Employment services for persons with serious mental ... - IOS Press

77

Work 43 (2012) 77–89 DOI 10.3233/WOR-2012-1449 IOS Press

Employment services for persons with serious mental illness in northeastern Ontario: The case for partnerships Karen L. Rebeiro Gruhla,b,∗ , Carol Kauppic,d , Phyllis Montgomerye and Susan Jamesf School of Rural and Northern Health, Laurentian University, Sudbury, ON, Canada Community Mental Health and Addictions Program, Health Sciences North, Sudbury, ON, Canada c Social Work, Laurentian University, Sudbury, ON, Canada d Centre for Research in Social Justice and Policy, Laurentian University, Sudbury, ON, Canada e School of Nursing, Laurentian University, Sudbury, ON, Canada f Midwifery, Laurentian University, Sudbury, ON, Canada a

b

Received 1 May 2010 Accepted 9 February 2011

Abstract. Objective: To better understand why employment success is low, a case study was conducted to examine the influence of place on access to employment for persons with serious mental illness (SMI) residing in two northeastern Ontario communities (Rebeiro, in progress). Methods: Community-based participatory research methods were used to engage persons who experience SMI, decision-makers and providers in the research. Forty-six interviews were conducted, complemented by primary and secondary quantitative data sources. Results: While most consumers consider employment to be a key element of their recovery, employment rates for persons with SMI remain limited in northeastern Ontario, Canada. The findings of this case study reveal the importance of collaborative partnerships to fostering better employment outcomes in northeastern Ontario. Conclusion: The challenges of collaboration due to rural and northern tensions, as well as various jurisdictional and funding tensions existing at the level of community support the case for partnerships in the provision of employment services in northern and rural places. Keywords: Employment, mental illness, northern and rural places, collaborative practices

1. Introduction It seems to be somewhat redundant these days to identify and justify reasons for the promotion of employment within mental health services, especially for those with serious mental illness. Employment has been demonstrated to have a significant effect on a person’s physical, mental and social health; it not only provides ∗ Address

for correspondence: Karen L. Rebeiro Gruhl, Community Mental Health and Addictions Program, Health Sciences North, 127 Cedar Street, 6th Floor, Sudbury, Ontario, Canada, P3E 1B1. E-mail: kl [email protected], [email protected].

a source of income, but it also affords people a sense of identity and purpose, social contacts at a personal level and opportunities for personal growth [2]. Further, employment has been shown to have an important role in recovery from mental illness [3] and in reducing the stigma associated with mental illness [4]. Notwithstanding these benefits and a variety of task forces identifying employment as desired, and an unmet need [2, 11], employment for persons with serious mental illness (SMI) remains limited in northeastern Ontario. People who reside in northern and rural communities experience high unemployment in the general population [5] and typically, individuals with SMI who reside

1051-9815/12/$27.50  2012 – IOS Press and the authors. All rights reserved

78

K.L. Rebeiro Gruhl et al. / The case for collaborative partnerships

in rural places experience less employment success [6, 7]. In northeastern Ontario, greater than 91% of the beneficiaries with SMI who were enrolled in the Ontario Disability Support Program were unemployed [8]. Why people with SMI experience such high unemployment in northeastern Ontario remains unclear, especially when evidence exists to do better. While many have speculated as to the reasons for low employment success for persons with SMI, few have highlighted place as an explanatory factor. In general, statistics inform us that the province of Ontario is not doing well to assist people who have SMI into employment [9,10]; however, less is known about why they are not doing better. Consumer surveys often reveal that assistance with employment remains an unmet need – a need often unrecognized by the practitioner [11]. In Ontario, employment has been a recurring expressed need for the past decade for persons who experience SMI, but employment rates remain unacceptably low [10]. Reports highlight employment as one of the highest unmet service needs in the province however, community based best practice teams have successfully assisted fewer than 1% of enrolled clients to obtain paid employment [10,12,13], barely scratching the surface of this need. Moreover, the recent release of a four-year evaluation of community mental health investments in Ontario identifies that people with mental illness are still confronted by extreme poverty, lack of education and unemployment [14]. Statistics do little to help us to understand how the local practice of employment services is experienced and understood at the level of the service users and providers, whether these local practices influence regional employment rates, or help to explain why it is that people with SMI experience such limited employment success. Hence, the aim of this study was twofold: first, to explore experiences of accessing employment from consumers, providers and decision makers to better understand their perspectives; and second, to explore the northeastern Ontario landscape within which employment policy and programs operate so as to identify any place-related influences that can help explain why it is that persons with a SMI in northeastern Ontario experience some of the lowest employment success in the province. 2. Literature review For individuals with SMI residing in northeastern Ontario, needs assessments would suggest that employ-

