Availability of Supported Employment in Specialty Mental Health Treatment Facilities and Facility Characteristics: 2014

National Mental Health Services Study

Short Report

June 15, 2017

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In Brief

Past research indicates that many people with serious mental illness (SMI) want to work and can be successful with the right supportive services.
Supported employment, which focuses on matching individuals with SMI to jobs best suited for them and providing continuous support during employment, is an evidence-based practice backed by many research studies.
In 2014, only 19.6 percent of specialty mental health treatment facilities in the United States offered supported employment and percentages varied by state.
Facilities that delivered services in inpatient settings were less likely to offer supported employment (12.4 percent) than facilities that delivered services in residential (23.1 percent) or outpatient settings (21.6 percent).
Facilities operated by public agencies or departments were more likely to offer supported employment (29.1 percent) than those that were privately operated (10.3 percent of for-profit and 19.4 percent of non-profit facilities).

Availability of Supported Employment in Specialty Mental Health Treatment Facilities and Facility Characteristics: 2014

Authors

Laura J. Sherman, Ph.D., Sean E. Lynch, Ph.D., L.C.S.W., Judith Teich, M.S.W., and William J. Hudock

Introduction

Over two-thirds of individuals with serious mental illness (SMI) want to work and indicate that finding appropriate employment opportunities is a top priority.¹ In addition to providing income, the opportunity to work facilitates social inclusion and influences many aspects of health status.² For people with disabilities, employment can serve to increase self-esteem, social integration, and participation in community activities. Employment is viewed as a primary treatment goal for people with a psychiatric disability. For these reasons, the employment of individuals with SMI is being measured as part of the Healthy People 2020 objectives, a set of scientific objectives for improving the health of Americans, which are measured over a 10-year period.³

Despite the widespread recognition that employment is a crucial component of recovery, prevalence estimates from the National Survey on Drug Use and Health indicate that the proportion of individuals with SMI (i.e., those surveyed who live in households and met criteria for a diagnosable mental illness with substantial impairment) who were employed fell from 56.0 percent in 2008 to 48.5 percent in 2013.⁴ This decline is in contrast to substantial improvement in the overall U.S. employment rate during the same period.⁵ Employment rates are found to be even lower among individuals receiving public mental health services, ranging from 17.9 percent to 39.0 percent depending on the definition of the sample.⁶ Many people with a psychiatric disability want to work and could be successful in achieving competitive employment with the help of an evidence-based supported employment service known as Individual Placement and Support (hereafter referred to as supported employment).^2,7

Supported employment is an important intervention that can enable people with SMI to succeed in finding and maintaining jobs.² Supported employment services differ from traditional vocational rehabilitation services.² Supported employment focuses on achieving outcomes by matching individuals to jobs best suited for their skills, strengths, interests, and capacities, and by providing continuous support during employment. Vocational rehabilitation focuses on career counseling, job-seeking skills, training, and assistance navigating job markets. More specifically, supported employment uses eight guiding principles,⁸ which distinguishes it from other vocational support programs:

Every person who wants to work is eligible.
Competitive jobs are the goal.
Supported employment services are integrated with mental health services.
Personalized benefits counseling is provided (to address concerns about potential loss of health benefits and disability payments).
The job search starts soon after a person expresses interest in working (there is no requirement of readiness other than interest).
Employment specialists build relationships with employers (individuals receive more than employment leads).
Individualized job supports are time unlimited (before and during employment).
Individual preferences are honored (this effectively focuses the job search on positions that use individual's strengths and skills and that are aligned with his or her interests).

Along with psychotherapy, medication, family support and education, and case management, supported employment can play a key role in successful recovery.⁹ Moreover, supported employment in itself can be the main motivating factor for which an individual with SMI seeks treatment; individuals may not be ready to admit that they have an illness, but if they are struggling with employment they may accept help from programs that offer supported employment.⁹ However, despite the strong evidence base supporting this type of intervention, recent surveys of state mental health authorities indicate that only about 2 percent of adults with SMI have access to supported employment.^2,10

Specialty mental health treatment facilities provide an ideal setting for individuals with SMI to receive supported employment services. Using data from the most recent national survey, the goal of this report is to describe the number and characteristics of specialty mental health treatment facilities that offered supported employment in the United States.

