IPS Supported Employment Fidelity Report

Date: March 3, XXXX

To: Olinda Garcia, Executive Director; Rueben Acosta, Clinical Director; and Susan
Wolf, IPS Supervisor

From: Ed Garrido, State Division of Vocational Rehabilitation; Isabelle Ortiz, National

Alliance for Mental Illness; and Tracy Allen, State Department of Mental Health

Purpose:
This report describes IPS supported employment services at XYZ Behavioral
Healthcare. The fidelity review was requested by the agency for the purpose of
measuring IPS program inplememntation so that the agency can begin working on a
quality improvement plan to achieve good fidelity to IPS.

XYZ Behavioral Healthcare provides mental health and social services to adults and
children. One of six divisions at XYZ is the Behavioral Health Division encompassing
case management and mental health treatment for people who have serious mental
illnesses. Referrals to IPS come from those two teams. The IPS program includes one
employment specialist who reports to the supervisor of one of the mental health
treatment teams.

Method:
On February 17th and 18th, Ed Garrido, Isabelle Ortiz, and Tracy Allen conducted the
fidelity visit which consisted of interviews with the IPS supervisor, agency executive
director, medical director, clinical director, the employment specialist, one Vocational
Rehabilitation counselor, three mental health practitioners, one family member, and five
consumers. Reviewers observed the employment specialist conducting employer visits,
observed an employment unit meeting (supervision), observed two mental health
treatment team meetings, and reviewed ten consumer records.

The Supported Employment Fidelity Scale was completed following the visit. Attached
to this report is a copy of the completed scale. The scale is divided into three sections,
including staffing, organization, and services. Each item is rated on a 5-point response
format, ranging from 1 = no implementation to 5 = full implementation, with
intermediate numbers representing progressively greater degrees of implementation.
Agencies that fully implement IPS supported employment according to the scale criteria
have shown to have higher competitive employment rates than those that do not. The
following section addresses the three areas based on the visit.

Summary:
XYZ Behavioral Healthcare began implementing IPS two years ago by downloading
information from the Dartmouth website and attempting to design services that were
congruent with the IPS approach. Agency adminstrators made organizational changes
such as restructuring job duties so that the employment specialist focuses exclusively on
employment and they used the fidelity scale as a part of the annual quality assurance
process. Mental health and vocational services are integrated, including weekly
practitioner meetings. It was also clear that all practitioners at the agency believe in, and
practice, zero exclusion criteria. Leaders said throughout the visit that they wish to learn
more about IPS and improve services at XYZ Behavioral Healthcare. It is uncommon to
achieve a good fidelity score (100 or higher) at a baseline fidelity review, though it
appears that agency leaders and staff are well on their way to achieving good fidelity.

The employment specialist for the program is creative and committed to helping the
people that he serves. In spite of limited access to training, he has attempted to shape
his practices to the IPS approach. He has helped a number of people to find jobs and
enjoys working directly with employers.

Fidelity items that the agency may wish to prioritize for improvement include:
1. Item: Individualized job search. Job searches are not consistently individualized.
The reviewers recommend that practitioners collaborate with family members,
Vocational Rehabilitation counselors or others who can share information about
client strengths and interests. Also, the employment specialist should collect
detailed work histories in order to consider, with his clients, lessons learned from
previous jobs. Refinement of techniques to develop relationships with employers
will broaden job opportunities available to consumers in spite of the poor economy.
Please see pages 16-17 and for more information.
2. Item: Diversity of job types and Diversity of employers. Please see page 15.
3. Item: Ongoing work-based assessment. Sheltered workshops, transitional
employment, volunteer jobs, and unpaid “apprenticeships” are sometimes used as a
first step to employment. Please see pages 11-12.
4. Item: Individualized and time-unlimited follow-along supports. Services related to
both of these items were inconsistent. Please see page 16-17.

The reviewers would like to participate in a conference call with agency leaders to
discuss this report in more detail and to help the agency begin to develop a fidelity
action plan. Reviewers will contact Rueben Acosta to schedule a call.

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 IPS SUPPORTED EMPLOYMENT FIDELITY REPORT

Staffing

1. Caseload size
Employment specialists have individual employment caseloads. The Rating -5
maximum caseload for any full-time employment specialist is 20 or
fewer clients.

Comments: There is one employment specialist whose caseload size was 17.

Sources of information: Caseload list, IPS supervisor interview, employment specialist

interview.