ment is both desired and limited [13]. A variety of place-related factors have emerged in the empirical literature that may help to explain why persons with SMI might experience poor employment outcomes in rural and northern places. Gowdy [15], for example, identified regional explanations based on weak economies and high unemployment rates as significant contributing factors to lower employment rates. Organizational characteristics, such as chronic human health resource shortages, recruitment and retention issues, as well as individual factors (i.e. lower educational achievement) were also raised [16]. In addition, high unemployment rates, low educational attainment and chronic health professional recruitment and retention are common challenges locally [5]. Employment is susceptible to the influence of place – if for no other reason than the fact that the availability of work is context-specific. The type and quantity of work can vary depending upon the context (i.e. mining and forestry versus retail and manufacturing) and access to employment can also vary depending upon distance and geography. Additionally, how local communities implement employment-related services and an individual’s access to them may have an impact on the outcomes realized [15,17,18]. According to Twohig [18], while the focus is often on federal or provincial responsibilities for health, much of the real activity of health care takes place in an even more local setting, in the town or municipality or in health regions. It is not surprising therefore, that there is great variance from setting to setting. Place, then matters not only in the organization and delivery of health services but also in terms of health outcomes (p. 6). In this sense, context contributes to the variability of implementation of employment services and supports experienced in northern and rural places, and also demands variability in implementing programs and services to meet place-specific needs and to correct for place-related impacts on services. The influence of geography and place is recognized as an important variable to understanding health outcomes in northern and rural places in particular. Rural research [19,20] has shown how a focus on illness and acuity has done little to effect change in the health of rural Canadians – pointing to the need to consider primary health and prevention initiatives, including consideration of the social determinants of health. There is also growing recognition of the need to shift the emphasis towards the social determinants of health, includ-


ing employment, to address the complex health challenges faced by rural and northern Canadians [21–23]. Kirby [17], for example, emphasized the association between the social determinants of health and mental health recovery: In particular, the Committee believes it is extremely important to stress the significance of what are called the social determinants of health in understanding mental illness and in fostering recovery from it. The Committee was repeatedly told that factors such as income, access to adequate housing and employment, and participation in a social network of family and friends, play a much greater role in promoting mental health and recovery from mental illness than is the case with physical illness (p. 41). Given this complexity, often involving the unique interplay of social determinants, health status and place, it seems especially important to examine variables at the local level of the community in order to understand how access to social determinants,such as employment, is experienced by individuals with SMI, and influenced by context (i.e., rural and urban) [24–26]. Supported employment, a standardization of the principles and practices demonstrated to assist people with SMI into competitive employment, is recognized as an evidence-based practice [27,28]. Randomized clinical trials highlight that the Individual Placement and Support (IPS) model of supported employment has consistently demonstrated superior employment outcomes across a variety of regional, organizational, and individual arenas; in rural environments and regions with high unemployment and seasonal employment; and, in different countries and health care contexts [29–31]. The IPS model of supported employment [27] in particular has been shown to meet and exceed most expectations regarding the employability of persons with SMI, and studies have demonstrated that high IPS fidelity may help to insulate against the effects of place [32–34]. In fact, the evidence has been so compelling that the Out of the shadows at last [35] report on mental health services in Canada recommended the establishment of a nation-wide supported employment program to assist Canadians living with a mental illness to obtain and retain employment. The standardised supported employment principles and practices for persons with SMI are based upon zero exclusion criteria, rapid placement into a job of choice, and the provision of necessary and time unlimited support [33]. There is growing empirical evidence that per-