Data and Methods

The National Mental Health Services Survey (N-MHSS) is an annual survey conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA) of all known mental health treatment facilities in the United States, both public and private.¹¹ The survey is the only source of national and state-level data on the mental health services reported by publicly and privately operated specialty mental health treatment facilities. The N-MHSS is designed to collect data on the number, location, services, and characteristics of mental health treatment facilities throughout the 50 states, the District of Columbia, and the U.S. territories.¹² The N-MHSS is a point-prevalence survey, meaning that it provides a picture of facilities' activities on a given day during the year but may not represent the full scope of facility characteristics or services in a given year.

The 2014 N-MHSS data, which are the most recent analytic data, are used for this report.¹³ There were 14,706 eligible mental health treatment facilities that responded to the survey (the overall response rate was 88.1 percent). Of the 14,706 facilities in the 2014 N-MHSS, basic facility information, service characteristics, and client counts were reported for 13,176 facilities. The remaining 1,530 facilities were excluded from analyses because their service characteristics were not reported, or they were subsequently found to be out-of-scope.

This report focuses on the availability of supported employment.¹⁴ In addition, facilities reported separately whether they offered vocational rehabilitation services.¹⁵ This report examines whether the percentage of facilities offering supported employment differed based on facility characteristics: service delivery setting, facility operation, and religious affiliation. In addition, the report examines whether facilities offering mental health treatment programs or groups designed exclusively for persons with SMI offered supported employment and whether the types of payments or funding accepted were related to offering supported employment. Item response rates were high for basic facility characteristics and services offered (98.1 to 100 percent); response rates for funding sources were slightly lower (75.0 to 97.6 percent). For calculating percentages, facilities with missing responses were considered to not have the characteristic or service specified.

Because the N-MHSS is considered a census of facilities and provides actual counts rather than estimates, statistical significance and confidence intervals are not applicable. The differences between proportions mentioned in this report were assessed using Cohen's h. The results described in the text have a Cohen's h effect size ≥ 0.20, which indicates that there are meaningful differences between the groups.

Overview

The majority of mental health treatment facilities offered neither supported employment nor vocational rehabilitation services. In 2014, just 19.6 percent of facilities offered supported employment (i.e., 2,586 facilities out of 13,176), and 15.9 percent offered vocational rehabilitation services (i.e., 2,093 facilities). However, the delivery of these two services overlapped in most facilities that offered them: 1,435 facilities offered supported employment and vocational rehabilitation services, 1,151 facilities offered supported employment only, and 658 facilities offered vocational rehabilitation only (Figure 1). Therefore, 75.4 percent of facilities offered no employment services.

Figure 1. Employment services offered in mental health treatment facilities: 2014

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Mental Health Services Survey (N-MHSS), 2014.

Facility Characteristics

This report examines whether the percentage of facilities offering supported employment differed by service delivery setting, facility operation, and affiliation with a religious organization (Table 1). Facilities that delivered services in a 24-hour hospital inpatient setting were less likely to offer supported employment (12.4 percent) than facilities that delivered services in residential (23.1 percent) or outpatient settings (21.6 percent). Private facilities (for-profit and non-profit) were less likely to offer supported employment (10.3 and 19.4 percent, respectively) than facilities operated by public agencies or departments (29.1 percent). Approximately half of facilities operated by the U.S. Department of Veterans Affairs (VA) offered supported employment (47.5 percent). Facilities that were affiliated with a religious organization were less likely to offer supported employment than those that were not affiliated with a religious organization (10.0 vs. 20.4 percent).

Table 1. Number and percentage of mental health treatment facilities that offered supported employment by facility characteristics: 2014

* Indicates Cohen's h ≥ .20 compared with the U.S. percentage of 19.6 percent.
¹ Service settings were not mutually exclusive; facilities can offer services in multiple settings.
Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Mental Health Services Survey (N-MHSS), 2014.

Programs or Groups for Persons with Serious Mental Illness

Most mental health treatment facilities (58.5 percent) offered a mental health treatment program or group designed exclusively for persons with SMI. Among these facilities, 27.4 percent offered supported employment; in contrast, only 8.6 percent of facilities that did not offer mental health treatment programs or groups designed exclusively for persons with SMI offered supported employment.

Payments or funding accepted

Figure 2. Percentage of mental health treatment facilities that offered supported employment by type of payment and funding accepted: 2014

IHS = Indian Health Service.

* Comparison between the facilities that accepted the form of payment/funding and those that did not accept the payment resulted in Cohen's h ≥ .20.

