caseload working, and 21 new job starts – one of the highest in the region. EARN’s total caseload was the largest in the region; even as big program, EARN managed as well as our region’s smaller agencies, earning comparable fidelity scores and getting similar outcomes to the other high-performing regional SE programs. EARN had 10 people enrolled in education programs during the quarter, the highest number and the second highest percentage (6%) in the region.

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EARN’s only shortcoming was documentation. EARN staff are employed by Chrysalis but are housed at CRMHC and receive all their referrals from CRMHC. There were several areas where Chrysalis (EARN) excelled in this review, but one of particular note is the QM. The QM staff was extremely knowledgeable, data driven, and thorough. They connected data to outcomes, and made the data available to the vocational team on a monthly basis. Reviewers noted strong clinical support for the employment program, but the vocational staff is new so there is some room for growth. Although they seemed to take some suggestions made by reviewers well, it appears they need more experience dealing with the mental health population. Many scores on EARN’s fidelity review would be greatly improved if there was more of a focus on documentation. Charts were one-line notes, lacking both detail and history. Fidelity scores for Chrysalis (EARN) will continue to go up as these practices improve.

CONCLUSIONS: Overall, reviewers were impressed with the general philosophy of all agencies that “Employment is Everyone’s Business.” From the Executive Director of the LMHA (who runs monthly employment reports), to the Executive Directors of the not-for-profit agencies who can give a history of employment in his agency with complete detail; to the Medical Director, QM Director, employment specialists, counselors, case managers – everyone had a knowledge of employment. Areas that need attention include family involvement; making time for success stories to be shared; and involving significant others in the employment journey of the people we serve. Attention should also be paid to the fact that people in recovery don’t believe that any of the agencies included in this review would hire them for a job. This issue should be considered and addressed. Moreover, documentation was an area where points were lost on this fidelity review – paying mind to paperwork will help everyone. All reviewers noted that it would probably be beneficial for all employment specialists from all three agencies to have some meeting time on a regular basis. It would be beneficial to all of them since they are all working in the same area, and trying to do the same job development work for their people in recovery. This type of information sharing could be helpful to the employment process.

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Last but not least, the relationship with BRS Vocational Services was strained at best. Efforts must be made to repair this relationship, which will open additional opportunities for the people we serve.

II. Clubhouse - Recovery and Empowerment Center (REC), Chrysalis: Chrysalis Center provides supportive services to assist people to transform their lives. The Recovery and Empowerment Center (REC) strives to empower members to forge the direction of their own recovery through education, employment, volunteer opportunities, socialization, advocacy and peer-to-peer support to shape their own destiny. The agency recognizes the members’ need for socialization as a basic component of the REC and desires to balance that with a community campus approach that encourages members to move forward with individual goals. The plan is for members to run the social aspects, day-to-day operations, and program planning at the REC with staff facilitating the psychosocial rehabilitation programming. The agency is in the process of working with a consultant, staff, and members to redefine and reshape programs.

REVIEW TEAM FINDINGS: Our team went out to Chrysalis Center, and found it a bustling place with many structured day programs for members. Since Chrysalis shares its space with a program that offers vocational services to formerly incarcerated people, a plethora of certification programs were offered. Everything from cooking to forklift certification programs enabled people to access job opportunities. There was a fully operational kitchen offering a diverse menu for breakfast and lunch, run by a professional chef who trained apprentices. The cooking apprentices earned certificates that allowed them to work as line cooks in professional restaurants. Most opportunities were catered to men looking for blue-collar, manual labor type employment. However, an Employment Specialist from the DOC program also ran a daily program catered to people looking to find jobs – offering job skills such as interviewing, dressing up, and resume prep. Additionally, a library was in the process of being set up, replete with computers and a transportation kiosk, to help people navigate options. Members mixed with people from the Department of Corrections (DOC) program, and the people we spoke to talked positively about their experiences connecting with employment. Two men who were formerly incarcerated shared that Chrysalis gave them a second chance, and that it gave them valuable skills and certifications to work towards. The clubhouse members talked about how all the Chrysalis staff were friendly and approachable, and that they didn’t realize that some staff also worked concurrently for the DOC program. There was a jovial

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vibe around the place – people seemed relaxed and convivial, but they also eagerly attended groups and classes and gatherings. An announcement board greeted all members in the center space, and a member updated the board with a timeline of activities for the day, as well as the menu. A staff was designated to meet with and give tours to new members. A filling and nutritious meal was offered at minimal cost to all guests. Chrysalis seemed to have many resources and supports for its members.