79

sons who experience SMI can be successful in work given the appropriate environmental and employment supports [32,33,36,37]. The Making it Work policy framework for the employment of persons with disabilities was developed to encourage the participation of persons with SMI in employment and to establish employment as an integrated component of the community mental health system in Ontario [13,38]. Notwithstanding this progressive policy framework, low provincial employment rates for persons with SMI suggest that there has been little uptake of this policy and that employment has not become an integrated component of provincial rehabilitation and recovery programs [10,12, 39]. Despite strong empirical support linking participation in employment to health and to mental health, how people with SMI spend their time has been less emphasized in care programs than whether people are compliant with medication, asymptomatic and not in hospital. How people with serious mental illness spend their time receives less funding, dialogue and policy attention, despite the consistent feedback from service users that how they spend their time is important to them and their health [13]. And, while it is understood that we are not doing well in assisting persons with SMI into employment based upon the available statistical data [9], we know less about why this is so, especially in the face of strong policy support and empirically proven practices. The current study examined this practice discrepancy.

3. Methods The study employed a case study design guided by a participatory approach, to examine the experience of access to competitive employment for persons with SMI in two northeastern Ontario case communities. The case study design allows for in-depth understanding of processes, explanatory theories, for answering how and why questions and for generating hypotheses for future research [40,41]. Cases are usually specific, unique, bounded systems consisting of patterned behaviour and are selected based on their intrinsic, instrumental or collective value [40]. The cases chosen for study were two geographic areas in northeastern Ontario that provide best practice mental health services to persons with SMI, provide services in urban and rural places, and could be purposively sampled for mental health users, providers and decision makers involved in service planning and delivery.

80


Fig. 1. The research design.

Community-based participatory research (CBPR) methodology [42] was selected since the aim was to increase knowledge and understanding of a given phenomenon at the local level [18] and to integrate the knowledge gained with interventions, policy and social change to improve the health and quality of life of community members [43]. A collective case study design involving five study phases and guided by extensive consultation with and involvement of community partners was subsequently developed to examine access to competitive employment for persons who experience SMI across two northeastern Ontario case communities (Fig. 1). 3.1. Data collection methods In the present study, the case study design facilitated data collection from multiple informants and data sources, and across the large geographic area of

northeastern Ontario. Qualitative and quantitative data sources were collected to provide both breadth and depth to the description of the case communities and the participants’ experiences. Qualitative data collection techniques included (a) individual interviews, (b) group interviews, (c) field notes, and (d) theoretical memos. For the current study, decision-makers, providers and people with SMI were recruited by the community partners by case community and by rural or urban residency. Sampling was purposive to provide different instances of different people across different places. Individuals were not included in the study if they had been at any time a client of the researcher. The latter criterion was established to reduce or avoid potential researcher influence on participation (i.e., undue inducement). In total, forty-six individual or group interviews were conducted with individuals who resided in urban or rural communities within either case community.


Quantitative data included both primary and secondary data sources. All participants completed a demographic questionnaire that asked theoreticallydriven questions about known predictors of employment success. The primary data were augmented by customized statistical tables provided by the Ministry of Community and Social Services [8]. These data related to employment outcomes, tenure, earnings and economic self-sufficiency of income support beneficiaries residing in the case communities and served to complement the qualitative data. The secondary data sources provided a snapshot of employment participation rates during the study period. 3.2. Data analysis Two methods of data analysis were employed. Primarily inductive analysis of the qualitative data was supplemented by a synthesizing analysis [44] based upon the empirical literature and the conceptual framework of the study. Analyses were separate procedures and adhered to recommendations by Westhues [44], Creswell [24,45], and Morse [46]. The interview transcripts were examined mainly through inductive analysis; that is, categories of meaning were derived from the data as opposed to imposing a pre-defined coding system. Transcripts were read several times looking for comments, patterns or interesting points that stood out in order to answer the research questions of this thesis. Data analysis began with the first transcript and continued beyond the last interview transcript. Interviewing continued to the point of informational redundancy, whereby further interviews did not contribute new information or insights. The inductive data analyses resulted in the development of two themes that described participants’ perceptions of access to employment in northeastern Ontario – namely, stuck in the mud and the need to raise the bar and the expectations. Both themes were member checked with the research participants, and further confirmed by town hall forum participants. The generated themes were then subjected to further analysis driven primarily by an examination of place, and in particular, the ideas, interests and institutions of the political context of the case communities. 4. The results The research participants conveyed an overwhelming experience of being “stuck in the mud” concerning employment (Fig. 2). Whether participants were stuck