Note: These categories are not mutually exclusive; facilities can accept multiple types of payments and funding.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Mental Health Services Survey (N-MHSS), 2014.

As shown in Figure 2, the only funding sources associated with greater percentages of facilities offering supported employment were Community Services Block Grants (29.4 vs. 17.0 percent), Community Mental Health Services Block Grants (29.4 vs. 15.7 percent), and Indian Health Service/638 contract care funds (28.4 vs. 19.2 percent). The percentages of facilities offering supported employment across two additional funding sources—state mental health agency funds (22.8 vs. 15.3 percent) and VA funds (25.8 vs. 18.0 percent)—were close to the criteria for a meaningful difference (Cohen's h = 0.19).

State Results

Table 2 presents the percentages of specialty mental health treatment facilities that offered supported employment in each state. In 2014, these percentages ranged from 7.2 percent (Arkansas) to 44.6 percent (New Hampshire).

Table 2. Supported employment in mental health treatment facilities: 2014

^{* Cohen's h ≥ .20 compared with total U.S. percentage. Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Mental Health Services Survey (N-MHSS), 2014.}

Discussion

Despite widespread evidence and attention that supported employment is effective and beneficial, it was offered in relatively few specialty mental health treatment facilities. These data suggest that there is a clear gap in the availability of an evidence-based practice that can increase and sustain employment among adults with SMI and that can aid in their recovery.

Unsurprisingly, facilities offering inpatient services were less likely to offer supported employment services because inpatient settings tend to serve patients with more functional impairment than patients served in outpatient settings. Moreover, the goals of inpatient care are different from those of care delivered in residential and outpatient settings: the latter are more focused on recovery and rehabilitation.

The percentage of publicly operated or funded facilities that offered supported employment was higher than the percentage of privately operated facilities; yet because most mental health treatment facilities in the United States are privately operated, there were more private facilities that offered supported employment. Nonetheless, public operation and funding were associated with supported employment; for example, the higher rate of supported employment offered in facilities operated by the VA is a part of its programs to help veterans become integrated into their communities.

These data allow us to see a snapshot of services offered across the United States in public and private specialty mental health treatment facilities, but the data have some limitations and important considerations. The data, which are the most recent release, were collected in 2014, and the number of facilities offering supported employment may have changed in the last 2 years. In 2014, SAMHSA awarded seven 5-year grants to states (Alabama, Connecticut, Illinois, Ohio, Kansas, Utah, and Washington) to establish two site locations offering supported employment and to make policy and financial changes with the goal of sustainability and scalability under the Transforming Lives Through Supported Employment program. Further, because the N-MHSS is a survey of facilities and their characteristics, it cannot be determined whether or how many clients used supported employment services, the characteristics of clients who used these services, or the nature and quality of the services offered. Additionally, although facilities that accepted funding from federal government grants were more likely to offer supported employment, it cannot be stated from these data whether the federal funds were used to finance the supported employment services. It is also not known whether and how facilities distinguished the difference between vocational rehabilitation services and supported employment even if they used the provided survey definitions.^14,15

A main barrier to facilities offering supported employment is the financing and reimbursement of services.² Some states have made supported employment available under Medicaid, but states vary widely in their use of financing practices for the service. In 2011, the Office of the Assistant Secretary for Planning and Evaluation published Federal Financing of Supported Employment and Customized Employment for People with Mental Illnesses: Final Report, which describes ways that states can draw on multiple funding streams to offer supported employment,¹⁶ but funding challenges still remain.² Policy implications of the Social Security Administration's Mental Health Treatment Study suggest ways to increase funding, implementation, and approaches to improve access to supported employment services.¹⁷

Facilities can use SAMHSA's Supported Employment Evidence-Based Practices Kit to integrate services into their treatment programs.¹⁸

Given that most adults with SMI can and want to work, employers can help support and accommodate employees with mental illness in the workplace. Most accommodations can be provided with little or no cost to the employer (e.g., by offering flexible schedules or opportunities to telework).¹⁹

Individuals with SMI may also be able to obtain employment and vocational services from other settings beyond specialty mental health treatment facilities. For example, at the national, state, or local level, departments of labor, vocational rehabilitation offices, departments of education, and disability services may serve the population of adults with SMI and psychiatric disabilities. However, these types of agencies and organizations often have broader missions, focus on different populations, and provide more traditional vocational rehabilitation services rather than evidence-based supported employment.²

To find specialty mental health treatment facilities that offer supported employment, use SAMHSA's Behavioral Health Treatment Locator: https://findtreatment.samhsa.gov/.

