Serving MH Customers

• What is wrong with those people - Barriers

• Why should we care

– Largest Rehab customer group

– Largest group of Ticket to Work holders - 100,000+

– Highest unemployment rate of any disability group

– NAMI says VR system has a “Legacy of Failure”

• What can we do about it

– Use the Research to design systems that work

– Milestone/Results based payment systems

Research

• NIDRR Consensus Panel on Vocational Services for people with a Psych Disability

• Gary Bond - Indiana Univ/Purdue Univ

• Boston Univ. Psych Rehab - Choose-Get-Keep Model

• Dartmouth - IPS Model

• Virginia Commonwealth University

• Sheila Akabas and Lauren Gates at Columbia

Socio-Cultural Barriers

• Stigma is highest of any Disability

• Most Misunderstood disability - ex. depression, schizophrenia

• Consumers have been taught to be passive and unassertive - “good patient” role

• The Tyranny of Low Expectations - frequently Helpers expect little recovery

• Over-protectiveness by family and MH staff inadvertently promotes permanent poverty

Poor Predictors of Job Success

• Diagnosis

• Vocational Testing

• IQ

• Symptomology

• Functioning in other Life Domains

• Hygiene

• Performance in treatment program

Better Predictors of Job Success

• Employment History - 6-12 Months Cumulative

• Fewer and Shorter Hospitalizations

• Positive or Active symptoms of Schizophrenia - active hallucinations correlate with job success

• Current Marriage or family support

• Occupational level prior to onset

• Work Adjustment measures - Work Beh. Inv.

• Self Esteem, Ego Strength and DESIRE

THE KEY TO SUCCESS - YOU

• Informed helpers with a general knowledge of Mental Health who

– Are sensitive to the customers needs and respect their experiences

– Facilitate them making decisions - negotiation

– Value work and the power of success in building recovery/rehabilitation

– View the working relationship as a partnership

– Adapt services to individual needs

– Exercise - voices

Principles of Success

• Consumer Choice - ex. vendor and job

• Integrated Competitive Work - no Sheltered

• Psycho-Social service linkages for support

• Natural Supports - family, friends, co-workers, and especially supervisors

• Rapid Placement - Job of Choice (4-6 wks)

• Pro-active services - not reactive - ex. weekly support contacts

• Job Accommodations

Common Job Accommodations

• Job Sharing/Part-time work - 20 > 30 hr/wk jobs

• Structure the Job - Task Analysis - Checklists

• Job Carving/Restructuring - trade out tough tasks

• Flexible Scheduling - allow late start, Drs. Appts

• Train supervisors in positive feedback and gentle direct timely correction, preferably written

• Designate a co-worker as a mentor/prompter

Ongoing Support Essentials

• Increase support when change at work or home

– Monitor for management changes, layoffs/closure

– Watch for GOOD crisis, promotion or new tasks

• Regularly monitor customer job satisfaction

• Know and monitor early signs of Psych Crisis

• Remember that most entry level unskilled jobs turnover every 3-6 months - recycling is likely

• Encourage Career advancement and education

• Involve the Supervisor in supporting job retention

The Design Problems

• Cultural Differences

– MH System not supportive of work

– MH process not outcome focused, VR too closure (short-term) focused

• Poor outcomes contribute to creaming

– High dropout rate before closure - JC turnover

– Lack of follow-up support by MH case manager

• Lack of training on both sides

– MH little training on value of work in recovery

– VR lack of knowledge about Psych disability

Design Solutions

• Milestone Payment system

– paying for results/outcomes counters process focus

– Higher rates for more difficult cases counters creaming

– Allowing CRPs to bid makes risk of dropouts manageble

• Cross training addresses lack of knowledge

Ticket to Work Basics

• TWWIIA Signed into Law Dec. 1999

• Enhances Work Incentives, EZ Back On, 7 ^1/2 years Medicare, Limits CDR’s, Medicaid Buy-in

• Sets up vocational voucher – the Ticket to Work

• National Program Manager will manage Tickets and Employment Networks - Maximus, Inc.

• Employment Networks (EN) - the direct service providers - must be approved by SSA

• Some EN’s pre-selected-VR, One Stops ,AP’s

• Includes Milestone Payments during 1^st 9 Mos.