2. Vocational services staff

Employment specialists provide only employment services. Rating -5

Comments: The employment specialist reported helping a person find housing because
he felt that if the person did not have housing, he would have difficulty maintaining his
job. Client records and other sources of information indicated that almost all of the
employment specialist’s time is focused on employment, but reviewers caution the
agency to watch this area carefully.

Sources of information: Consumer record reviews, interviews with consumers, calendar

review with employment specialist.

3. Vocational generalists
Each employment specialist carries out all phases of employment Rating -5
services, including intake, engagement, assessment, job placement,
job coaching, and follow along supports before step down to a less
intensive employment support from another MH practitioner.

Comments: The employment specialist is responsible for all phases of the employment
process.

Sources of information: Consumer record reviews, interviews with the employment

specialist, interviews with consumers.

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 Organization

1. Integration of rehabilitation with mental health treatment through team

assignment.
Employment specialists are part of up to 2 mental health treatment Rating -5
teams from which at least 90% of the employment specialist’s
caseload is comprised.

Comments: The employment specialist receives 100% of referrals from two teams.

Sources of information: Employment specialist interview, IPS supervisor interview.

2. Integration of rehabilitation with mental health treatment through frequent

team contact.
Employment specialists actively participate in weekly mental health Rating -5
treatment team meetings (not replaced by administrative meetings)
that discuss individual clients and their employment goals with
shared decision-making. Employment specialist’s office is in close
proximity to (or shared with) their mental health treatment team
members. Documentation of mental health treatment and
employment services are integrated in a single client chart.
Employment specialists help the team think about employment for
people who haven’t yet been referred to supported employment
services.

√ Employment specialist attends weekly mental health treatment team meetings.

√ Employment specialist participates actively in treatment team meetings with
shared decision-making.
√ Employment services documentation (i.e., vocational assessment/profile,
employment plan, progress notes) is integrated into client’s mental health
treatment record.
√ Employment specialist’s office is in close proximity to (or shared with) his or her
mental health treatment team members.
√ Employment specialist helps the team think about employment for people who
haven’t yet been referred to supported employment services.

Comments: All components of this item were met (see above). Integration of the
employment specialist with the team is a particular strength of this program.
Observation of the team meetings demonstrated good discussion and problem solving by
both the employment specialist and mental health teams. In addition to the items above,
practitioners report that when a person is referred to IPS, the employment specialist and
case manager both attend the first meeting. Team members said that if the employment
specialist and a case manager do not agree about next steps for a person, “We try to use
a team approach. We brainstorm ideas. A lot depends on what the consumer wants—
that’s more important than what we want.” Mental health practitioners clearly believe
that helping with employment is part of their jobs. A mental health practitioner also

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said that when a new person is enrolled in treatment services, the employment specialist
often suggests employment.

Sources of information: Mental health practitioner interviews, employment specialist

interview, observation of two mental health team meetings, consumer record reviews.

Recommendation:
• Consider adding another employment specialist position to the IPS team so that each
specialist will be integrated with one team only.

3. Collaboration between employment specialists and Vocational Rehabilitation.

Employment specialists and VR counselors have frequent contact for Rating -3
the purpose of discussing shared clients and identifying potential
referrals.

Comments: The Vocational Rehabilitation (VR) counselor reported that when a

consumer has an appointment with her, either the case manager or employment
specialist also attends the appointment. The VR counselor does not have regularly
scheduled meetings with IPS to discuss shared cases.

There are only three people using both services at this time. Leaders from XYZ Agency
and the Vocational Rehabilitation supervisor may wish to discuss how the two programs
can collaborate on a regular basis in order to help each other with better employment
outcomes.

Sources of information: Vocational Rehabilitation counselor interview, IPS supervisor

interview, employment specialist interview.

Recommendations:
• Schedule a meeting that includes leaders from XYZ Behavioral Healthcare, VR
counselors, and the local VR supervisor. Discuss strategies to work together.
• Schedule monthly meetings between practitioners as the number of shared cases
increases.

4. Vocational unit
At least 2 full-time employment specialists and a team leader Rating -2
comprise the employment unit. They have weekly client-based group
supervision based on the supported employment model in which
strategies are identified and job leads are shared. They provide
coverage for each other’s caseload when needed.

Comments: The IPS unit reviewed has one employment specialist.

Employment specialists benefit from peers to share job leads, strategize how to build
employer relationships, and to help them consider good job matches and individualized
job supports for their clients.