Endnotes

McQuilken, M., Zahniser, J. H., Novak, J., Starks, R. D., Olmos, A., & Bond, G. R. (2003). The Work Project Survey: Consumer perspectives on work. Journal of Vocational Rehabilitation, 18(1), 59–68.
Drake, R. E., Bond, G. R., Goldman, H. H., Hogan, M. F., & Karakus, M. (2016). Individual placement and support services boost employment for people with serious mental illnesses, but funding is lacking. Health Affairs, 35(6), 1098–1105.
U.S. Department of Health & Human Services, Office of Disease Prevention and Health Promotion. (2010). Mental health and mental disorders objectives: MHMD-8. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders/objectives
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (n.d.). Healthy People 2020 [Web page]. Retrieved from https://www.healthypeople.gov/2020/data-search/Search-the-Data#objid=4818
Bureau of Labor Statistics. (2016). Labor force statistics from the Current Population Survey [Line graph]. Retrieved from http://data.bls.gov/timeseries/LNS14000000
Substance Abuse and Mental Health Services Administration. (2014). 2014 CMHS Uniform Reporting System output tables. Retrieved from https://wwwdasis.samhsa.gov/dasis2/URS.htm
Marshall, T., Goldberg, R. W., Braude, L., Dougherty, R. H., Daniels, A. S., Ghose, S. S., et al. (2014). Supported employment: Assessing the evidence. Psychiatric Services, 65, 16–23.
Dartmouth Psychiatric Research Center. (2011/2014). IPS Trainer's Guide to "IPS Supported Employment: A practical guide." Retrieved from https://www.ipsworks.org/wp-content/uploads/2014/04/trainers-guide-to-ips-supported-employment-a-practical-guide.pdf
Dixon, L. (2016, October 3). KSOC-TV: Altering the course: First episode psychosis intervention [Video file]. Retrieved from https://www.youtube.com/watch?v=nxCy-88hRXE
Bruns, E. J., Kerns, S. E., Pullmann, M. D, Hensley, S. W., Lutterman, T., & Hoagwood, K. E. (2016). Research, data, and evidence-based treatment use in state behavioral health systems, 2001–2012. Psychiatric Services, 67(5), 496–503.
Previously, N-MHSS was a biennial survey. Since 2014, N-MHSS has been conducted annually, alternating between a full-scale questionnaire and an abbreviated locator questionnaire. In 2012, the abbreviated locator questionnaire was administered with the questions about supported employment or vocational rehabilitation services omitted. In 2014, the full-scale version of N-MHSS was conducted, and the abbreviated N-MHSS-Locator Survey was conducted in 2015. The abbreviated N-MHSS-Locator Survey includes only basic facility information needed to update SAMHSA's online Behavioral Health Treatment Services Locator (https://findtreatment.samhsa.gov/).
In the 2014 N-MHSS, the territories included American Samoa, Guam, Puerto Rico, and the U.S. Virgin Islands.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2016). National Mental Health Services Survey (N-MHSS): 2014. Data on mental health treatment facilities (HHS Publication No. SMA 16-5000, BHSIS Series S-87). Rockville, MD: Author.
N-MHSS definition: Supported employment services include assisting individuals with finding work; assessing individuals' skills, attitudes, behaviors, and interests relevant to work; providing vocational rehabilitation and/or other training; and providing work opportunities (http://info.nmhss.org).
N-MHSS definition: Vocational rehabilitation services include job finding/development; assessment and enhancement of work-related skills (e.g., writing a resume, taking part in an interview), attitudes, and behaviors; as well as providing job experiences to clients/patients. Transitional employment is also included (http://info.nmhss.org).
Karakus, M., Frey, W., Goldman, H., Fields, S., & Drake, R. (2011). Federal financing of supported employment and customized employment for people with mental illness: Final report. Prepared by Westat, Inc., for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, under contract #HHSP23320095655WC. Retrieved from https://aspe.hhs.gov/basic-report/federal-financing-supported-employment-and-customized-employment-people-mental-illnesses-final-report
Drake, R. E., Frey, W., Karakus, M., Salkever, D., Bond, G. R., & Goldman, H. H. (2016). Policy implications of the Mental Health Treatment Study. Psychiatric Services, 67(10), 1139–1141.
Substance Abuse and Mental Health Services Administration (SAMHSA). (2010). Supported employment: Evidence-based practices kit (DHHS Pub. No. SMA-08-4364). Rockville, MD: Center for Mental Health Services. Retrieved from https://store.samhsa.gov/product/Supported-Employment-Evidence-Based-Practices-EBP-KIT/SMA08-4365
Substance Abuse and Mental Health Services Administration (SAMHSA). (2016, June 22). Accommodating mental illness in the workplace. SAMHSA NEWS. Retrieved from https://newsletter.samhsa.gov/2016/06/22/mental-illness-in-the-workplace/