81

in old ideas and beliefs about the employability of persons with SMI, stuck between a variety of existing systemic or local tensions, stuck with using providers who use different employment models, or stuck with entry level job opportunities and never being offered a paying job – the end results were similar – those involved in the employment of persons with SMI in northeastern Ontario were stuck in the mud. This paper draws from the larger study [1] some of the identified placerelated challenges of providing employment services and supports in northeastern Ontario which contributed to the condition of being stuck in the mud. Specifically, northern and rural tensions, jurisdictional tensions and funding tensions which complicated and muddied the provision of employment services and supports are described. These tensions are alleged to help explain the greater than 91% unemployment rate for persons with SMI in the case communities, and strengthen the case for collaborative partnerships as a necessary next step to raise the bar and the expectations for the employment of persons with SMI. 4.1. Rural and northern tensions The geography of northeastern Ontario complicated the provision of collaborative employment services in northeastern Ontario, and yet, also strongly indicated the need for such partnerships. The case communities spanned a geography in excess of 188, 000 square kilometers and challenged providers ability to service rural residents as well as provide timely services. The empirical evidence strongly associates collaboration and improved employment outcomes [15,16]. Bond [33], Bond et al. [47] and Corbière [29] have described key aspects of collaboration which foster better employment outcomes; the most robust factor of IPS success is the degree by which vocational services are integrated within the mental health service, or sit outside of the service as an adjunct or add-on service. In the case study communities, seventy percent of the provider participants reported to engage in collaborative practices less than 25% of the time. The lack of collaboration and place-related difficulties in collaborating (i.e. resources, distance, ideological) may help to explain why only 8.7% of ODSP beneficiaries with SMI reported any employment earnings, and of those who reported earnings, why most retained their jobs for less than 6 months [8]. A second rural and northern tension concerns human resources. The research participants raised the lack of access to employment specialists across the large geog-

82


Fig. 2. Conceptualization of access to employment in northeastern Ontario.

raphy of the case communities as an issue. In particular, participants spoke of the regional challenges geography posed to the provision of employment services, including only one employment specialist being available to assist individuals residing in Hearst, Kapuskasing, Cochrane, New Liskeard, Kirkland Lake, Cobalt and Haileybury into employment, and two employment specialists providing services for 10 000 clients with a disability in Sudbury Manitoulin. Given that Bond [48] and Becker and Drake [32,49], found that access to employment was predicted by the percentage of supported employment specialists per consumer with SMI served by the mental health agency, the provision of employment specialists based upon population density versus geography is problematic. Additionally, given that Becker et al. [32,49] found that rates of competitive employment were best predicted by fidelity to supported employment principles as well as to local employment rates, efforts are required to develop mental health team and vocational services capacity in supported employment principles given that unemployment rates in northeastern Ontario typically exceed provincial rates [4]. A third northern and rural practice tension related to the lack of dedicated vocational specialists on mental

health teams in northeastern Ontario. There were no dedicated vocational specialists on any mental health team in Cochrane Timiskaming, and few in Sudbury Manitoulin. In Sudbury Manitoulin, there are dedicated vocational specialist positions on each ACT team, giving the impression of a focus on employment; however, they dedicated less than 25% of their time to employment-related activities and services. Positions that previously existed (e.g., the vocational specialist with a local mental health agency) have recently been transformed to more generalist positions. Insufficient human health resources dedicated to employment challenged the ability of the system to rapidly place individuals into work when interest and motivation was high. Constrained participation of the mental health sector in employment served to limit access to employment, and kept people with SMI stuck in a cycle of unemployment and restricted labour participation. A lack of collaboration between the various employment services was raised as a fourth consequence of northern and rural geography. Collaboration and integration of mental health services was reported to be limited in northeastern Ontario by 1) geography and physical distance, 2) chronic human resource short-