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Two new employment specialists in a separate division of XYZ Behavioral Healthcare
provide services to transition-age youth using the IPS approach. The supervisor of that
team and those employment specialists meet weekly to discuss people on their
caseloads. This may provide opportunities for using a team approach for the new IPS
employment specialist and supervisor.

Sources of information: Agency leader interviews, IPS supervisor interivew,

employment specialist interview.

Recommendations:
• Include the employment specialist and IPS supervisor in the IPS team meetings for
transition-age youth to provide peers for the new IPS team. Ask employment
specialists to help each other provide services, as needed. For example, if one
employment specialist is away from work, another could take her client to a job
interview.
• Search for opportunities to hire a second employment specialist. The purpose would
be to build a vocational unit, but also because the total number of people served on
those teams is 260 so two specialists will be needed eventually.

5. Role of employment supervisor.

Supported employment unit is led by a supported employment team Rating -3
leader. Employment specialists’ skills are developed and improved
through outcome-based supervision. All five key roles of the
employment supervisor are present.

√ One full-time supervisor is responsible for no more than 10 employment

specialists. The supervisor does not have other supervisory responsibilities.
(Program leaders supervising fewer than 10 employment specialists may spend a
percentage of time on other supervisor activities on a prorated basis.)
√ Supervisor conducts weekly supported employment supervision designed to
review client situations and identify new strategies and ideas to help clients in
their work lives.
√ Supervisor communicates with mental health treatment team leaders to ensure
that services are integrated, to problem solve programmatic issues and to be a
champion for the value of work. Attends a meeting for each mental health
treatment team on a quarterly basis.
Supervisor accompanies employment specialists who are new or having difficulty
with job development, in the field monthly to improve skills by observing, modeling
and giving feedback on skills, e.g., meeting employers for job development.
Supervisor reviews current client outcomes with employment specialists and sets
goals to improve program performance at least quarterly.

Comments: The supervisor provides weekly supervision for the employment specialist
and also supervises one mental health treatment team team (four practitioners). She
works closely with both mental health treatment teams and is able to coordinate mental

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health and employment services. The supervisor collects employment outcomes for the
employment specialist and discusses outcomes with him, but does not help the specialist
develop goals for improved outcomes. She reported that she has not gone with the
specialist to help him develop relationships with employers (field mentoring).

Sources of information: IPS supervisor interview, employment specialist interview,

mental health treatment team leader interview, review of program outcomes.

Recommendations:
• Provide field mentoring for job development on a monthly basis. A field mentoring
form will help structure this activity. A sample form is available at
www.dartmouthips.org, select Programs, select Supervisor Tools.
• Help the employment specialist set goals for improved employment outcomes and
develop objectives to reach those goals. For example, “Increase job starts from an
average of two per quarter, to three job starts per quarter.”

6. Zero exclusion criteria

All clients interested in working have access to supported Rating -5
employment services regardless of job readiness factors, substance
abuse, symptoms, history of violent behavior, cognition impairments,
treatment non-adherenece, and personal presentation. These apply
during supported employment services, too. Employment specialists
offer to help with another job when one has ended regardless of the
reason that the job ended or the number of jobs held. If VR has
screening criteria, the mental health agency does not use them to
exclude anybody. Clients are not screened out formally or
informally.

Comments: Mental health practitioners said that they refer people who have substance
use disorders to IPS. When reviewers asked if extra income could lead to increased
substance use, a practitioner said, “Yes, but there is dignity in having choices and taking
risks.” They went on to explain that employment could help a person reduce substance
use and gave an example of a person who works in spite of continued drug use. They
said they help people think about strategies to manage substance use so that it will not
interfere with jobs. Practitioners also said that they encourage people to work in spite of
other problems and described providing job supports to help people with issues that
could negatively impact employment.

There was no evidence that the employment specialist or IPS supervisor had criteria for
who should be referred to IPS. Consumer records indicated that IPS practitioners work
with people who have active substance use disorders, those who experience significant
symptoms of mental illnesses, and those who have lost multiple jobs in the past.

Sources of information: Mental health practitioner interviews, mental health treatment

team leader interview, employment specialist interview, IPS supervisor interview,
consumer record reviews.

