Integrating vocational services on case management teams: outcomes from a research demonstration project

Barriers to vocational effectiveness in ACT: staff perspectives

Assertive community treatment (ACT), for persons with serious mental illness, includes a vocational focus as an important aspect of community integration. Nevertheless, research suggests that ACT does not assist significant numbers of consumers in achieving employment goals. A two-step survey of New Jersey ACT team members was designed to identify the key issues that hinder ACT staff members in assisting consumers with obtaining employment. Survey items were categorized into three sections: (a) staff attitudes, (b) consumer barriers, and (c) staff barriers to working on employment. The initial survey asked staff members to rate items in each of these categories. Highly rated items were used in a subsequent paired comparison survey to determine the relative importance of each. This method highlighted the following issues: four staff attitude items-(a) returning to work is positive, (b) employment is key to recovery, (c) abstinence from substance abuse is needed to work, and (d) consumers are too ill to work; four consumer barrier items-(a) fear of loss of Social Security Administration benefits, (b) symptoms related to the illness, (c) lack of motivation, and (d) poor social skills; and three barriers to working on employment issues items-(a) clinical issues take priority, (b) other case management issues takes priority, and (c) too many emergencies. The implications for staff training are discussed.

Supported employment outcomes of a randomized controlled trial of ACT and clubhouse models

OBJECTIVE

In a randomized controlled trial, a vocationally integrated program of assertive community treatment (ACT) was compared with a certified clubhouse in the delivery of supported employment services.

METHODS

Employment rates, total work hours, and earnings for 121 adults with serious mental illness interested in work were compared with published benchmark figures for exemplary supported employment programs. The two programs were then compared on service engagement, retention, and employment outcomes in regression analyses that controlled for background characteristics, program preference, and vocational service receipt.

RESULTS

Outcomes for 63 ACT and 58 clubhouse participants met or exceeded most published outcomes for specialized supported employment teams. Compared with the clubhouse program, the ACT program had significantly (p<.05) better service engagement (ACT, 98 percent; clubhouse, 74 percent) and retention (ACT, 79 percent; clubhouse, 58 percent) over 24 months, but there was no significant difference in employment rates (ACT, 64 percent; clubhouse, 47 percent). Compared with ACT participants, clubhouse participants worked significantly longer (median of 199 days versus 98 days) for more total hours (median of 494 hours versus 234 hours) and earned more (median of $3,456 versus $1,252 total earnings). Better work performance by clubhouse participants was partially attributable to higher pay.

CONCLUSIONS

Vocationally integrated ACT and certified clubhouses can achieve employment outcomes similar to those of exemplary supported employment teams. Certified clubhouses can effectively provide supported employment along with other rehabilitative services, and the ACT program can ensure continuous integration of supported employment with clinical care.

Randomized trial of supported employment integrated with assertive community treatment for rural adults with severe mental illness

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.