III. Peer Support and Recovery Resource Center, CRMHC: The Peer Support and Recovery Services Center does not consider itself to be a clubhouse, however it has been included in this review because we believe we can learn from some of the unique and innovative practices that have been developed there. The mission of Peer Support and Recovery Services is to partner with persons in recovery to ensure access to quality behavioral healthcare services. What distinguishes the services provided by the Peer Support and Recovery Services at CRMHC is that it is part of the clinical services delivery within the organization, yet also a separate advocacy group for persons in recovery within the organization. This hybrid of individual rights and clinical delivery of services yields a product that creates Person Centered Planning implementation on a spectrum within Capitol Region Mental Health Center. This is by design, and evolved over time, and any active person in recovery is welcome. The component of Peer Support and Recovery Services that has the most elements of a social club is the Peer Support Center. The place has comfortable furniture, pictures and other elements to help people in recovery feel more calm, along with coffee and tea and fresh fruit. There are 2 main rooms for Peer Support, though staff are moving and interacting throughout the agency. The Peer Support Center is also a resource center, with phones, computers with internet access, etc. where persons in recovery can obtain a bus schedule, information related to illness and recovery, etc.

REVIEW TEAM FINDINGS: The review team met with the Director of the Peer Support Center to ascertain her ideals and vision for the center. Her overall vision entailed writing grants and partnering with organizations to offer people the ability to create entrepreneurial programs. She believed that all people in recovery have the ability to be well through work, and that if people cannot find work from traditional companies, then they can create opportunities for themselves. She wanted to consider ideas that allowed people to get vocational training, or arts and

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crafts apprentices, so that they can cultivate micro enterprises. She saw opportunities to cultivate mini businesses within the context of the center. Overall, the Director’s vision ensured that people in recovery get access to the supports they need to create their own vision for their lives. Entrepreneurial work not only allows people to work on their own schedule and determine their own work schedules, it can help people identify their strengths and focus on developing skills for the economy that makes sense for them. While difficulties exist for small entrepreneurs, connecting people with internships, apprenticeships, or mentors who provide models for entrepreneurial work can only inspire people in recovery. Pursuing pilot program funding will be important for this work to transpire, as will fostering appropriate partnerships.

Relationship between SE Program and Clubhouse: There is no one clubhouse for all three SE programs, and not all the SE programs work with Chrysalis. It seems that the SE programs work somewhat independently, of each other and of the clubhouses. Chrysalis has an Employment Specialist who works on-site, because half his time is with the prison vocational rehabilitation program at Chrysalis, and that works well for the clubhouse and for the program. This Employment Specialist does programs inhouse, and gets to know everyone who frequents the clubhouse, so he can informally and formally work with people to get them towards employment. The certificates that people can earn via Chrysalis’ training programs are also major incentives. These were designed for people in the DOC program who are coming out of incarceration, but could be made available (based on available funding) for clubhouse members as well. Similarly, in the SE program and clubhouse model, a consideration towards integrating services and programming could further benefit people. One concern expressed by the Director of the Peer Support Center was that people could only be referred to the Chrysalis SE program by CRMHC clinical staff. Peer Support Center staff were not able to refer and people were not able to self-refer. At one time, an ES from Chrysalis regularly frequented the Peer Support Center and was very welcome there. The ES died tragically this year and no other SE staff had yet resumed that relationship with the Peer Support Center. Moving forward, if the two clubhouses (Phoenix Club and REC) and the Peer Resource Center were connected in a daily, programmatic way to the three SE programs, it might help more people transition from healing to being interested in working to finding gainful employment. PROVIDER COMMENTS: None of the providers in CAC 23 shared any comments.