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7. Agency focus on competitive employment.
Agency promotes work through multiple strategies. Agency intake Rating -3
includes questions about interest in competitive employment.
Agency displays written postings (e.g., brochures, bulletin boards,
posters) about employment and supported employment services.
The focus should be with the agency programs that provide services
to adults with severe mental illness. Agency supports ways for
clients to share work stories with other clients and staff. Agency
measures rate of competitive employment and shares this
information with agency leaders and staff.

√ Agency intake includes questions about interest in employment.

√ Agency includes questions about interest in employment on all annual (or semi-
annual) assessment or treatment plan reviews.
√ Agency displays written postings (e.g., brochures, bulletin boards, posters) about
working and supported employment services, in lobby and other waiting areas.
Agency supports ways for clients to share work stories with other clients and staff
(e.g., agency-wide employment recognition events, in-service training, peer
support groups, agency newsletter articles, invited speakers at client treatment
groups, etc.) at least twice a year.
Agency measures rate of competitive employment on at least a quarterly basis
and shares outcomes with agency leadership and staff.

Comments: An annual assessment includes excellent questions about interest in

employment or school. Reviewers observed one poster about IPS and one about
Vocational Rehabilitation in public areas of the buildings. Agency administrators
provided the rate of competitive employment for the past fiscal year, but do not collect
the data quarterly.

Sources of information: Consumer record reviews, tour of the agency, interviews with
agency leaders and practitioners.

Recommendations:
• Help working people share their stories with other consumers and with practitioners.
For example, help people write their work stories and post them in waiting areas. Or
ask working people to speak at mental health treatment team meetings. Place a
“jobs board” in a public area of the agency to inform unemployed consumers about
the job types and wages earned by people in the IPS program.
• Collect employment outcomes on a quarterly basis for people served by the mental
health treatment teams. Share these outcomes with all practitioners. Share the
definition of competitive employment with all staff on a regular basis to ensure that
data are accurate.

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8. Executive Team Support for Supported Employment
Agency executive team members (e.g., CEO/Executive Director, Rating -3
Chief Operating Officer, QA Director, Chief Financial Officer,
Clinical director, Medical Director, Human Resource Director)
assist with supported employment implementation and
sustainability. All five key components of executive team are
present.

√ Executive Director and Clinical Director demonstrate knowledge regarding the

principles of evidence-based supported employment.
√ Agency QA process includes an explicit review of the IPS SE program, or
components of the program, at least every 6 months through the use of the
Supported Employment Fidelity Scale, or until achieving high fidelity, and at
least yearly thereafter. Agency QA process uses the results of the fidelity
assessment to improve IPS SE implementation and sustainability.
At least one member of the executive team actively participates at IPS SE
leadership team (steering committee) meetings that occur at least every six
months for high fidelity programs and at least quarterly for programs that have
not yet achieved high fidelity. Steering committee is defined as a diverse group
of stakeholders charged with reviewing fidelity, program implementation, and the
service delivery system. Committee develops written action plans aimed at
developing or sustaining high fidelity services.
The agency CEO/Executive Director communicates how IPS SE services support
the mission of the agency and articulates clear and specific goals for SE and/or
competitive employment to all agency staff during the first six months and at
least annually (i.e., SE kickoff, all-agency meetings, agency newsletters, etc.).
This item is not delegated to another administrator.
√ SE program leader shares information about EBP barriers and facilitators with the
executive team (including the CEO) at least twice each year. The executive team
helps the program leader identify and implement solutions to barriers.

Comments: The executive director demonstrated detailed knowledge about IPS. He said
he believes that competitive jobs are an important way to include people in their
communities and consumers should have the right to work just like everyone else. The
agency has not developed a steering committee of diverse stakeholders to help
implement IPS. The executive director has not had a recent opportunity to share his
beliefs about employment with all practitioners on the mental health treatment teams.

Sources of information: Interview with the agency executive director, medical director,
and clinical director.

Recommendations:
• Develop a steering committee comprised of diverse stakeholders to assist with IPS
implementation. See information about steering committees at
www.dartmouthips.org, select Programs, select Program Implementation and
Fidelity.

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• Executive director: Share your thoughts about the importance of competitive
employment with all practitioners, for example, speak to practitioners in team
meetings or send emails to celebrate success stories. Do this at least twice each year.

Services

1. Work incentives planning.

All clients are offered assistance in obtaining comprehensive Rating -5
individualized work incentives planning (benefits planning) before
starting a new job and assistance accessing work incentives planning
thereafter when making decisions about changes in work hours and
pay. Work incentives planning includes SSA benefits, medical
benefits, medication subsidies, housing subsidies, food stamps, spouse
and dependent children benefits, past job retirement benefits and
any other source of income. Clients are provided information and
assistance about reporting earnings to SSA, housing programs, VA
programs, etc., depending on the person’s benefits.

