The Center

The Work and Recovery Project: Site Status and Activities

Updated: November 29, 2004

Site Status and Activities

St. Luke’s-Roosevelt Integrated Psychiatric Services

  • The St. Luke’s-Roosevelt proposal sought to use the WRP to make a culture shift, on both consumer and systems level, in thinking away from an institutional model toward a model instilling hope and emphasizing rehabilitation at all levels of service delivery.
  • As a result of the consultation, the IPS sought to provide clinical and vocational services across the full continuum of services for clients with serious mental illness.
  • IPS aimed to see major increases in program expectations for clients’ independence and employment and in numbers of consumers competitively employed.
  • The WRP at St. Luke’s began in December 2002 and concluded in May 2004
  • During the curriculum phase, 20 staff from administrative leadership, program management including the CDT, dual diagnosis program, and case management clinic participated in six sessions including didactic, experiential, and application components.
  • During this phase, St. Luke’s hosted the first networking meeting with the other Work and Recovery Project sites to present their experience to date and to provide a tour.
  • In May 2003, following completion of the curriculum phase, a project team was identified for the purposes of integrating the curriculum learning into practice. The project team consisted of six leadership and line staff who completed the Work and Recovery Curriculum, two consumers, and both consultants.
  • This phase included consultation to the process of project team development and the integration and design of outcomes and activities intended to promote the infusion of recovery and work activities into the Integrated Psychiatric Services (IPS) ongoing programming.
  • The Project Team identified several short and long term outcomes for further definition, application and evaluation. These included:
    • Improving linkages within the IPS and with outside providers
    • Raising awareness of recovery, periodically re-evaluating recovery goals and adjusting programming based on their impact
    • Increasing consumers’ sense of empowerment and community involvement
    • Linking staff development needs to clients’ work and recovery outcomes
  • The Project Team led
    • The development and implementation of an instrument intended to seek staff attitudes about their clients’ journey toward recovery and work, pre and post their involvement in the Work and Recovery project;
    • A staff development training session with all IPS staff, led by Project Team members, to bring the entire staff within IPS on board to collaborate in the above identified outcomes;
    • The creation and meetings of four subcommittees to work on the key outcomes identified above;
    • A full staff meeting to review subcommittee priorities and recommendations.
    • Project Team members continued leading the subcommittees toward completion of identified outcomes in the areas of linkages, staff education, patient satisfaction, and staff satisfaction. Outcomes via sub-committee work included:
      • Development of a list of community medical providers to increase clients’ access to medical care (the lack of which is a frequent impediment to securing and maintaining work)
      • Consideration of foundation proposals for on-site primary care provider
      • Inclusion of line staff in monthly leadership meetings
      • Staff to be represented on building move committee
      • Plans for work and recovery-oriented programming following the integration of Start and Dual Diagnosis programs from March through May 2004
      • Implementation of a Consumer Advisory Committee
      • Planning for additional staff education activities
    • An IPS Retreat in February 2004 to review subcommittee reports and outcomes and discuss next steps, as well as to discuss the reorganization of the Start (CDT) and Dual Diagnosis programs
    • A follow-up meeting was held in May 2004 with the following service delivery changed noted and observations made:
    • Service Delivery Changes

      • Integration of clients with dual diagnoses into the day treatment program (START) has included work as a significant program component, with more MICA clients involved in vocational and GED services than before.
      • Staff have different emerging expectations for clients that do not focus primarily on disability.
      • There is an expanded view of hiring practices, with thoughtful attention to hiring staff who have vocational and rehabilitative knowledge.