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COMMENTS FROM TOWN PERSONNEL IN REGION IV COMMUNITIES ISSUES TO CONSIDER: I. Lack of knowledge about SE Services: When NCRMHB reached out to this region’s Social Services directors to inquire whether they knew about SE services, the numbers indicated that more outreach and marketing efforts must be made. Of 11 towns that responded, five towns or 45% of the sample had no knowledge of SE services in the region. Of the 4 towns that knew about SE services, 58% of staff from one town didn’t know about SE. Four towns made a referral last year, or only 36% of our sample connected people in recovery to SE. However, 8 out of 10 – or 80% of the sampled towns knew about Clubhouses or programs that help people develop skills to prepare them for employment. In terms of outreach, EARN reached out to 3 towns last year, while the rest of the towns had no contact or nominal contact from years ago, so only 30% of towns were contacted to encourage SE referrals. CHR was scheduled to come to Manchester, but the staff said it’s an “intimidating organization to access.” II. Different towns have unique needs & challenges regarding SE programs: West Hartford and Avon have not had good luck with referrals to Chrysalis since move from the West Hartford office and the change to the CSP/RP program. There were lengthy waiting times for services, and people felt like they fell through the cracks. Moreover, there was poor access to services now that regular transportation is no longer provided to the REC Center. People assumed they needed to refer directly to Chrysalis rather than CRMHC; however, they have not been redirected to CRMHC when Chrysalis is at capacity. On another level, the two organizations used to be partners, and people used to be able to call for consultation even if they were not in the system – however this is no longer the case. People reported that even those who have tried to access the clubhouse have been “stonewalled,” that Phoenix is no longer accessible. Finally, access to care is a huge issue for the Farmington Valley. There are people in the Farmington Valley who have no connection to mental health services. Town personnel from the Farmington Valley would love to have a staff person for a half day, or one day per week in one of their Social Service offices. In Bolton, the Social Service Director had only been in her role for a little over a year and is also director for the senior services program. She was not aware of anyone who needed mental health services. Manchester social services staff reported that they do not maintain ongoing involvement with people in long-term recovery. People came in with crisis situations or specific needs like food, benefits, or housing, and the staff did not follow along to see the results of a referral to CHR or after contact information is shared. They indicated it would be helpful to have a flyer that explained what

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SE is to hand to people and suggest they ask about it with the CHR staff they are working with. We often heard that people they have referred used to be involved with CHR but have been non-compliant with services and therefore discharged. People wished there was another level of service for outreach and engagement for people who don’t fit CSP/RP. One suggestion was to invest in a bunch of Dunkin’ Donuts gift cards and meet with people every so often. In Suffield, employment is considered an important piece of mental health recovery and staff described a good working relationship with CHR. More discussion between providers as well as people in recovery needs to be happening in regards to individuals’ need for employment. Plymouth had a transportation issue. Without Para-transit in that area, it was difficult for people without a car to work.

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OTHER MODELS FOR SUPPORTED EMPLOYMENT In the Supported Employment Review for 2013-2014, we looked at formal Supported Employment programs and their associated clubhouses. Our findings led us to believe that while all efforts contributed to the health and well-being of people in recovery – Supported Employment programs had a limited reach. Only 8% of those receiving DMHAS services were exposed to Supported Employment offerings. Therefore, the work that clubhouses do to connect people in recovery to Supported Employment programs and to orient folks to employment mindsets did a great deal to broaden and deepen the effect of transitional supports for people seeking employment in recovery.

OVERVIEW: In CT, the Supported Employment model follows the Dartmouth/SAMHSA evidence-based employment model. There are 30 DMHAS operated and funded agencies in the state. Every two years, DMHAS conducts fidelity reviews for each LMHA and their affiliates. The outcomes are monitored through DMHAS report cards. In addition, a few other initiatives exist to expand the offerings beyond Supported Employment. These alternatives are sometimes DMHAS funded, and other times initiated by people in recovery and progressive mental health agencies. We highlight a few below.

