Finding meaningful purpose in life is one of behavioral health’s pillars of recovery from serious mental illness. Without purpose, recovery may be shallow, says Rick Cagan, executive director of the National Alliance on Mental Illness’ Kansas state organization. “People need a reason to wake up in the morning,” Cagan explains. “Employment is one of those reasons.”
“Most Americans with serious mental illness would like to work; of those, not even one in four is actually employed. But a dozen mental health centers in Kansas are using Individual Placement and Support to find such individuals jobs.”
However, while about 65 percent of people with serious mental illness say they’d like to work, only about 15 percent are employed. For those with serious mental illness, getting a job is often easier said than done. Some face difficulties because of a spotty work history with few references or a criminal record. Others lack important career development skills.
Individual Placement and Support (IPS) is an evidence-based practice that can help people with serious mental illness gain competitive employment.
Kansas was one of the first states to implement IPS, in 2002. Now—a decade and a half later—current and former leaders in supported employment in Kansas share their perspectives on what has worked and what hasn’t. The story of supported employment in Kansas may help other states and agencies as they strive to implement and sustain evidence-based employment services for those with serious mental illness.
“When we started in Kansas, we started from scratch,” says Linda Carlson. “It was a great experiment and we learned an incredible amount in that first year alone.” Linda coordinated training for IPS program supervisors at the School of Social Welfare in the University of Kansas (KU) from 2002 until 2011.
Kansas had tried various other forms of supported employment for people with serious mental illness for about a decade before adopting the evidence-based IPS program. “We weren’t getting very far,” remembers Charlie Rapp, a former professor at the School of Social Welfare at KU. “Progress was uneven and inconsistent.” He began looking for other options. When Rapp found IPS, he introduced it to the state mental health authority.
In the IPS model, which had been developed by psychiatrists at Dartmouth University in New Hampshire, individuals with mental illness receive training in job-related skills and also receive immediate assistance in finding and applying for jobs in the competitive workforce. After job placement, these individuals continue to receive support from employment specialists as needed.
IPS differs from traditional or sheltered employment programs, in which workers with serious mental illness or disability receive special training to develop work-related skills but don’t necessarily integrate into the workplace.
In Kansas, the state mental health authority had a longstanding contract with KU, and the KU School of Social Welfare became the de facto hub for research and training in the implementation of IPS, while the state provided seed money to mental health centers to kick-start the program. That contract ended in 2016, and the state mental health authority now oversees the training and fidelity reviews.
Implementation: Succeeding with Job Development
The evidence-based IPS program started out small in Kansas, with 2 of the state’s 29 mental health centers participating in the first year.
“One of the things we quickly realized was that job development was probably the hardest thing for centers to understand how to do,” says Carlson.
In the IPS model, employment specialists cultivate relationships with local employers, in order to broaden employment options for the consumers of the services. However, centers that struggle to achieve high fidelity to some components of the IPS model often neglect the job development component, according to Carlson.
“Many people find out about job openings through a family member, friend, or associate,” says Galen Smith, a former Kansas state IPS trainer, adding “But those with serious mental health conditions may have very fractured social networks.” With IPS, the employment specialist becomes that social network, advocating for the consumer with employers and serving as the proverbial “foot in the door,” Smith explains.
A key component of job development is dispelling stigma around hiring people with mental illness, Smith says. There’s always the risk that a hire won’t work out. The employment specialist works to minimize that risk for the employer by understanding the employer’s needs and preparing the consumer to transition successfully into the workplace.
After early difficulties in Kansas, IPS has gained popularity as an effective approach to employment services for those with serious mental illness. By 2008, 17 of the state’s 29 mental health centers had implemented the evidence-based IPS program, serving around 1,400 consumers. In 2017, that number is slightly down: 12 centers serve an estimated 850 consumers.
Implementing evidence-based supported employment programs in Kansas’s rural communities, however, remains a challenge. Jobs can be harder to come by in rural areas, and consumers often must travel farther to get to work.