      Observations

      • In order to deal with recovery, the work needs to be understood in the context of larger system goals
      • Subcommittee work has been empowering for exchanging ideas and keeping staff focused. However, implementation has continued to be an issue, without clarity about who holds the authority to make programming changes happen.
      • There is increased cohesiveness among staff.
      • Maintaining momentum can be difficult, given competing organizational initiatives
      • IPS programs are in the midst of a developmental shift, holding the tensions inherent in keeping a safe environment for clients while also encouraging work opportunities and increased independence

F.E.G.S. Manhattan CDT

  • At F.E.G.S., the WRP began in March 2003, the assessment phase was completed in May, training and Project Team work went on through the autumn and the project concluded in December.
  • The F.E.G.S. proposal focused on integrating clinical and work services, each of which is offered in separate divisions (Behavioral Health Services and Work Services), in order to further the goals of increased CDT prevocational programming and linkages to supported employment.
  • Focus group feedback also suggested the possibility of softening boundaries between IPRT and CDT, possibly infusing the CDT with some of the goal orientation and employment emphasis characteristic of the IPRT.
  • The challenges of service and program integration in a large, complex agency with separate divisions were highlighted throughout the assessment process.
  • The consultants and the interdivisional administrative group constituted for the project agreed that the curriculum phase should be undertaken with this administrative group.
  • The consultants then designed a leadership seminar, with participants attending from Administration, the CDTP, Clinic, IPRT and Work Services. In order to promote integration and support increased emphasis on work and recovery, the seminar process consisted of
    • readings to stimulate thinking about structure and program options to promote integration;
    • identification, initiation, and ongoing review and evaluation of specific changes within and between Behavioral Health Services and Work Services.
  • The Administrative Group decided to focus on specific actions to
    • increase the numbers of CDT consumers referred to Work Services;
    • educate CDT staff about Work Services;
    • present options for CDT consumers to spend time in Work Services settings.
  • After exploring a number of approaches to these tasks, the group agreed on specific steps for staff from the respective divisions to "live in" the other division.
  • Goals of this process included
    • working together to identify and act upon work opportunities with and for consumers, and
    • assisting in reciprocal case finding and referral
    • initiating a pilot project of CDT clients participating in Work Services programs
  • The administrative group provided ongoing oversight, led efforts to work through the details of this enhanced collaboration and has also undertaken needed problem-solving to promote these shared efforts designed to integrate services more effectively.
  • The administrative group functioning as a project team, with the assistance of the consultant, provided oversight for ongoing actions, including
    • Work Services staff spending time in CDT, Clinic, and IPRT to co-assess clients for work readiness and opportunities
    • Behavioral Health services staff participating on-site in Work Services to assist in case-finding and referral to BHS
    • Other actions designed to integrate behavioral health and work services for the benefit of consumers.
  • The Administrative Group continued meeting to provide ongoing oversight, undertake problem-solving, and spearhead program re-design.
  • Throughout its work, the group recognized the importance of helping staff develop more positive attitudes about the possibilities for work and recovery for CDT clients.
  • Consequently, the consultant offered two training sessions during October and November 2003 to staff and respective leadership on topics related to work values and promoting work and recovery.
  • The networking meeting, together with a tour, was held in December 2003.
  • Project outcomes and service delivery changes included:
    • Bi-monthly service integration meetings
    • Pilot project for selected CDT clients in Work Services, with improved CDT attendance noted
    • Consultation from Work Services to CDT to increase work-related programming;
    • Consideration of benefits group and travel training
    • Intake form revision to include employment-related information
    • Consideration for staff training for motivational interviewing

Observations

  • Participants recognized the importance of changing staff attitudes.
  • They noted the difference between offering a continuum of services rather than an array of unconnected services.
  • Readings served as a catalyst to thinking about program redesign.
  • Pilot project results included improved CDT attendance and compliance, providing direct evidence for benefits of work-related experience.
  • Leadership sought a safe way to test hypotheses about work; the pilot project experience helped to change staff attitudes.
  • The administrative group aims for further changes within the CDT, including enhanced staff competencies and program changes more oriented towards work.