Comments: Work incentives planning from a local Work Incentive Planning Assistance
(WIPA) program appear to be excellent. Consumers receive a written report including
“bottom line” information about how benefits will be affected by various levels of
earned income. The WIPA benefits planner is able to help not just with social security
benefits, but also with housing, food stamps, etc. Further, a worker on one mental health
treatment team helps people manage benefits while working. Consumer records
indicated that people regularly access benefits planning. Case managers help consumers
report income and no one in the program has yet encountered an overpayment situation
due to working.

Sources of information: WIPA planner interview, mental health practitioner interviews,

consumer interviews, consumer record reviews.

2. Disclosure.
Employment specialists provide clients with accurate information Rating –3
and assist with evaluating their choices to make an informed decision
regarding what is revealed to the employer about having a disability.

√ Employment specialists do not require all clients to disclose their psychiatric

disability at the work site in order to receive services.
Employment specialists offer to discuss with clients the possible costs and
benefits (pros and cons) of disclosure at the work site in advance of clients
disclosing at the work site. Employment specialists describe how disclosure
relates to requesting accommodations and the employment specialist’s role
communicating with the employer.
√ Employment specialists discuss specific information to be disclosed (e.g.,
disclose receiving mental health treatment, or presence of a psychiatric disability,
or difficulty with anxiety, etc.) and offers examples of what could be said to

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 employers.
Employment specialists discuss disclosure on more than one occasion (e.g., if
clients have not found employment after 2 months or if clients report difficulties
on the job).

Comments: The employment specialist does not require consumers to disclose a

disability. Because it is a small community, the specialist tells consumers that many
employers already know that he is from XYZ Behavioral Healthcare, but says that,
“everyone is okay with that level of disclosure.” He encourages people to share only
what they are comfortable sharing. Consumers interviewed said that they appreciated
that the employment specialist spoke to potential employers on their behalf. Few
programs are able to consistently meet all of the components of this item without using a
checklist or worksheet (see recommendations below).

Sources of information: Employment specialist interview, consumer record reviews,

consumer interviews.

Recommendations:
• Develop a worksheet to guide discussions about disclosure of a disability in the
workplace. A sample form is at www.dartmouthips.org, select Programs, select
Program Tools.
• Discuss the possible advantages and disadvantages to disclosure of a disability with
job seekers. Ask job seekers for their opinions.
• Revisit the issue of disclosure from time to time so that consumers can change their
decisions about using disclosure at any time during the job search or while working.

3. Ongoing, work-based vocational assessment

Initial vocational assessment occurs over 2-3 sessions and is updated Rating -2
with information from work experiences in competitive jobs. A
vocational profile form that includes information about preferences,
experiences, skills, current adjustment, strengths, personal contacts,
etc. is filed in the client’s clinical chart and is updated with each new
job experience. Aims at problem solving using environmental
assessments and consideration of reasonable accommodations.
Sources of information include client, treatment team, clinical
records, and with the client’s permission, from family members and
previous employers.

Comments: While some consumers are helped directly with regular jobs, others use non-
competitive employment as a first step. One person works as an unpaid apprentice
building boats. An agency that provides transitional employment is viewed as “…a
good teaching place. They address hygiene, willingness to follow instructions, etc.”
Several people work at a sheltered workshop as a stepping stone for competitive
employment. The IPS program does not use a career profile to learn about, and record,
information about job preferences, work history, etc.

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Sources of information: Consumer interviews, employment specialist interview. IPS
supervisor interview, consumer record reviews.

Recommendations:
• Refrain from referring people to other types of employment programs. When a
person wants to work, refer her to IPS and begin searching for a competitive job
directly.
• Develop a career profile to be completed during the first few weeks of IPS services.
Include information from various sources. Use the profile to develop an
individualized employment plan. Update the profiles with each job and education
experience. See an example of a career profile, and forms to update the profile, at
www.dartmouthips.org, select Programs, select Program Tools.

4. Rapid search for competitive job.

Initial employment assessment and first face-to-face employer Rating -4
contact by the client or the employment specialist about a
competitive job occurs within 30 days (one month) after program
entry.