suggested citation

Sherman, L.J., Lynch, S.E., Teich, J. and Hudock, W.J. Availability of supported employment in specialty mental health treatment facilities and facility characteristics: 2014. The CBHSQ Report: June 15, 2017. Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Rockville, MD.

Summary

Background: Many people with serious mental illness (SMI) want to work and can be successful with the right supportive services. Supported employment is an evidence-based practice backed by many research studies. Method: Using data from the 2014 National Mental Health Services Survey (N-MHSS), this report examined the number and percentage of facilities that offered supported employment by facility characteristics and by U.S. state. Given that the N-MHSS is a census of all public and private mental health treatment facilities in the United States, Cohen's h was used to test the magnitude of differences between percentages (Cohen's h ≥ .20 is considered a meaningful difference). Results: In 2014, only 19.6 percent of specialty mental health treatment facilities in the United States offered supported employment. Supported employment was more common in facilities that offered services in outpatient settings (21.6 percent) than inpatient settings (12.4 percent). Facilities operated by public agencies or departments were more likely to offer supported employment (29.1 percent) than those that were privately operated (10.3 percent of for-profit and 19.4 percent of non-profit organizations). The only funding sources associated with greater percentages of facilities offering supported employment were Community Service Block Grants (29.4 vs. 17.0 percent), Community Mental Health Services Block Grants (29.4 vs. 15.7 percent), and Indian Health Service/638 contract care funds (28.4 vs. 19.2 percent). States had varying percentages of facilities that offered supported employment, ranging from 7.2 percent in Arkansas to 44.6 percent in New Hampshire. Conclusion: Despite widespread evidence that supported employment offers many benefits to individuals with SMI, it is offered in less than a quarter of mental health treatment facilities.

Keywords: employment, supported; facilities; mental health; mental health services; N-MHSS; serious mental illness; services

Author Information

CBHSQrequest@samhsa.hhs.gov

Keywords

Alabama, Alaska, All US States and Territories, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming, Short Report, Mental Health Facility - Treatment Data, 2014, Funders, Policymakers, Public Health Professionals, Public Officials, Researchers, Mental Illness, People with Mental Health Problems as Population Group, Unemployed, Supported Employment

The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.

The National Mental Health Services Survey (N-MHSS) is an annual survey designed to collect information from all facilities in the United States, both public and private, that provide mental health treatment. N-MHSS provides the mechanism for quantifying the dynamic character and composition of the United States mental health treatment delivery system. The objectives of N-MHSS are to collect multipurpose data that can be used to assist the Substance Abuse and Mental Health Services Administration (SAMHSA) and state and local governments in assessing the nature and extent of services provided and in forecasting treatment resource requirements, to update SAMHSA's Inventory of Behavioral Health Services (I-BHS), to analyze general treatment services trends, and to generate the Mental Health Treatment Facility Locator [https://findtreatment.samhsa.gov/].

N-MHSS is one component of the Behavioral Health Services Information System (BHSIS), maintained by the Center for Behavioral Health Statistics and Quality (CBHSQ), SAMHSA. N-MHSS collects three types of information from facilities (1) characteristics of individual facilities such as services offered and types of treatment provided, primary focus of the facility, and payment options; (2) client count information such as counts of clients served by service type and number of beds designated for treatment; and (3) general information such as licensure, certification, or accreditation and facility website availability. In 2014, N-MHSS collected information from 14,706 facilities from all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and the U.S. Virgin Islands. Information and data for this report are based on data reported to N-MHSS for the survey reference date April 30, 2014.

The N-MHSS Report is prepared by the Center for Behavioral Health Statistics and Quality, SAMHSA; and RTI International, Research Triangle Park, NC.
Latest N-MHSS public use files and variable definitions: http://www.datafiles.samhsa.gov - Other mental health reports: https://www.samhsa.gov/data