Upper Manhattan Community Mental Health Center

  • The Upper Manhattan proposal focused on making its CDTP a strong recovery model program, and aimed to
    • significantly increase the proportion of clients engaged in employment and related programs at time of discharge
    • increase the pace of client movement through the CDTP
    • decrease long-stay clients
    • disseminate the recovery model throughout the agency
    • assure a vocational assessment during the intake process
  • The assessment phase was completed at UMMHC in July 2003.
  • The Executive Director sought to include membership from the onsite Transitional Employment Program, the psychosocial Rainbow Program and outpatient program in the curriculum and ongoing consultation process.
  • All of these programs were involved in the assessment phase, since the agency sees the benefit of providing vocational activities more successfully for CDT consumers, yet struggles with implementing services system-wide in an integrated, sustainable way.
  • Curriculum delivery took place from November through December 2003, with participants from the Transitional Employment Program, the psychosocial Rainbow Program, outpatient program and the CDTP. Short and long term outcomes were generated.
  • As of June 2004, staff representing all three programs were working, with client input, to operationalize these outcomes in the Project Team phase.
  • A follow up meeting was held on June 16th, with a networking meeting anticipated to be convened and jointly held with New York Psychotherapy Counseling Center in September 2004.

Service Delivery Changes

  • Project team participants co-designed and participated in two sessions of training on work and recovery principles for AOPD and case management staff. Yearly training in work and recovery during ground rounds is being planned, as a way of institutionalizing work and recovery practice.
  • CDTP, TEP and Rainbow program staff hosted Family and friends day June 18th, to educate families on mental illness, medication and the concepts of work and recovery.
  • Monthly meetings with TEP and CDT staff have been established to discuss issues and access with shared clients across both programs.
  • TEP and CDT staff co-lead a CDT group to begin to integrate conversations about pre-vocational and work possibilities. The next step is to provide the same opportunity with a monolingual group of clients.
  • The agency’s psychosocial assessment has been adjusted to include a vocational assessment for clients at Intake and in ongoing treatment planning.
  • A peer led MICA group has been initiated and an interest has been expressed in the agency to provide peer counselor position(s).
  • A resource manual on recovery resources to be used agency wide is planned.
  • An orientation manual on work and recovery principles and practices for new employees to the agency is planned.

Observations

  • The project provided a forum for the CDTP and TEP to work together in a more collaborative and formalized way.
  • The project team process provided a way to concretize and sustain new skill development and staff attitudinal shift in the areas of work and recovery.
  • Project team participants realize the importance of observing the impact of current programmatic changes to service delivery and making adjustments based on client progress.
  • Participants recognized the importance of changing staff attitudes
  • The project team will be the driving force in moving the recovery model forward on behalf of the organization and aims for further changes in tying recovery training to the agency’s existing supervisory training, establishing ongoing work and recovery training within the grand rounds forum and formally orienting new and existing staff to work and recovery practices.

Fordham-Tremont Community Mental Health Center

  • The Fordham-Tremont proposal built upon a performance improvement project focusing on CDTU clients successfully engaged in employment and assessing whether integration of vocational rehabilitation services and mental health treatment has improved client employment outcomes.
  • Fordham-Tremont aimed to
    • increase the number of clients obtaining employment or volunteer positions
    • help encourage both staff and clients to achieve recovery and vocational goals
  • The project began in September 2003, with the assessment phase completed at the end of the month.
  • Curriculum delivery took place from October through December, with two consumers participating in the training.
  • The Project Team was constituted in December 2003 and met from January — May 2004.
  • The follow-up meeting was held May 10, and the networking meeting took place on May 24 with a PowerPoint presentation by Project Team members.

Service Delivery Changes

  • Project Team accomplishments and outcomes included:
    • Initiation of Work and Recovery performance Improvement Project, including development of a screening tool regarding employment history and interests to be used at intake;
    • Working to integrate vocational assessment into psychosocial assessment through the quality assurance process;
    • development by consumers of an informational hand-out describing benefits of work;
    • Plans to design a consumer poster contest to generate enthusiasm about employment
    • Initiation and implementation of a transitional employment project employing 7 CDT consumers part-time in a mail messenger project as a step towards continued employment.
    • Consideration of other possible employment options, including a thrift shop, repair crew, and other client-run businesses