Comments: Reviewers read 10 consumer records and noted the date of the first
appointment with the employment specialist and the date of the first in-person contact
with an employer by the client and/or employment specialist. The number of days to
first employer contact were: 2, 14, 14, 15, 22, 28, 31, 35, 39, 48. The median was 25.

Consumers reported that they began looking for work within a few weeks of entering the
IPS program.

For the highest score, the IPS supervisor would also track the number of days between
first appointment with employment specialist and first in-person contact with an
employer (by the job seeker and/or employment specialist). This method would provide
better information about rapid job search because it would include information for
everyone in the program rather than a sample.

Sources of information: Consumer records, consumer interviews.

Recommendations:
• Track the number of days from first appointment with employment specialist to first
date of in-person contact with an employer (by the client and/or employment
specialist). For example, during weekly supervision, ask if the specialist met a new
consumer during the week. Then ask if a client or the employment specialist had a
first in-person meeting with an employer about a job.

5. Individualized job search

Employment specialists make employer contacts are aimed at Rating -2
making a good job match based on clients’ preferences (relating to
what each person enjoys and their personal goals) and needs

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(including experience, ability, symptomatology, health, etc.) rather
than the job market (i.e., those jobs that are readily available). An
individualized job search plan is developed and updated with
information from the vocational assessment/profile form and new
job/educational experiences.

Comments: Reviewers heard examples of some job searches that were individualized. For
example, some mental health practitioners said that the employment specialist was once
able to find a job with extremely limited hours (individualized). On the other hand,
reviewers met with one consumer who was preparing to start a job that he did not want
because he did not want to clean toilets. Another person who has psychotic symptoms
was helped with employment without discussions about how his symptoms might affect
working and the types of jobs where his symptoms could be less problematic. A third
person was encouraged to take a job he did not like because he has a felony and “needed
to start somewhere.”

The employment specialist said that he does not review work histories because he wishes
to be future-focused. Reviewers appreciate that the employment specialist wants to help
people with jobs in spite of any past problems, but work histories can provide important
clues about what types of jobs and work environments would be good matches for each
person.

The IPS program rarely asks family members for their ideas about good job matches or
job supports. With consumer permission, the employment specialist is encouraged to set
up meetings with family members and the job seeker to talk about strategies for
successful employment.

Sources of information: Employment specialist interview, observation of the vocational

unit meeting (supervision), consumer interviews.

Recommendations:
• Choose which employers to approach based upon each job seeker’s interests, skills,
strengths, preferences, what has been learned from past employment, etc.
• Learn about people in the program by talking with mental health practitioners,
family members (as defined by the person and with permission) and others. Use
mental health team meetings to brainstorm job ideas to share with job seekers.

6. Job development-Frequent employer contact.

Each employment specialist makes at least 6 face-to-face employer contacts Rating -2
per week on behalf of clients looking for work. (Rate for each then
calculate average and use the closest scale point.) An employer contact is
counted even when an employment specialist meets an employer twice in
one week, and when the client is present or not present. Client specific and
generic contacts are included. Employment specialists use a weekly
tracking form to document employer contacts and the form is reviewed by
the supervisor on a weekly basis.

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Comments: The employment specialist makes employer contacts on a weekly basis,
though reviewers could not determine the number of contacts related to job development
because logs include contacts for job supports and also include contacts regardless of
whether the person contacted had hiring authority. (The purpose of employer contacts
for job development is to build relationships with employers, so it is important to meet
with people who have hiring authority.) The IPS supervisor does not review employer
contact logs on a regular basis.

Sources of information: Employer contact logs, employment specialist interview, IPS

supervisor interview.

Recommendations:
• Revise the employer contact logs so that contacts with hiring managers can be
differentiated from contacts with others. A sample employer contact log is available
at www.dartmouthips.org, select Programs, select Program Tools.
• Do not include job supports on the employer contact logs.
• Supervisor: review and sign the logs on a weekly basis so that you know if the
employment specialist is connecting with employers on a regular basis (six times
each week). Also, review the logs during supervision to help the employment
specialist think of next steps with each employer.

7. Job development—Quality of employer contacts.

Employment specialists build relationships with employers through Rating -3
multiple visits in person that are planned to learn the needs of the
employer, convey what the SE program offers to the employer, and
describe clients strengths that are a good match for the employer.

Comments: The employment specialist includes elements of relationship building in his

job development strategies. He meets with employers regardless of job openings,
describes what he does, and asks a couple of questions about the business.

