Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Supported Employment
Workbook
Chapter 4: Referrals
Chapter overview
This chapter describes how consumers who may benefit from supported employment are identified and referred to these services.
Making consumers and practitioners aware of the goals and practices of supported employment, and implementing a simple referral process, is crucial to linking people to the supported employment program. To make services accessible to as many consumers as possible, minimal criteria must be used. Informing different stakeholders about the availability of supported employment, and the process for receiving these services, increases the potential number of consumers who may be engaged in supported employment.
Using this Chapter
In the sections that follow, case examples illustrate the principles of an effective referral process for supported employment services, including:
- Eligibility criteria
- Making the referral process simple
- Getting the word out about supported employment
After reading the vignettes, please challenge yourself by listing possible strategies for solving the problems described before reading on.
Remember:
An effective process for referring consumers to supported employment:
- imposes minimal exclusion criteria
- is simple
- involves multiple stakeholders
Supervisor’s note
This chapter lends itself to group teaching and discussion.
You can use one section each week to stimulate a discussion of the issues.
Eligibility Criteria
This section describes issues related to determining who may benefit from supported employment, as illustrated with Caleb’s experience.
Case history: Caleb's story
Caleb is a 28-year-old man with dual disorders of schizophrenia and substance use disorder. During a weekly team meeting, Caleb’s case manager reported that Caleb has expressed an interest in getting a job. The case manager described his concern about Caleb increasing his alcohol and marijuana use if he earns money. The past two urine screens have indicated that he continues to use substances.
Tackling the issues
If you were the employment specialist, what would you do?
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Reasonable responses
Some Possible Responses: There is no single correct answer as to how to handle this situation, but here are a few ideas.
In supported employment, consumers who express interest in working are referred directly to the supported employment program. They are not screened for abstinence, work readiness, cognitive impairment, etc. As the employment specialist, you support this process by encouraging referrals of potentially interested consumers in team meetings. You educate the team about how work can motivate someone to manage their substance abuse. You could suggest that a plan be developed with Caleb around managing his work earnings. Jobs that may promote abstinence should be considered.
Recommended criteria for entrance into supported employment
The criteria for receiving supported employment services should be kept to a minimum, and are best limited to the following:
- The consumer is unemployed (or working non-competitively) and wants competitive work, or
- The consumer is working but not receiving employment supports, and he/she wants such support.
Making a Referral
This section describes how to establish a simple referral process, and the steps needed to engage consumers after a referral has been made.
Case history: Sandra’s Story
Sandra has not worked in four years, and her case manager has begun to discuss with her the possible benefits of working. Sandra has a daughter who lives with her mother, but with whom she has regular contact. At first, Sandra expressed concerns about her ability to deal with what she perceived to be the stress of working. In exploring this issue with her case manager, Sandra also began to see that work would provide extra money that she could use when spending time with her daughter, and that she would provide a good role model for her daughter. Although Sandra was concerned about meeting the demands of a competitive job, she also thought work would make her feel better about herself. Sandra told her case manager that her mother is concerned that she will lose her benefits if she begins working again. The case manager mentions Sandra’s interest in work at a treatment team meeting.
Tackling the issues
If you were the employment specialist, what would you do?
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Reasonable responses
Some Possible Responses: There is no single correct answer as to how to handle this situation, but here are a few ideas.
The process for referring consumers to supported employment services should be as simple as possible, standardized, and widely known by all, including practitioners and consumers. Within the treatment team, referral should be sent to you, as the employment specialist, and to the team leader, so that he or she can track activity. Referrals can be made either verbally or in writing, with the critical information recorded on a simple form (see Appendix A for Sample Referral Form). Any person on the treatment team can make the referral, as well as the consumer himself or herself. Sandra’s case manager could refer her to the supported employment program by contacting you, as the employment specialist on her team, either during a team meeting or outside of the meeting.
Treatment teams and vocational teams are organized differently from one agency to the next. In terms of the referral process, the key point is to make sure the consumer is paired with an employment specialist as soon as the consumer expresses interest. It should be clear to everyone who receives the referral, e.g., treatment team leader, employment coordinator, or employment specialist.