Observations

  • Project participants noted the benefits of consumer involvement
  • They noted increased contacts between the CDT and other units
  • The importance of changing staff thinking was stressed
  • It was helpful to start the project with the CDT, whose clients are perceived throughout the agency as the most ill
  • Often trainings are good but not implemented since there is no follow-up. The Work and Recovery Project set up a committee to implement recommendations made in the training. This was a good plan.
  • Clients are affected by staff attitudes.
  • There is no way to predict who will succeed in work; this suggests offering employment opportunities to all clients.
  • Motivation and attitudes among staff and clients are important factors in progress towards employment.
  • It is important to be aware of the influence of old behavior patterns and guard against their re-emergence.

New York Psychotherapy and Counseling Center Queens Adult Home CDT

  • The New York Psychotherapy proposal aimed to make the CDTP a conduit by which recipients successfully move into the world of work, and a percentage become self sustaining in independent housing.
  • Additionally, the agency aimed to utilize knowledge obtained in the project to benefit its other two CDTPs and on-site clinic programs at the three adult homes in Brooklyn and Queens.
  • The project began in September at New York Psychotherapy, assessment was completed at the end of October, and curriculum training was delivered in November and December of 2003. The Project Team met from March through May 2004.
  • A follow up meeting was held on June 10th, with a networking meeting anticipated to be convened and jointly held with New York Psychotherapy Counseling Center in September 2004.

Service delivery changes

  • The transition to work group has increased in attendance as a result of the project and recipient’s involvement in the thrift shop.
  • A future goal is to have a new website that will provide staff with work and vocational resources that can be shared across all NYPCC programmatic sites.
  • Providing a greater range of services for recipients to experience successful attempts at work through involvement in two transitional group opportunities, involving visits to familiarize oneself with potential work sites to observe work practices, tasks and relationships.
  • A compendium of job referral information has been made available to staff and recipients who are looking to return to work.
  • Members from the Transition to Work group and staff are in the process of developing a manual and site visits for programs offering competitive employment. The Transition to Work Group is developing a brochure to share with the CDT community, outlining what they are learning about various competitive work opportunities.
  • The Project Team in collaboration with the transition to work group and the CDTP community council has decided to implement a monthly presentation series, inviting guest speakers to educate the community regarding relevant work related issues
  • The project team is expanding the consciousness of recipients and staff regarding recovery and work through holding ongoing focus groups focusing on work related topics.

Observations

  • The project team process provided a place to develop external relationships, resulting in concrete work referrals for recipients.
  • The project reinforced methods to promote clients desired move in the direction of work and provided a process for staff to become engaged and enthusiastic about programmatic and attitudinal change.
  • Staff experienced less resistance than anticipated, on the part of recipients, to explore work as a viable goal in one’s recovery. Similarly, staff learned more about a recipient’s needs regarding work, by asking directly about their interest, rather than assuming about their readiness to work. Recipient goals for work were often realistic upon inquiry.
  • Staff continue to be interested in the varying perspectives on "meanings of recovery" from both a staff and recipient point of view and see this phenomenon as supporting the need for one’s individual journey toward work and recovery.
  • Staff see a benefit to exploring ways to engage a recipient’s "drive and ambition" through their service delivery approach.
  • The challenges of integrating a work and recovery approach within a CDTP, whose recipients reside in an adult home setting, are significant to note. Consideration needs to be given to the impact that culture has on recipients and staff alike, in designing modifications in service delivery.

Key Project Activities and Outcomes

Examples of changes implemented at one or more sites as a consequence of the Work and Recovery Project follow according to the categories identified.