Sources of information: Observation of the employment specialist conducing three

employer contacts, employment specialist interview.

Recommendations:
• Schedule an appointment to come back to learn about the business rather than trying
to accomplish everything in one visit. Use the scheduled appointment (15-20
minutes) to focus on learning about the employer rather than describing the IPS
program. Wait to talk about a job seeker until a third meeting unless the employer
has a pressing need to fill a position.
• Avoid asking about job openings. Instead, focus on a good job match with the
employer and ask the employer to meet the job seeker whether or not there is a
current opening.
• Learn about job development strategies by attending job development training or by
taking the online course for IPS practitioners (www.dartmouthips.org, select
Training and Consultation).

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8. Diversity of jobs developed.
Employment specialists assist clients in obtaining different types of Rating –3
jobs.

Comments: During the past six months, five consumers held three different types of
jobs: cashier(2), dishwasher (1), janitor (1). Three divided by five = .6 (60% diversity).

Source of information: Data provided by the IPS supervisor.

Recommendations:
• See recommendations for individualized job search.

9. Diversity of employers.
Employment specialists assist clients in obtaining jobs with different Rating -3
employers.

Comments: During the past six months, five consumers worked for three different
employers. Three divided by five = .6 (60% diversity).

Sources of information: Data provided by the IPS supervisor, consumer interviews.

Recommendations:
• Develop relationships with a wide range of employers based upon the current
preferences and needs of individuals in the IPS program. Do this for every job
seeker.
• IPS supervisor: help the employment specialist identify businesses to approach for
each job seeker on his caseload.

10. Competitive jobs.

Employment specialists provide competitive jobs options that have Rating -2
permanent status rather than temporary or time-limited status, (e.g.,
transitional employment positions). Competitive jobs pay at least
minimum wage, are jobs that anyone can apply for and are not set
aside for people with disabilities. (Seasonal jobs and jobs from
temporary agencies that other community members use are counted
as competitive jobs.)

Comments: During the past six months, two people worked at transitional employment
positions and two people worked as volunteers (not included in data for diversity of job
types or diversity of employers). Four noncompetitive jobs divided by nine total jobs =
.44 (66% of jobs were competitive).

In IPS, employment specialists refrain from helping with volunteer jobs unless a person
specifically asks for help with a volunteer job because he believes it will lead to
employment. For example, a person heard that the way most AIDS Educators were

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hired at the local HIV/AIDS clinic was through volunteering for the clinic, so his
employment specialist helped him with a volunteer position. Employment specialists do
not suggest volunteer positions.

Sources of information: Data provided by the IPS supervisor, employment specialist

interview.

Recommendation:
• Refrain from suggesting non-competitive jobs. Encourage people to try regular
employment by pointing out their strengths and skills related to competitive jobs.

11. Individualized follow-along supports.

Clients receive different types of support for working a job that are Rating -3
based on the job, client preferences, work history, needs, etc.
Supports are provided by a variety of people including treatment
team members (i.e., medication changes, social skills training,
encouragement), family, friends , co-workers (i.e., natural supports)
and employment specialist. Employment specialist also provides
employer support (e.g., educational information, job
accommodations ) at client’s request. Employment specialists offer
help with career development, i.e., assistance with education, a more
desirable job, or more preferred job duties.

Comments: The level of job supports provided by the employment specialist was not
always congruent with job performance. For example, in one case a working person
appeared to have difficulties with symptoms but rarely saw the employment specialist.
In another case, the specialist has been job coaching a working person (at the worksite)
for more than six months. In many cases, the employment specialist provides supports
to employers while the case managers provide supports to working consumers. For
example, case managers had information about recent changes in pay rates and work
schedules, while the employment specialist was able to provide feedback from the
employer.

In IPS, employment specialists provide job supports to both employers (with consumer
permission) and consumers during the first year or so of employment. Mental health
practitioners also provide job supports related to their scope of positions (medication
adjustments so a person is better able to concentrate at work, practicing new social skills
to use at work, etc.)

Sources of information: Observation of mental health treatment team meetings, mental

health practitioner interviews, employment specialist interview, consumer interviews.