Transitional Employment Programs: On May 20th, 2014, in addition to offering Supported Employment programs and to supporting clubhouses’ vocational programs, DMHAS started a Transitional Employment (TE) pilot affecting 5 agencies: CHR, Chrysalis/CRMHC, CMHA, Mental Health Association, and Prime Time House. Transitional Employment is a time limited real wage work opportunity (competitive employment) in the community that combines real work experience, skill development and support services to assist consumers in overcoming barriers to employment. Employers from a variety of work sectors provide Transitional Employment Program (TEP) opportunities that are individually assigned up to 25 hours per week and will be time limited, up to nine months, depending on the opportunity. People who participate in the TEP will:  Learn routine work place skills  Learn life skills to ensure a positive work experience  Establish an employment record  Generate employment references

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Additionally, several of the pilot programs have embraced the traditional TE model of having a staff member cover the shift if the employee calls out. This traditional TE model seeks to offer employers a security measure to incentivize hiring someone with a mental health history. Additional reviews and evaluation efforts will help ascertain the effectiveness of this new pilot program.

Entrepreneurial Pilot Programs: At InterCommunity, the staff and people in recovery have an ongoing collaboration to develop entrepreneurial programs. These include a dog-treat making enterprise, an ice cream cart franchise, a cake business, a community garden, and a film production company. All these programs are under the auspices of “Innovation to Creation,” a program that strives to offer people in recovery alternatives to the Supported Employment model. Many people who were ready to work found that it was difficult get into the Supported Employment program, and once accepted, they discovered they couldn’t create an appealing resume with their gaps in work history. Entrepreneurial work allows the flexibility in their schedule and the appropriate job skills development that would empower people to be successful and become independent wage earners in the community. Within the context of InterCommunity, people are in a sheltered environment, where they are supported, given the tools, and offered emotional and financial support to strive towards creating a unique enterprise. The Innovation to Creation program officially started in July 2014 as a curriculum for entrepreneurial ventures. After completing the program, which would take 6-9 months to complete, a person would come out with a business plan, and a binder with the necessary tools to ask for loans. The program was created to support people who had project ideas, but who didn’t have the tools and ability to pursue their dreams.

A Model from the Homelessness Field: While continuing to work towards improving current Supported Employment models, the mental health field may consider looking to other fields to learn from their efforts to develop Supported Employment. For example, in the field of providing services to homeless families, Massachusetts recently piloted a sizable “Secure Jobs Initiative,” which involved a unique multi-faceted Supported Employment program. That program has enjoyed such impressive employment results that it is being adopted and expanded by the Commonwealth’s Department of Housing and Community Development (Reaching Home – Partnership for Strong Communities, 2014). The program surpassed its goal of placing 80 families with jobs; at the time of the report, 83 families achieved this

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goal. The initiative considered the “three-legged stool” of stability: housing, job, and childcare. By considering how each of these needs could be met, program providers were able to help their families gain and maintain stability. For example, TANF provided childcare vouchers to families, so that single mothers could have the childcare support to pursue more rigorous, higher education and develop a professional career. The four key aspects of the initiative that worked were partnerships, employer engagement, coordination between case manager and employment specialist, and being part of a legislative conversation. A partnership with the Chamber of Commerce also yielded good results. In terms of job development, instead of having Employment Specialists be responsible for both job development and client skills development, the Secure Jobs Initiative designated the job development role to staff who were prepared and able to cultivate deep trust with employers and develop region-wide partnerships. In Western Massachusetts, job development specialists focused on approaching businesses who could offer childcare, and then offered employers on-the-job training and cost-savings methods to incentivize employers to hire clients. The Initiative also helped businesses with background checks. In Brockton, Massachusetts – the Initiative helped employers screen clients, and job development specialists built good reputations by ensuring a good fit for the work site. The Initiative moreover tied in local mayors and legislators in the job development process. They then offered business owners who hired clients public acknowledgement of gratitude at big awards events with legislators to give these businesses good press. To tackle transportation issues, the Initiative offered flexible funds to pay for bus passes. They offered a job to a client to drive a van, so that the person could drive their peers to job sites. Finally, the initiative split clients into 3 groups: jobreadiness, ready-to-go, and short-term training. The clients were given different opportunities that coincided with their level of ability and engagement with employment. Brockton connected clients with opportunities at a social enterprise that offered 6-12 months of pre-employment. The career center staff went to the shelters to meet with people – which eased clients’ ability to remain connected to vocational development goals. Of course, the program’s $1.5 million funding was helpful to attaining its goals. People got $4,000 to stay out of shelters, or $6,000 to move out of shelters in a rapid rehousing program. Five different sites managed the program, and they all had flexible models. The programs focused on the family unit rather than the individual unit. Finally, program assistance included small grants or loan funds to address the issue of being cash poor.