Shifting programming toward work and recovery and incorporating work and related content into CDTP programming

  • Addressing vocational issues from the first contact at Intake through the use of a vocational screening and assessment form
  • The creation of groups that focus on employment readiness, seeking, securing and sustaining employment
  • The development of a patient survey to determine the services and resources clients want to assist them in their recovery
  • Plans to establish a client resource center in a new CDTP site where computers and work stations can be available to clients seeking competitive employment, in addition to teaching job skills
  • Development of work-related groups within the CDTP
  • Arranging for CDT clients to participate in work activities for a portion of their day
  • Developing an in-house supported employment/transitional employment project

Promotion of teamwork and collaboration among programs

  • The development of committees across programs designed to infuse work and recovery practices for those clients who are served by more than one program
  • Creation of an alliance among several agency programs to develop and support possible vocational endeavors
  • Improved interdepartmental communication
  • Development of more structured time for staff to meet together and support each other in the work and in one’s role
  • Realignment of service delivery for those who have a dual diagnosis to include more focused vocational attention in the form of assessment and peer support.
  • Empowering an administrative group to oversee and direct interdivisional efforts
  • Agency-wide planning to increase employment-related assessments

Increased staff skills, knowledge and role development in areas of recovery and employment

  • Seeking grants for ongoing staff training in enhancing competencies in the areas of work and recovery
  • Plans for ongoing in-service training for agency staff
  • Expanding the provision of training to agency staff in work and recovery concepts to broaden the dialogue agency wide and teach new competencies to staff whose programs interface with the CDTP
  • Provision of training on recovery for outpatient staff facilitated by a consumer Assessing attitude change among CDTP and other staff

Increased intra and interagency collaboration

  • Provision of multi-family groups to engage partners in a client’s recovery process
  • Developing linkages with internists for clients’ medical care
  • Instituting more programming efforts that are client driven and reflect an advocacy role
  • Initiating and continuing an inter-divisional leadership and coordination group
  • Constituting a work and recovery team to continue working to implement identified outcomes and develop new goals

Increased attention to consumer empowerment and choice

  • Flier on the benefits of work developed by consumers
  • Employment interest form to be completed at intake
  • Consumers increasingly involved in training and program development decisions
  • creation of a Consumer Advisory Committee to support and create work and recovery opportunities for clients
  • Poster competition regarding mental illness and work

Observations

  • Organizational membership of each site engaged in designing a process with the consultants intended to facilitate the integration of work and recovery concepts into existing practice, through the identification of targeted outcomes that will be sustainable and generative after the consultation ended.
  • At each site there was a focus on expanding the scope of the consultation beyond the CDT, involving those programs within the system that play a significant role in ensuring a consumer’s success in exploring and securing work opportunities.
  • These have often included case management, outpatient and existing work services programs, whose staff also recognize a limitation in their ability to provide independently for consumers’ work and recovery needs.
  • Despite the uniqueness of each site’s staffing, program configurations and organizational history, it is worth noting some key characteristics similar across sites that have contributed to these limitations:
    • During earlier de-institutionalization, CDTPs were initiated to provide state hospital-level care without walls. Therefore their program design and staff represented the most traditional community-based clinical service delivery model. The belief was, and in some cases remains that consumers appropriate for this level of care will always be in need of it.
    • In response to this mandate, CDTPs have told us that they have typically envisioned their mission/purpose as providing care that stabilizes symptoms first, with vocational assessment and planning seen as a secondary or tertiary step. (Some staff, however, recognize that addressing vocational and clinical goals together from the outset may be preferable.)
    • We believe that this emphasis on "clinical first, vocational later" may, together with other organizational factors, contribute to the marginalization of work services and activities in those systems where work services are present.
    • This dynamic is experienced system-wide as well in the creation of services that are generally developed and offered in isolation, limiting flexibility of care based on consumer needs, and reinforcing inconsistency of service providers as a consumer moves from one level of care to another. Staff report difficulties in working interdependently and accessing services on behalf of their clients, with gaps in the competencies needed to assist consumers in transitioning to work successfully.
    • Leadership and staff at each site reported that they found it difficult to design vocational services that would "take hold" within their systems.
    • Funding sources for these programs have had a significant impact on shaping service delivery, often generating program criteria and development. As a result, we noticed that programs might have structural disincentives, limiting access to care and prevent more flexibility system-wide.
    • Initiating and working to sustain organizational change efforts often reveal competing forces, which when understood can have a positive impact on change efforts. During this project we witnessed the following forces at play to one degree or another in the five sites:
      • Staff’s familiar experience of having change mandated administratively;
      • Administration experience of their relationship to funders and regulators as prescriptive, at least in part;
      • With PROS implementation in process, a new dimension of regulation was added to the Project’s purpose and intention; with the premises and practices of the Work and Recovery Project setting the stage for necessary changes that are on the horizon for CDTPs. This approach could be adapted to assist CDTPs in needed restructuring;
      • The history of the original CDT mission and the ways in which traditional community-based clinical services are configured and delivered challenge practitioners’ sense of competency with work and recovery concepts;
      • Working with a recovery model requires practitioners to be in relationship to clients in a non-expert role, clients to expand views of self in relationship to their mental illness, and delivery systems to structure their programs in an extended as well as more integrated way, creating a transformational shift in the current culture.
      • As a result of their experiences of working to internalize a new set of skills and cultural shift in their work roles, project participants expressed a need and desire for additional training both for themselves and for staff not included in the Work and Recovery Project training. This suggests that early on in the consultation process agency leaders be attentive to providing a continuous learning environment. The train-the-trainer model may be helpful in assuring that expertise cultivated in the agency continues to be of benefit organizationally.

