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By Sarah C. Threnhauser, MPA

Accessing supported employment services can be a challenge for consumers with serious mental illness (SMI). Only about 2.1% of consumers with SMI who received mental health services through their state mental health agency had access to supported employment (SE) in 2016—with accessing ranging across states from nearly 28% in Vermont to 0% in 11 states (see 2% Of People With SMI Receiving Public Mental Health Services Receive Supported Employment Services).

There are two primary funding streams for supported employment. The Department of Education’s Vocational Rehabilitation Program, which provides funding to state vocational rehabilitation agencies for supported employment services through Title IV-B or Supported Employment for Individuals With the Most Significant Disabilities grants, provided total funding of around $27 million in 2017 (see Supported Employment State Grants: Funding Status). State Medicaid programs provide funding for supported employment as an optional service – states can choose to provide the service, but are not required to (see How Are Supported Employment Services Funded & Delivered?). The question we wanted to answer is: Why are there so few consumers with SMI receiving supported employment services? I turned to our team at OPEN MINDS. They offered several possible explanations.

First, historically the focus on SE has been on the intellectual/developmental disabilities (I/DD) population, not the SMI population. This means that provider organizations serving SMI consumers may not have the awareness or training needed to provide SE. This lack of awareness may lead to provider organizations looking to other supports and service for consumers. Second, in spite of funding, resources are limited. SE may not be a priority in every organization’s portfolio of services—and Medicaid and grant funding for SE needs to be supplemented by the provider organization to cover non-reimbursable components of SE programs. Fear and resistance to employment from consumers and their families, coupled with stigma about the mental health community from employers, also created barriers.

George Braunstein

OPEN MINDS senior associate George Braunstein was surprised at the low percentage, considering the importance of the service, and he questioned whether SE was the primary way most provider organizations seek employment for consumers. He noted that there are several ways of getting employment for consumers—such as vocational rehab and job training—that can be more affordable ways for consumer to get access to vocational training. This is especially true through peer run organizations.

I also reached out to OPEN MINDS senior associate Bob Dunbar, who has extensive experience as the chief executive officer of an organization that he described as “a comprehensive community mental health center that provided award winning supported employment services to people with serious mental illness.” His organization received a SAMHSA grant to financially support the development and operation of supported employment, in partnership with Dartmouth, to train staff in the model. He noted:

Bob Dunbar

I think there are many factors that contribute to the scarcity of supported employment (SE) services for people with SMI. First, although it’s a SAMHSA-identified and evidence-based practice, vocational services have historically been available in the I/DD system but not in mental health system (see Supported Employment Evidence-Based Practices (EBP) KIT). Mental health staff are generally not trained in the SE model, and they typically don’t view vocational services such as SE as a critical component of their business model or continuum of services. In many respects I view the lack of training and failure to identify SE as an essential service as the primary factor impacting the availability of SE in mental health services.

Then there are financial issues. Most mental health providers organizations will encounter financial barriers to the provision of SE services. Medicaid may reimburse for certain components of SE, but many critical elements of SE including job search, job placement, and on-site coaching are often not reimbursable. Also, many state mental health authorities do not identify SE as an essential mental health service eligible for public mental health authority funding. In some states the public mental health authority and/or publicly-funded mental health providers have collaborated with state vocational rehabilitation agencies to access services in support of SE, but this is not common.

And, there are consumer and caregiver perceptions to deal with. People with serious mental illness and/or their family member care givers may resist SE because they fear that paid employment will jeopardize receipt of disability, Medicaid, and other benefits. SE providers must engage SMI consumers and caregivers in an assessment of the impact of paid employment on continued receipt of benefits.

Finally, there is stigma—more broadly and within the health care community. Job-finding and placement is a key component of all SE programs. The ability of a SE provider to successfully place a person with SMI in a paid position is impacted by “stigma” as well as the “job market.” While stigma and the job market will impact SE placements, effective SE programs are able to locate and partner with select organizations committed to making opportunities available to disadvantaged populations, who will also add value to the employer. There certainly are mental health organizations that don’t believe that people with SMI have the capacity for paid employment. However, organizations with a history of prioritizing services to people with serious mental illness realize that with proper training and support employment is a realistic and worthwhile goal.

Employment is an important part of recovery for consumers with SMI. As we move towards a more value-based market that is focused on “whole person” outcomes and consumer-directed care, meeting both the health care and social support needs of consumers will become essential. Supported employment is an evidence-based, a reimbursable program that is currently being under-utilized in mental health care. This is one path that executive teams of specialty provider organizations can utilize as part of their comprehensive care strategy (see Behavioral Health Evidence-Based Practices As Population Health Management Tools).

For more on supported employment services, check out these OPEN MINDS resources:

  1. Supported Employment Produces Positive Outcomes For Individuals With Serious Mental Illness
  2. Improving Employment Outcomes For People With Psychiatric Disorders & Other Disabilities
  3. Supported Employment: Building Your Program
  4. Scorecard Ranking for Supported Employment Provider Ranking
  5. Supported Employment: Where Mission And Opportunity Meet
  6. Evidence-Based Supported Employment Program Shows Significant Benefit For Veterans With PTSD
  7. New Clinical Service Prepares To Launch, Address Mental Health Issues In Washington, DC
  8. North Carolina Medicaid To Launch Cognitive Rehabilitation TBI Pilot
  9. Behavioral Health Evidence-Based Practices As Population Health Management Tools
  10. Less Than A Third Of People With Serious Behavioral Disorder Receive Evidence-Based Treatment

And to read our research on supported employment services funding and regulations, see How Are Supported Employment Services Funded & Delivered?: An OPEN MINDS Market Intelligence Report.

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