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APPENDIX A Eight Core Principles: Individualized Placement and Support (IPS) Supported Employment* 1. Eligibility Based on Client Choice: IPS services are open to all. Any individual who has a mental illness and wants to work is eligible for IPS services. Individuals with mental illnesses are eligible for IPS services irrespective of the nature, severity, or rehabilitation status of their mental illness. Individuals with cooccurring substance abuse disorders are also eligible for IPS supported employment regardless of their level of sobriety. 2. Focus on Competitive Employment: IPS services are designed to help individuals gain integrated employment in the competitive marketplace. IPS supported employment does not place individuals in programs designed specifically for people with disabilities. Instead, it focuses on ensuring individuals with mental illness locate jobs where they will be fully integrated with their nondisabled co-workers in traditional jobs that pay above the minimum wage. 3. Integration of Mental Health and Employment Services: IPS supported employment services are integrated into an individual’s overall treatment program. IPS employment specialists serve as part of an individual’s mental health team and work closely with providers to ensure employment goals align with the overall treatment plan. 4. Client Preferences: IPS services are focused on an individual’s preferences, goals, and talents. Employment Specialists work with individuals to find jobs that match their specific goals and interests. 5. Benefits Counseling: IPS supported employment provides individualized benefits counseling. Employment Specialists work with individuals to ensure they have accurate information about how employment will affect access to various programs such as Medicare, Medicaid, and Social Security Disability Income. Employment Specialists will work with individuals to help ensure they have the economic supports and benefits in place as they transition to the workplace.

*Dartmouth IPS Supported Employment Center: Practices Principles of IPS Supported Employment, http://www.dartmouth.edu/~ips/page48/page79/files/ips-practice-principles-002880029.pdf.

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6. Rapid Job Search: IPS programs are designed to help individuals locate jobs as quickly as possible. IPS supported employment does not utilize pre-vocational training programs. Instead IPS employment specialists help individuals locate integrated jobs within the competitive marketplace as fast as possible and provides ongoing support as individuals transition to work. 7. Time-unlimited Services: IPS supported employment services do not have a time limit. Services do not end when a person has completed the transition to work. IPS services are available as long as a person needs the services. 8. Systemic Job Development: IPS employment specialists engage in systematic job development for people. Employment specialists develop an employer network by engaging with local employers and businesses and developing relationships. This network assists employment specialists in locating jobs that match an individual’s talents, interests, and goals.