These system-wide issues and challenges may continue to merit consideration at individual sites, at networking meetings involving all sites and in looking toward the future as sites continue to make programmatic and system wide changes in the context of a recovery oriented paradigm.

Future Considerations

Undertaking a process of the scope and intent of the Work and Recovery Project requires viewing such a project in the context of an institutional change effort, not merely as a training event. Effectively and respectfully integrating recovery within a service delivery system demands no less than a complex marshalling of an organization’s resources. Additionally complex, yet necessary, is the work of helping all those who participate in such a project to "find their own way" in the work, searching for a conceptual and personal integration of recovery in one’s individual practice and experiencing anew the power of a collaborative relationship.

The following considerations serve to further illustrate these points:

  • The consultation was a useful tool to guide particular sites in considering the impact organizational culture had on how services were delivered. The focus on recovery, along with the project’s collaborative and exploratory design, provided an opportunity for engaging in real institutional change, clarifying roles, and broadening the possibility of dialogue and considering the potential link of client empowerment to staff satisfaction at work.
  • The collaboration between line staff, administration and consumers in the consultation model was a productive one, beginning the process of crystallizing roles and providing forms of communication that broaden the possibility for dialogue, which can lead to substantive organizational and programmatic change.
  • Practitioners are often placed in the role of experts; an assumption inherent in the structure and delivery of most mental health services. The Work and Recovery Project challenged this assumption and encouraged practitioners and system alike to involve consumers every step of the way in their recovery and service provision.
  • Working in partnership with consumers on their behalf allows both practitioner and consumer to diminish the restrictions often placed on them by systemic regulations and arbitrary role distinctions and provides a catalyst for thinking creatively regarding programming, in turn generating a wealth of resources previously unavailable to individuals and systems.
  • At present we cannot predict which consumers will successfully attain and retain competitive employment, leading us to recommend that employment opportunities be offered to everyone with no restrictions.
  • We have, however, noted numerous apparent correlates for consumers securing and maintaining competitive employment that emerged across the five CDTP sites. These are:
    • Working with clients flexibly at different phases of vocational involvement until a client needs or wants a lower level of care
    • Providing a robust transition from interest in work to the acquisition and integration of work in one’s life.
    • Access to resources internal and external to the agency that provide empowering experiences for consumers
    • Effective and efficient external linkages and collaboration as essential
    • components of a service delivery system that supports work endeavors
    • Staff better equipped at targeting skill and role developments with clients
    • Improved staff attitudes about engaging clients in employment
    • Taking on work readiness as a necessary skill in recovery at initial assessment, followed by a more in-depth vocational assessment at intake

Leaders, staff and participants in each organization undertaking a change process will need to adapt the concepts and observations we have presented in this guide to their own unique circumstances. We hope that the guidance we have offered will be of assistance in this regard.