• Only VR can choose the existing reimbursement system or the Ticket payment by individual

Ticket to Work Implementation

• Fall 2000 National Program Manager - Maximus

• November 2000 –13 Ticket States selected

• Dec. 2000 – Draft Ticket Regulations

• April 2001 - RFP for EN’s, CRPs, WIBs and Business

• Summer 2001– Final Ticket Regulations

• Summer 2001 – Implemented in 13 Pilot States

• Oklahoma - 99,000 Tickets, 30%+ MH, 20% DD

• Jan 2002 – 20 additional states

• Ohio 300,000+ Tickets issued in 2002 or 2003, about 100,000 MH consumers, Schizophrenia & Affective

• Jan 2003 – Remaining States and Territories

VR Primary Ticket Provider

• Voucher worth $10-16,620

• paid to EN over 6 years - can be assigned to any eligible Employment Network

• Milestone Payments - $1410 SSDI/$900 SSI

– paid during the first year of employment

– balance of voucher value paid monthly over 5 years if

– beneficiary check goes to $0

• VR can choose the reimbursement system by client at the time the plan is signed

• VR may be the only willing Provider for SSI recipients

Vendor Risk Management Options

• Employment Network has Deferred Payment Risk

• Option 1 - Profile/Cream the $1,500 Clients

• Option 2 - Only accept Ticket for individuals you intend to hire - ex. NISH, Blind Vendors

• Option 3 - Join a publicly financed Employment Network – One Stops, VR, MH, DD

Forming a VR Funded Network

• VR/VS Agencies are positioned as the Market Leaders

• Oklahoma DRS is piloting a VR sponsored Employment Network

• Potential 200% growth of Case Service Funds at 3%-4% Ticket use rate

• Need a system for Choice based Screening

State Agencies Need a Contingency Plan

• If 10% (30,000) of Ticket Holders in Ohio apply for services this will greatly increase the number of applications to process

• As many as 100,000 may call for information, stressing phone systems and staff

• How can we take more applications

– Screen prospective customers using One-stop system to limit number of apps

– Hire VR Clients as Temporary Work Incentive Staff

– Streamline application and eligibility process

Choice Based Self Screening

• We must have a system to handle a huge increase in SSA Beneficiary interest

– 4 Step Self Screening Process

– Recruiting by advocacy organizations by mail and phone – 100% of Ticket Holders

– Work Incentive Meeting at One-Stop to brief beneficiaries on benefits of working and Work Incentives – 20-30% of Ticket-holders attend

– Facilitated use of the One-Stops Core and Intensive Services – Screening - 10% complete

– VR Application and referral to CRP under Milestone contract for Short Term Job Coaching or Supported Employment - after screening - 5%

One Stop - Work Incentive Meeting

• Trainers and Exemplars/Role Models explain value of work as part of recovery

• Trainers review SSI/SSDI work incentives

• Trainers review “average” scenarios using VCU’s WorkWORLD software

• Assign Service facilitator to assist customer to:

– complete core services, Resume, Career Exploration

– Gather benefits and application information and

– write an assessment summary for VR counselor

Okla. SSA funded Voucher Pilot

• To Inform consumers, advocates and MH Staff on the value of work in recovery and use of Work Incentives

• Facilitate Medicaid buy-in

• Pilot Ticket Implementation Issues:

– Started issuing Vocational Vouchers Sept. 1999

– Response Rate - 35-40% attended Work incentive meeting and 8-10% got on caseload

– Equitable provider payment rates - $3500-$10,000

– Facilitating Consumer Choice - Vendor Report Card

– Work out methodology for a VR sponsored Employment Network

OKLA DRS Pilot Structure

• VR Contracts with competing Vendors

• Issue OK Vocational Voucher at Work Incentive Meeting

• Issue Vendor Performance Report Card

• Consumer has choice of 2 Models (Clubhouse and IPS model) & 4 Vendors

• Consumer Assigns Voucher to Vendor

• Enrolled by VR – 6 Milestones total=$6,500 ave. for SE

• SSA funds used for Incentive Payments to provider for Job Retention, reaching SGA, jobs with Medical Benefits

Subcontracting: Vendors as Partner

• Vendors will bring Tickets to VR if they are full partners paid at Market based rates

• We need them

– We don’t have the capability to JC with our staff, most SSA beneficiaries will need a JC or Personal Assistant

– Cheaper, faster with better quality to contract out

– May have longstanding relationships - DD/MR/MH

• They need us

– They don’t have risk tolerance we do - RSA funds

– Under Ticket we can manage the risk better

– We can choose by individual whether to bill under existing reimbursement system or Ticket system

DRS Ticket Implementation

• Create a Unit/work group charged with Ticket Implementation and tracking, add staff to 2 units

• Identify current clients who are SSI/SSDI

• Educate Staff on purchasing supports for success - Supported Employment & Short JCing

• Set rates for services for Ticket Holders

• Expand provider network - sub-contracts (SE+)

• Actively recruit Ticket holders

• Pilot Screening with One-Stop/Workforce

• Track services provided and SSA payments

• Create incentives to encourage staff

OK Pilot Milestone Payments

• Six Milestone Supported Employment payment structure + Ongoing Support

• Determination of Needs - 10% of Bid $650

• Vocational Preparation - 10% of Bid $650

• Placement 3rd day of work- 10% “ $650

• 4 Weeks Job Retention - 20% “ $1,300

• Stabilization 10 weeks work - 20% $1,300

• Rehabilitated 6 months work - 30% $1,950 Total = $6,500 BID

• Quarterly Job Retention Payment - SSA Funds - $400/Qtr.