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APPENDIX B Clubhouse Program Components 1) Work-ordered Day: Central to the operation of some Clubhouse models is the concept of a work-ordered day, generally an eight-hour period from Monday through Friday that parallels a traditional work environment. Members work alongside staff to manage and operate the Clubhouse. 2) Employment Services: Members of a clubhouse have the option to participate in employment programs. Clubhouses generally have two types of employment programs: Transitional employment and independent employment. Transitional employment is a structured program that permits Clubhouse members to work as part of a team in a temporary job within the community. Teams are composed of clubhouse members, and clubhouse staff members are available to substitute for members who are unable to attend work. Independent employment programs help members look for ongoing competitive employment, on their own, within the community. Staff may assist members with resume preparation, interview coaching, and support once the member has attained a job. Most clubhouses also operate some form of supported employment, though job coaching or support generally takes place within the clubhouse, not on the job site. There are no time limits on employment supports through the Clubhouse Model. 3) Evening, Weekend and Holiday Activities: In addition to the work-ordered day, some clubhouses offer members a chance to socialize through some evening, weekend and holiday activities. The goal is to help foster a sense of community and support for members. 4) Education: Clubhouses offer members an opportunity for continuing education and training. Some education may take place on site Clubhouses also offer members support in starting or completing degree or certificate programs at educational institutions within the community. 5) Community Support: Clubhouses ensure that members have access to necessary support services within the local community, including psychiatric services, medical services, benefits counseling and support, case management, and any other necessary services. Clubhouse members serve as generalists, not specialists in any particular area, but clubhouse staff ensures that members receive referrals to, and access to, necessary services within the broader community. 6) Reach-Out to Members: Clubhouses conduct outreach—as necessary—to active members. For instance, if a member is in the hospital, or cannot attend the

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clubhouse for any reason, staff will ensure that the member receives a visit and feels supported by the community. 7) Housing: Some members of clubhouses may need support finding housing. Clubhouses work to help members find quality, affordable and safe housing if necessary. 8) Decision Making & Governance: Decision-making and governance are critical components of the Clubhouse Model. Clubhouses hold open-forum meetings where staff and members together discuss policy, operations, and planning issues. Clubhouses also have a board of directors that helps oversee fundraising, management, public relations and communication, and partnership with local businesses.*

*Clubhouse

International, How Clubhouses Function, www.iccd.org/function.html.

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APPENDIX C: Model Legislation, IPS Supported Employment Section 1: Definitions Competitive employment means employment within an integrated setting in a job that pays at least minimum wage. Competitive employment shall not refer to jobs set aside for individuals with disabilities, nor jobs that take place in a segregated setting. Integrated setting means a workplace where individuals with disabilities work alongside individuals without disabilities. Employment specialist means the individual on the evidence-based supported employment team responsible for providing a full range of employment services, including intake, assessment, job development and ongoing job support, to a caseload of individuals with psychiatric disabilities who are receiving program services. Integrated clinical team means a team that consists of an employment specialist and mental health treatment providers including but not limited to counselors, medication prescribers, nurses, doctors, and case managers. Integrated clinical teams may also coordinate with other specialists including but not limited to Vocational Rehabilitation counselors and benefits specialists. Benefits specialist means a person with an expertise in government benefits including but not limited to Supplemental Security Income (SSI), Social Security Disability Income (SSDI), Medicaid, Medicare, and Veterans Administration (VA) benefits who helps to provide counseling to individuals enrolled in evidencebased supported employment. Fidelity Scale means a tool used to measure the effective implementation of an evidence-based practice. Section 2: Provisions The [state mental health authority], in coordination with the [state department with authority over Vocational Rehabilitation], shall enact supported employment services consistent with evidence-based supported employment standards to aid individuals with serious mental illness in finding and maintaining employment. Article I. The program shall include the following components: 1) The program shall be available to any person utilizing services of the Community Mental Health Authority who has a serious mental illness and wishes to obtain employment. 2) The program shall ensure that individuals are placed in competitive employment positions in an integrated setting.