ages, 3) a lack of prioritization of employment services within mental health organizations, 4) limited time and funding dedicated to collaboration, 5) mental health and vocational service systems operating from different theoretical positions, using different models, and working in different silos (i.e., sectors), and 6) the underlying competitive nature of organizations that tends to get fostered when large systems are requested to work together, integrate services and create efficiencies. Campbell et al. [50] noted that some types of organization may be more compatible with implementing high fidelity supported employment, including collaborative practices. For example, historical reasons such as separate funding streams for mental health and vocational rehabilitation and ideologies about separation of these two service systems, may help explain why some agencies continue to provide brokered supported employment services, despite the evidence that provision of employment services through an agency separate from the mental health provider is not optimal (p. 6). In summary, northern and rural issues were seen to contribute to employment being stuck in the mud primarily because participants did not perceive services to be funded to account for the geography; because of limited priority given to employment on mental health teams; and because limited human resources combined with distance impacted providers’ capacity to provide supported employment in an empirically-based manner and to work collaboratively. 4.2. Jurisdictional tensions A fundamental jurisdictional tension situates employment as a desired mental health outcome enjoying policy and research support, yet lacking an implementation plan. An additional tension is that employment services are primarily funded and implemented by providers existing outside of the jurisdiction of health. In the province of Ontario, the Ministry of Community and Social Services funds and implements employment services for persons with SMI outside of ACT teams and consumer businesses. The jurisdiction of employment services for persons with SMI is subsequently broad; suffering a lack of policy agreement regarding what is considered to be an essential service for enabling employment success; and importantly, lacking clarity about who will provide the service and pay for it. This jurisdictional chiasm created a variety of tensions, often resulting in service and program decisions based upon finances (who will pay), rather than up-

83

on the empirical evidence or fidelity criteria. The lack of agreement fuels competing interests and ideologies which were found to maintain the condition of being stuck in the mud. In Ontario over the past decade, a parallel system has evolved within the community mental health service sector to address the employment needs of persons with SMI. However, research participants described services as not working in collaboration, but instead existing and operating as separate services. The lack of clear jurisdiction on the one hand, and the lack of policy or cross-sectoral guidance to work in partnership on the other, have contributed to some decision makers openly questioning the place of employment within health and led to a great deal of misunderstanding regarding empirically based practices, who should lead, who should fund these services, and based upon what evidence. Clearly, a muddy situation. Monica, a local decision maker stated that “until the province decides that employment is important for persons with mental illness and flows dollars to the Local Health Integration Networks (LHINs) for that expressed purpose, little will change within the community mental health system” in the area of employment. Campbell [50] noted that the lack of integration of mental health and vocational services is likely reflective of two distinct, but important interests: first, the influence of funding agencies that continue to encourage separate agencies and brokered services; and second, a continued emphasis on job readiness activities and the use of transitional employment. . . including in-house employment activities. . . these practices being antithetical to the rapid job search and based upon individual rather than collective interest (p. 7). In northeastern Ontario, the vocational service sector providing most employment services for persons with SMI continues to rely upon prevocational assessments and job trials to determine readiness. The lack of jurisdictional interest in employment by the mental health system in the case communities routinely resulted in delegating employment responsibility to a sector with limited knowledge of the needs of persons with SMI, and of evidencebased supported employment (SE) practices to enable their successful employment. The Mental Health Commission of Canada identified how, in a transformed mental health system, it will become increasingly necessary to collaboratively engage in joint actions across multiple jurisdictions – departments, levels of government, schools, workplaces, primary care and correctional systems – in order to successfully address the many structural factors that

84


impact individual and community mental health and well-being, such as, housing, income, education and employment [51]. The last jurisdictional tension raised by the participants concerned whether employment should exist within the mental health sector and be funded as an essential service, or whether this was the mandate (and responsibility) of another sector. One provider participant described the tensions created when attempting to incorporate employment within the current team jurisdiction: Yes, it takes away our time to actually do recoverybased stuff or goal-focused work with the client because it just comes down to straight maintenance, or keeping them out of hospital, or just doing the basic stuff that really they could be doing on their own and we could have a lot more productive time on our hands otherwise. Employment has often been referred to as an afterthought in the mental health system [13] and this discourse appears to remain well entrenched in northeastern Ontario to date. 4.3. Funding tensions Participants at all levels (i.e., decision makers, providers and persons with SMI) spoke of the various funding tensions that serve as barriers to accessing employment. They identified how many of the policies and procedures involved with funding employment services were antithetical to enabling employment for individuals requiring longer term support, for those residing in rural places, and, to working in partnership. Paradoxically, current funding models foster a competitive environment for jobs and consumers, contrary to best practice evidence that recommends collaborative practices [16]. For example, decision makers identified the difficulty of funding mechanisms and how despite a framework for employment within Health, the province has yet to adequately finance employment. Most providers conveyed being stuck by a funding model that does not favour clients who require job coaching, additional training or extended longterm, follow-along employment support. According to one vocational provider, the funding model is, “a predictable model with unpredictable people”. The funding model would be one of the most blatant paradoxes of the system – that those individuals needing the most support are stuck in a competitive funding model which tends to discourage it. In fact, the provision of