Quality Indicators - Example

• Milestone 5-Stabilization on the Job

• Tenure on Job - 10 weeks minimum

• Job matches the career goal

• Job Coach has reduced job support to maintenance level, twice per month.

• Worker/Consumer Satisfaction

• Employer Satisfaction

Vendor Performance Report Card

• Developed over 3 months with consumer/ customer focus groups with vendor comment

• Identified key information for decisionmaking

• Report Developed with and Published by National Results Council

• Two Components

– Vendor Background - refreshed annually or on request

– Report Card - compares vendors, refreshed quarterly

Vendor Background Sheet

• Name, Address, Picture, Map, contact person

• Vocationally Related Services Available

– case management, medications, worker support

• Type of Job Placements by percentage, 4 F’s

• Percent of Customers with PASS Plans

– indicator of career focus

• Length of Job Experience of Job Coaches

– consumers tired of training new JC’s

Report Card

• Consumer Satisfaction - Independently Surveyed by Consumer Advocacy Organization at 30 days and 6 months on the job

• Percent of Jobs rated by

– Wage by High, Medium and Low

– Hours average per week

– Benefits percent with Medical Benefits

• Length of time prior to starting a job - Time from intake to first placement

Overview of Milestone Concept

• Based on incentive payments for outcomes

• Win/Win/Win

– Consumers receive quick, quality service

– Vendors receive adequate compensation, less regulation and greater flexibility

– Funding Agency purchases outcomes not process, achieving better results at lower cost with greater accountability.

Milestones Four Essential C’s

• Customer Centric valued outcomes, services, length

– not Funder Centric (VR status’ and 90 day closure)

• Consumer Choice/Control over the funding flow

– Customer satisfaction is a payment criteria

– Customers can reallocate funds to Vendors who get more outcomes for them – ex. vouchers

• Collaborative Stakeholder Planning and Evaluation

– Customers, Vendors, Funders have equal voices in design

• Contains Creaming Countermeasures

– Risk Referenced Rates-more difficulty=higher rate

– Reasonable Risk-use a probability based (stochastic) model to allow for drop-outs and stop-outs

Definition of a Milestone

• An important event or turning point in a lifetime or career.

• Three Levels of Milestones

– The BIG Milestone - such as 12 cumulative months of employment or starting a career that leads to improved self esteem and identity shift.

– The small milestones or steps that help reach the BIG Milestone.

– Ongoing milestones related to maintenance of the Job and Career advancement.

VR-MH Contracting System

• A level of service to match consumer needs

• Four levels - Three contracted out to CRPs

1) VR Counselor + Placement Specialist - 5%

- customers who can make use of Job leads

2) Placement - CRP, Individual Job Counselor - 10%

- customer who needs Job Club + directed Job Search

3) Short Term Job Coaching Contractor - CRP - 25%

- customer who needs a Job Site Trainer and

- 90 days of support is adequate

4) Supported Employment -Experienced MH CRP- 60%

- customer needs Job Site Training and Support as long as employed to insure retention

Vendor Milestone Bidding

• The Bidding Process

– Vendors develop program budget

– Estimate the numbers who can be served

– Estimate the number who will complete each Milestone (project the number of dropouts)

– Plug the above figures into the weighting formula to arrive at a bid per consumer

– Bids represent average cost per customer outcome

– Costs out each partial result for the customer

• Next 3 Slides show a Supported Employment Bid

Results of Bidding Process

• Vendors and Funder share risk

• Meets funders need for accountability

• Vendors for liquidity - cash flow

• Customers get Quick/Quality Service

• Bidding-vendors can customize risk

– allowance for stop-outs and drop-outs

– differing levels of difficulty

– allows vendors to adjust costs to reflect micro-economic factors

Planning the Change

• Executive authorizes change and timetable

• Executive delegates planning to cross-functional team and sets parameters

• Planning Team process-6+meetings/3+mths

– Develop operational definitions for outcome(s)

– sub-divide into incremental steps/Milestones

– develop payment % for each step/Milestone

– define quality indicators for Milestone paymnts

Grant Revell (VCU) How To’s

• Define the specific outcome desired

• Define the Payment Units or points

• Establish a cost or percentage for units

• Establish the total cost of final outcome - bid or cost averaging

• Add any supplemental services

The Solution - Planning

• Cross-functional teams - Agency +Vendors +Stakeholders plan the incentive structure

• All planning partners agreed to create a system which will meet customer, vendor and agency needs

• Committed to collaboration and negotiation

• Resulted in less resistance to change

Obstacles to Change

• Ending US and THEM thinking

• Changing Adversarial to Collaborative

• Change Process thinking to Results

• Change from Ruling to Coaching

• Philosophy change from Command & Control (Soviet Model) to Strategic Incentive Management

Website Address:

www.milestonemanagement.com

email:

dan.obrien@milestonemanagement.com

or

deobrien@aol.com