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Competitive, integrated employment: The next step in achieving community integration for people with disabilities
Introduction
This year marks the 25th anniversary of the Americans with Disabilities Act (ADA).1 As the U.S. Supreme Court held in Olmstead v. L.C., the ADA requires states to ensure that people with disabilities are served in the most integrated setting appropriate to their needs.2 While it is important to celebrate the advances made by people with disabilities since the ADA was passed, it is equally important to examine what remains to be done.
People with disabilities wish to be integrated into all aspects of society, including the workplace. Yet nationwide, people with disabilities are employed at a rate of 19.5 percent compared with 68.5 percent of the general population.3 In Illinois, only 264,874 of the approximately 736,900 people with disabilities are employed.4 To fully realize the community integration mandate of the ADA, this employment gap must be bridged.
The Concept of Employment First
Across the nation, states have endeavored to increase community-based services for people with disabilities. In keeping with this trend, the concept of Employment First has gained momentum. Thirty states now have an Employment First policy either in statute or Executive Order.5 Employment First means that “employment in the general workforce is the first and preferred outcome in the provision of publicly funded services for all working age people with disabilities, regardless of level of disability.”6 As envisioned by this concept, employment should occur in an integrated setting and pay a competitive wage—not in a sheltered or segregated setting that pays below minimum wage or no wage at all.
Illinois Employment First Act
In 2013, Illinois enacted a law to make competitive and integrated employment the first option considered when serving people with disabilities of working age. The Illinois Employment First Act requires state agencies to follow this priority and ensure its effective implementation in their programs and services.7 In 2014, Governor Quinn issued an Executive Order requiring the development of a preliminary five-year plan by December 31, 2014, and a final plan by June 30, 2015, to improve community-integrated private employment outcomes for people with disabilities statewide.8 It calls for the appointment of an Employment First Liaison (Liaison) within the Governor’s Office who is responsible for developing the preliminary and final plans in collaboration with state agencies and the Economic and Employment Opportunities for Persons with Disabilities Task Force (Task Force). A preliminary plan was developed by the Task Force by the stated deadline.9 However, an Employment First Liaison has yet to be hired and progress towards devising a final plan has been delayed.
Illinois Employment First Blueprint
The enactment of the Illinois Employment First Act prompted Equip for Equality10 to examine employment services in Illinois and to conduct a survey of every state and Washington, D.C. to discern what others have done to implement Employment First. Highlighting the promising practices of other states, Equip for Equality released the Illinois Employment First Blueprint (Blueprint) in October 2014.11 The Blueprint identifies reforms needed in six key areas to effectively implement Employment First in Illinois and sets forth recommendations to achieve those reforms. The following discussion is based on the findings and recommendations of the Blueprint regarding employment services for people with mental illness.
Supported Employment Services
Supported employment provides personalized supports for people with significant disabilities to find and keep paid employment. It is based on the principle that with the proper supports, all individuals, regardless of the nature or extent of their disability, can be gainfully employed.12 Since 2005, Illinois has offered supported employment services using an evidence-based practice that is targeted to individuals with serious mental illness. This model, known as Individual Placement and Support (IPS), integrates employment services with mental health services. Developed at Dartmouth University, the IPS model is predicated on seven core principles:
1. Consumer choice—all individuals who are interested in working are eligible for IPS;
2. Integrated services—vocational and mental health services are part of the overall treatment approach;
3. Competitive employment in regular work settings—there is no pre-employment training or placement in sheltered or segregated work settings;
4. Place and train—individuals are placed in competitive work settings as soon as they feel ready, without extensive training or a career exploration period;
5. Personalized follow-on support—after placement, individuals and their employers receive ongoing support, if desired, for as long as it is needed;
6. Person-centered service—the job search and follow-on supports are driven by the individual’s personal preferences, experiences, strengths, and choices, not the judgment of the employment specialist; and
7. Benefits counseling—provided to clients to ensure that they can successfully handle any impact of employment on Medicaid or Social Security benefits.13
In the final quarter of Fiscal Year 2014, 1,662 people were receiving IPS services in Illinois.14 For agencies providing these services, a case is considered successful when an individual is employed in a competitive, integrated setting, usually for a minimum of three out of six months. In Fiscal Year 2014, the success rate for this program was 72 percent, an increase from 63 percent in the previous fiscal year.15
Yet despite its success rate, the number of people with mental illness in Illinois who are unemployed has not significantly declined. This is attributable to several factors. One is that funding has been inadequate. Another is that there are not enough qualified providers of IPS services to support the number of individuals with mental illness who need them. An employment specialist working for a provider of IPS services may not exceed 20 consumers on his or her caseload at one time. Because most providers have only one or two employment specialists on staff, the number of individuals they can serve is very limited. Further, because ongoing support services are not Medicaid billable and not reimbursable under IPS, they are difficult to fund. And while provider agencies may hire qualified employment specialists who are well-trained in the IPS model, many clinicians have yet to embrace employment as a necessary part of service delivery or the need to incorporate it into clinical services.16
Lessons to be Learned from Other States
To have a significant impact on the employment rate of people with mental illness in Illinois, use of the IPS model should be expanded. Existing IPS sites should be allowed to serve additional consumers and the number of IPS sites should be increased.17 In this regard, having sufficient funding is critical. New Hampshire provided specific earmarked funds to community mental health providers to enable them to integrate evidence-based supported employment practices, offer training and technical assistance about these practices and build the infrastructures needed to sustain them.18
In addition to adequate funding, providers and clinicians must understand the critical role that employment plays in service delivery and recovery and how to deliver the supports that are needed in an appropriate way. Missouri provided technical assistance to providers to encourage them to integrate employment services into their mental health services and guidance on appropriate delivery of employment supports. The state also employs a support team to assist and provide technical assistance to providers.19 Illinois should take similar actions to effectively implement its Employment First policy.
Conclusion
Increasing opportunities for people with mental illness and other disabilities to procure and retain competitive, integrated employment is the next logical step in rebalancing Illinois’ disability service system towards community-based services. Taking that step will bring Illinois closer to compliance with the ADA’s integration mandate, increase the independence and productivity of people with disabilities and, in turn, reduce their dependence on publicly-funded programs.
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