Recommendation:
• Employment specialist: Provide job supports consistently to people who are
working (in addition to employer supports). Examples include meetings to talk
about the job, rides to work, morning phone calls to manage nervousness, help

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 developing natural supports at work, wake-up calls, assistance asking for a change in
work hours, job coaching, help learning orientation material, family meetings to talk
about the job, career planning, celebrations related to the job, meetings with an
employer and consumer to discuss job performance, etc.
• Design job supports based upon each person’s preferences, work history, current
position and performance, feedback from the mental health team, and suggestions
from family members (with permission from the worker).

12. Follow-along supports – Time unlimited.

Employment Specialists have face-to-face contact within 1 week Rating -3
before starting a job, within 3 days after starting a job, weekly for
the first month, and at least monthly for a year or more, on average,
after working steadily and desired by clients. Clients are
transitioned to step down job supports from a mental health worker
following steady employment. Employment specialists contact
clients within 3 days of learning about a job loss.

Comments: The employment specialist reports that he typically provides job supports
for about 90 days post employment. Consumer record reviews demonstrated that he
provided supports for about a year for two working people. This information was
consistent with consumer interviews.

Regarding intensity of supports for new jobs, reviewers observed diverse practices. In
one case, the employment specialist did not provide any job supports, and in another
situation, he met weekly with a person who was newly employed.

Sources of information: Observation of the vocational unit meeting (supervision),

employment specialist interview, consumer record reviews, consumer interviews, mental
health practitioner interviews.

Recommendations:
• Provide job supports from the IPS program for a year or so, on average.
• Provide adequate supports as people start new jobs, for example, most people benefit
from weekly supports during the first couple months of employment.
• Offer supports in locations and at times that are convenient for each person. An
example is providing someone with a ride to work and discussing the job on the way.

13. Community-based services

Employment services such as engagement, job finding and follow- Rating -4
along supports are provided in natural community settings by all
employment specialists. (Rate each employment specialist based
upon their total weekly scheduled work hours then calculate the
average and use the closest scale point.)

Comments: Consumer records indicated that more than half of consumer services were
provided in the community. Reviewers asked the specialist to review his activities for a

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previous week, hour by hour, and it appeared that the employment specialist spent half
of his scheduled work hours in the community.

Sources of information: Consumer record reviews, employment specialist schedule

review.

Recommendation:
• Spend at least 65% of scheduled work hours in the community meeting with
consumers, employers, family members, etc. Meet at businesses, consumer homes,
libraries, coffee shops and other places identified by consumers.

14. Assertive engagement and outreach by integrated team.

Service termination is not based on missed appointments or fixed Rating –5
time limits. Systematic documentation of outreach attempts.
Engagement and outreach attempts made by integrated team
members. Multiple home/community visits. Coordinated visits by
employment specialist with integrated team member. Connect with
family, when applicable. Once it is clear that the client no longer
wants to work or continue in SE services, the team stops outreach.

Comments: The employment specialist reports that he rarely has trouble with
engagement. When a person stops attending appointments he talks to the case manager
and they are able to quickly meet with the person together to discuss her interest in
employment.

Sources of information: Mental health practitioner interviews, observation of the

vocational unit meeting (supervision), employment specialist interview, and consumer
record reviews.

Recommendation:
• No recommendations for this item.

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 Staffing
1. Caseload size Score: 5
2. Employment services staff Score: 5
3. Vocational generalists Score: 5
Organization
1. Integration of rehabilitation with mental health thru team
assignment Score: 5
2. Integration of rehabilitation with mental health thru frequent
team member contact Score: 5
3. Collaboration between employment specialists and Vocational
Rehabilitation Score: 3
4. Vocational unit Score: 2
5. Role of employment supervisor Score: 3
6. Zero exclusion criteria Score: 5
7. Agency focus on employment Score: 3
8. Executive team support for SE Score: 3
Services
1. Work incentives planning Score: 5
2. Disclosure Score: 3
3. Ongoing, work-based vocational assessment Score: 2
4. Rapid job search for competitive job Score: 4
5. Individualized job search Score: 2
6. Job development—Frequent employer contact Score: 2
7. Job development—Quality of employer contact Score: 3
8. Diversity of job types Score: 3
9. Diversity of employers Score: 3
10. Competitive jobs held Score: 2
11. Individualized follow-along supports Score: 3
12. Time unlimited follow-along supports Score: 3
13. Community-based services Score: 4
14. Assertive engagement and outreach by integrated treatment Score: 5
team

Total: 88

115 - 125 = Exemplary Fidelity

100 -114 = Good Fidelity

74 - 99 = Fair Fidelity

73 and below = Not Supported Employment

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