Kansas is now looking at ways to improve mental health services, including IPS, in rural communities, as part of funding from the SAMHSA block grant.
“Transportation is a major barrier for some consumers,” says Melissa Bogart–Starkey, a project coordinator at the Kansas Department of Aging and Disability Services. In Kansas, KDADS is the state agency that partners with community mental health centers to administer federal funding for mental health services such as IPS.
“We’ve urged our frontier site to apply for other grants that may be able to assist with transportation for consumers,” says Bogart–Starkey. And they’re looking for creative solutions too. “We’re even reaching out to Uber agencies and trying to work out some agreements with them,” she adds.
Identifying and removing barriers to the success of the IPS program – such as the barrier of inadequate transportation -- can help ensure the ongoing sustainability of IPS in Kansas, says Bogart–Starkey.
Sustainability: The Importance of Funding
An even more important key to the long-term sustainability of IPS, however, according to SAMHSA senior public health advisor Bill Hudock, is finding the revenue to pay for it.
The cost of implementing IPS varies, but Hudock says it’s usually in the ballpark of $5,000 per consumer. He says that makes IPS quite cost effective. “If an individual is able to work successfully, then their use of medical resources and emergency services tends to go down,” he says.
Yet, traditionally, there have been no reliable funding mechanisms to support IPS.
According to David Lynde, an IPS consultant, the states that do best at sustaining funding for IPS typically enjoy strong collaboration between the state mental health system and the state vocational rehabilitation system, the system that is tasked with helping individuals with disabilities meet their employment goals.
Such collaborations can provide continuity of leadership and can reduce disruptions in state funding due to the inevitable changes in political leadership.
However, Kansas has so far not had that kind of inter-system collaboration, says Smith. As a result, agencies in Kansas, in order to be successful, have had to braid together funding from various funding streams, including self-funding.
When political changes in the state have occurred, some funding streams have evaporated, since there was no infrastructure in place to protect those programs. Many centers have had to cut back or completely drop their supported employment programs.
However, Medicaid in Kansas does provide a financial incentive to achieve high fidelity to the IPS model, and this has helped to generate state-level revenue for IPS in Kansas’s centers. Specifically, sites that achieve a high fidelity score by adhering closely to the IPS model receive a higher rate of Medicaid funding for their services.
Medicaid in Kansas does not, however, reimburse for job development hours, an essential component of the evidence-based IPS program, and this has posed a challenge for the implementation of the full IPS model in Kansas.
Low levels of penetration for supported employment services—both in Kansas and nationally—present another challenge, says Cagan. Penetration refers to how many individuals challenged by serious mental illness in a state actually benefit from IPS compared with the number of individuals that could potentially benefit from the service. The national penetration rate for the evidence-based IPS program in 2015 was tiny—around 2 percent.
Kansas does better, at about 14 percent. Yet that isn’t enough, says Cagan. He believes educating consumers and their families about supported employment services is key to creating sustainable demand for IPS. Many people don’t know that these benefits exist or don’t understand what the benefits entail, he says. Some people even worry that they might lose their eligibility for Medicaid if they begin to work, even though supported employment typically doesn’t jeopardize Medicaid eligibility.
While high fidelity can help centers reap the benefits of the IPS model in Kansas, some experts believe that having the flexibility to adapt services to a state’s particular needs may be an important part of sustainability.
In Kansas, that adaptation has taken the form of a pilot program to offer supported employment outreach directly to the homeless population in frontier counties. In the rural, western half of the state, access to behavioral health centers and services can be difficult, explains Bogart–Starkey. Reaching this vulnerable population as early as possible can help increase their access to health care services in rural areas.
In the long run, Bogart–Starkey says the ability to adjust IPS programs to new realities will contribute to the success and long-term sustainability of the IPS model of supported employment in Kansas.