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3) Employment specialists shall work closely with individuals to ensure placement in jobs that match their interests, goals and skills. Employment specialists shall respect individual client preferences. Employment specialists shall ensure that clients receive information about the range of jobs within the community including the benefits and drawbacks of such jobs. 4) Employment services shall be integrated with a client’s overall mental health services consistent with training specified in section II 2(b) 2(c) and 3. 5) Employment specialists shall help clients engage in a rapid job search, obtaining competitive employment consistent with the individual’s goals and preferences at the first available opportunity. 6) Employment support services shall not have a time limit. Services shall not terminate simply because an individual has located employment. Services shall be provided as long as necessary to assure job sustainability, transition to another position and/or adjustments to psychiatric and interpersonal stressors. 7) Employment specialists shall engage in job development, reaching out to employers in the community and making contacts to help clients find competitive employment that is consistent with their goals and preferences. 8) The employment specialist will coordinate with a benefit specialist to provide accurate and consistent information regarding government benefits including, but not limited to: Social Security Income, Social Security Disability Income, Medicare, and Medicaid. Employment specialists shall make timely referral to a benefits specialist to counsel individuals on their eligibility for such benefits and clearly explain how employment may affect that eligibility. Article II. To ensure that this program is properly administered, the Departments shall: 1) Ensure that supported employment services conforming to the above standards are available through every local mental health authority or region within the state. 2) Provide ongoing training and development for employment specialists. This training shall include, but is not limited to: a. Job development training, including strategies for engaging employers within the community; b. Training in the practices and principles of evidence-based supported employment; c. Training to ensure that employment specialists are fully integrated as part of a client’s mental health team. This training shall include strategies for communicating with mental health professionals and training to advocate for client’s interests. d. Training on government benefits, including changes to laws and regulations that may affect clients.

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3) Provide ongoing training for mental health professionals and human service professionals. This training shall include cross-agency training on service delivery systems. This training shall help professionals to understand individual and agency roles and responsibilities in supporting clients engaged in supported employment services consistent with Article I. 4) Monitor service providers implementing supported employment consistent with Article I to ensure that they are implementing services as designed and are adhering to the eight components stipulated in Article I. 5) Assess the performance of evidence-based employment programs using a tested fidelity scale measurement. 6) Service providers shall be required to report to the state data on numbers of individuals served, numbers of individuals involved in supported employment programs, job acquisition, wage and tenure figures, dates and locations of training for mental health professionals and employment specialists and fidelity measures demonstrating adherence to the eight components listed in Article I. Service providers shall also be required to conduct a client satisfaction survey. This survey shall include, but is not limited to, information on whether clients are satisfied with their employment, whether opportunities for advancement exist, whether quality of life is improved and whether clients felt adequate support and information was made available to them. 7) The state shall provide training to employment specialists and human service professionals about the rights of individuals with disabilities under the Americans with Disabilities Act, the Rehabilitation Act of 1973, and the State Human Rights Act. Employment specialists shall make clients aware of their rights and the protections afforded by these laws. 8) The state shall develop a system to establish and maintain linkages between community agencies designed to support individuals with mental illness. This shall include, but is not limited to, Vocational Rehabilitation, substance abuse and mental health programs, health education programs and health services, supportive housing and education, and economic assistance services. Training should be provided to any and all service providers about the mechanics of supported employment as described in Article I. Section 3: Appropriations The state shall ensure [type of funding such as Community Mental Health Block Grant or general funds] is appropriated [optional: in the amount of [$_______] over [number of years] to fully implement this employment service throughout the state.

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APPENDIX D: Vocational Supports Act The [state department with authority over Vocational Rehabilitation] and the [state mental health authority] shall establish programs of supported education and employment services for individuals with serious mental illness that meet the following criteria: Section 1: Definitions Evidence-based practice means a program registered in the U.S. Department of Substance Abuse and Mental Health Services Administration (SAMHSA)’s National Registry of Evidence-Based Programs and Practices (NREPP). Promising practice means a program with a strong record of effectiveness in preliminary outcome evaluation that is not yet registered with the SAMHSA/NREPP system. To be considered a promising practice for the purpose of this legislation a program must prepare individuals for competitive employment in an integrated setting. Competitive employment: means employment within an integrated setting in a job that pays at least minimum wage. Competitive employment shall not refer to jobs that take place in a segregated setting. Integrated setting: means a workplace where individuals with disabilities work alongside individuals without disabilities. Quality of life measures means measures that account for non-vocational outcomes assessed through the use of an established instrument shown by research to be valid and reliable. Time-Unlimited means services will be available to clients or students as long as necessary, without time limits. Trained Mental Health Service Provider Includes professionals licensed to deliver mental health treatment and non-licensed support service providers. Licensed professionals include, but are not limited to physicians, clinical psychologists, social workers, nurse practitioners, physician’s assistants and nurses, licensed counselors and pharmacists. Support service providers include, but are not limited to case managers, psychosocial rehabilitation providers, certified peer support specialists, certified family support specialists. Mentorship Programs means a program that will match students, job seekers and workers with psychiatric disabilities with a mentor who is already established in their field.