Once a referral has been made for Sandra, it is important for you to meet with her as soon as possible, preferably within one week of the referral. The purpose of this meeting soon after the referral is to confirm Sarah’s interest in work (or in obtaining support if the consumer is working), and to begin the process of identifying work interests, background experience, etc. This meeting can occur with just you and the consumer, or may involve another practitioner (e.g., the case manager) or significant other of the consumer’s choosing (e.g., family member). Because of Sarah’s ambivalence about working, it may be helpful to include the case manager in this meeting. Consumers who have difficulty establishing new relationships with practitioners may also benefit from their case manager participating in initial meetings with you.
After an individual meeting has been held between you and Sarah, and an agreement to work together has been established, the treatment team should be notified and periodically updated regarding her progress. At this time, with Sarah’s permission, it would also be important to contact Sarah’s mother and arrange a meeting to explain the nature and purposes of the supported employment program, to ally her concerns about the effects of work on Sarah’s disability entitlement, and to develop a collaborative working relationship that is supportive of Sarah’s goal. The initial meeting with Sarah’s family could also provide possible job leads.
Getting the Word Out
This section describes how to maximize referrals to the supported employment program by informing multiple stakeholders of the availability of the program.
Case history: No one wants to work: One agency’s story
A new supported employment program had been recently developed at River Valley Mental Health Center. At a team meeting, a supervisor commented that she had read research literature indicating 70% of people with severe mental illness have a goal of working. She said that only 7% of the consumers at their center are working. Several case managers said that consumers are not expressing an interest in going to work and few consumers have been referred to the supported employment program.
Tackling the issues
What are possible reasons for the low rate of referrals and how could River Valley stimulate consumers’ interest in work and referrals into their supported employment program?
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Reasonable responses
Some Possible Responses: There is no single correct answer as to how to handle this situation, but here are a few ideas.
There are many strategies the supported employment program at River Valley could use to encourage referrals of consumers to the program. As an employment specialist, you should educate team members about your supported employment program, and actively seek referrals by exploring with team members potentially appropriate consumers during team meetings. Mental health practitioners often are not aware of the high value placed on work by consumers, and may be unfamiliar with the principles of supported employment. Practitioners may also inaccurately perceive that work may be unduly stressful, or that certain consumers may be unable to work because of cognitive impairments, symptoms, or medication side effects. Arranging a session in which working consumers describe their experiences or inviting a supported employment speaker to address practitioners’ concerns are helpful ways to educate practitioners. Communicating the values of work, the fact that many consumers can work despite persistent symptoms or cognitive impairments, and the fact that most consumers do not find that work increases stress (and some report that it decreases it) would help to stimulate referrals at River Valley. Conducting an inservice on supported employment, making brochures available (see EBP website for information sheets for different stakeholders), and mounting posters at the Center are additional strategies for informing staff about the program. The goal is to create a culture of work. All practitioners provide hope and encouragement for consumers to consider working and realizing their dreams.
Increasing referrals: some strategies
Strategies for increasing referrals
- Educate the other team members about supported employment.
- Talk to consumers who may be interested in work to let them know about the new program.
- Speak at the local consumer peer support center, if there is one, to educate consumers about work and supported employment.
- Speak at a National Alliance for the Mentally Ill (NAMI) meeting to let families know about the offering.
Another way of encouraging referrals is to offer to meet individually with consumers who are interested in learning more about supported employment, but have not yet expressed a clear desire for competitive work. Rather than making contact with you contingent upon the consumer expressing a clear desire for these services, you can meet with interested consumers to educate them about supported employment, and to help them explore whether they might like to try it. Making it clear to the other team members that you are willing to meet with consumers who have not yet decided to participate in the program can increase the chances that consumers will become interested and choose to pursue supported employment.
Motivation for referral can come directly from consumers and their families as well as from other practitioners. Consumers can be educated directly about supported employment services, either by their case managers, through consumer-related activities (such as a peer support program or resource center), or through “information groups” conducted periodically (e.g., weekly or biweekly) at River Valley. Highlighting the supported employment program during the agency’s intake process informs consumers who are new to the agency. In some cases, the supported employment program may be what interests people in receiving agency services at all. Similarly, family members can be informed about the availability of supported employment services through practitioners who have regular contact with them or by means of local support groups, such as local chapters of The National Alliance on Mental Illness.
Chapter summary
Getting the referrals coming can take some work at first. This chapter suggests writing simple eligibility requirements for referrals, making it easy to refer, and educating all relevant practitioners, consumers, and family members about the availability of supported employment services.
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