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Section 2: Establishment of Vocational Assistance Programs The State Department of Health and Human Services in conjunction with the [state department with authority over Vocational Rehabilitation] shall establish and administer vocational assistance programs for individuals with psychiatric disabilities. Programs established by the state must be evidence-based or promising practices shown to effectively assist individuals with psychiatric disabilities with finding jobs. Time-unlimited vocational assistance must be available to all individuals with psychiatric disabilities who want to work [statewide or insert regions counties or cities]. The [department with authority over Vocational Rehabilitation] shall coordinate with the [state mental health authority]to ensure that individuals receiving vocational assistance through these programs have access to a broad array of support services including, but not limited to, mental health treatment, health and wellness services, benefits counseling and housing support services. Section 3: Establishment of Supported Education Programs The [state mental health authority], in coordination with the [state department of education] shall establish a set of supported education programs for youth and young adults with psychiatric disabilities, ages 16 to 26. As part of this program, the state may establish vocational training programs, certificate programs and postsecondary education programs that adhere to an evidence-based model. Evidence-based and promising supported education programs for transitional age youth and young adults shall be available to all students who wish to pursue postsecondary education or training in preparation for employment [statewide or insert regions counties or cities]. Section 4: Establishment of Pilot Programs The state shall establish a set of pilot programs in [___] counties. These pilot programs shall utilize peer support services, support groups and mentorship programs for individuals with psychiatric disabilities enrolled in a supported education program or a vocational assistance program. Peer support services and support groups shall follow an evidence-based practice model. Support groups shall be open to students, job seekers and/or workers with psychiatric disabilities, the purpose being to discuss educational challenges, job-seeking and/or employment experiences, to provide emotional support and to develop strategies to overcome barriers. Support groups shall be moderated by mental health service providers who are trained and credentialed in supported education or supported employment practice. Individuals who have achieved success in a chosen field shall be encouraged and trained to serve as mentors. Mentors shall successfully complete training conducted by the [state mental health authority] to educate them on the complexities of employment for individuals with psychiatric disabilities. Mentors shall be under the supervision of the employment assistance program.

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Section 5: Monitoring and Evaluation (a) The [department with authority over Vocational Rehabilitation or state mental health authority] shall monitor the programs established by this act and shall evaluate the performance of providers. All programs will be evaluated on an annual basis according to the criteria specified below and any other criteria established by the Department. (b) Vocational assistance program evaluation must include, on an ongoing basis, statistics on the numbers of individuals served by the program who obtain paid employment, job tenure, wages, the number of individuals employed in full-time, part-time or contract positions, and the number of individuals who are self-employed. (c) Vocational assistance programs must administer on an annual basis a client satisfaction survey to [__percent] of individuals served by the program. The survey shall include questions regarding the accessibility of employment services, quality of services provided and quality of life measures. (d) Supported education programs must report statistics on the number of students served by the program; the duration of education for each student; the number of students able to complete a degree, training, or certificate program; and whether or not students were able to achieve vocational outcomes consistent with their level of education and training. (e) Evaluation of the pilot programs shall measure the numbers of individuals enrolled in peer support, support groups and mentorships. Evaluation shall assess whether the education outcomes of students enrolled in these programs improve, whether job seekers enrolled in these programs have improved success in obtaining and maintaining employment, and whether individuals enrolled in these programs showed improved quality of life outcomes. (f) No program established by this act shall discriminate on the basis of race, color, sex, age, national origin, disability, or sexual orientation. Section 6: Appropriations The state shall ensure [type of funding such as Community Mental Health Block Grant or general funds] is appropriated [optional: in the amount of $_______] over [number of years] to fully implement employment assistance as described herein.

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