necessary employment supports was identified as an economic disincentive to working with persons with SMI by most service providers. Funding tensions also existed for consumers. Both provider and consumer participants commented on how the provision of income support and associated benefits has removed the basic need to work, and resulted in lingering tensions between a need to work and a desire to work. Funding tensions related to declaring earned income and budgeting to account for deductions the following month were found to be stressful to both providers and to people with SMI. For example, one participant raised the paradox of being encouraged to work, but at the same time having restrictions placed on employment that do not dovetail with the reality of jobs in the community: I am encouraged to work and stay there because they encourage you to go back to work, but, who can go back to work and hold a job in a public place for 15 hours or less a week, it is impossible. In a grocery store like this, I love my job but . . . Ya, it is crazy and it is not encouraging but now I am stuck. What am I going to do in the new year? Am I going to risk that CPP that I am getting $741 compared to maybe I get $400 a month or $450. . . it’s just above the limit? Vocational service providers, in particular, experienced several funding tensions – the most pressing concerned the competitive funding model introduced by ODSP in recent years. For example, one service provider spoke of the tensions created by having to provide services for clients with SMI and yet, not being paid until the client reaches job retention (i.e., 13 weeks): And a lot of times this is one of those 40% cases where it just doesn’t lead to anything and we haven’t seen any kind of payment for any of that work that was done. Likewise, another related vocational service provider tension concerned the need for better collaboration between providers, (i.e. sharing employers) and the competitive funding environment: My employer, I worked for that employer, like I worked four years to get that employer to call me first so I’m not about to, if I can’t fill a position, to contact an alternate service provider. Why would they go through me next time rather than just going to that service provider, so that’s unfortunately the mindset. . . Yeah, and that’s the same as me going


to [names an agency] with my employer to get this wage subsidy. Well, I’m giving you my employers name, the, the employers phone number, you’re going to have a sit down meeting with this employer. Do you think he’s going to call [names service provider] next time or do you think he’s going to call [names agency] directly? The removal of collaborative supports as the reward for working was the next tension raised. According to service providers, once the individual is working for 20 hours a week, they are considered to be employed and their associated benefits, including job coaching, are ended: That you know the job coaching is there before they are employed, but once they are employed over that 20 hours, they’re considered employed and the services are no longer there, right? Where, with some of them, they need long-term job coaching, right? Maybe it’s not, you know, maybe but it might be like 2 hours a week. . . At that point because you’re considered already employed, there are no services for an already employed applicant. So that’s, that a barrier, right, so the services are not there longer term. The lack of longer term supports may help to explain why it is that negligible beneficiaries in a sample of 4112 persons with SMI were working beyond a year, and how less than 3% exited income support systems [40]. Funding tensions were raised at many levels and were related to disincentives to collaboration and a focus on reaching the 13 week target – sometimes at the expense of the client. For example, one provider spoke of the tensions created by a model that pits payment and salary against client interests: And that’s the problem with the competitive model is that sometimes we may be doing it for the wrong reasons, sometimes we may be wanting it more than they do and I think that’s what this model has done to us. Given the competitive nature of the brokered service provider model, various tensions are created, including access to funding for additional job coaching and supports. One provider stated that she will not access the fund because it adds another element of administration that the broker is not paid for (and therefore will need to be deducted from their flat fee at 13 weeks). A local decision maker commented on the tensions created by the way the system has organized provider’s access to the training dollars:

85

Service providers, some are more receptive to going through another service provider than others because basically you are giving a lot of your information to another service provider, which for all intents and purposes is a competitor. And that’s where it can get really dicey because each service provider obviously wants to retain working with his or her client as much as possible because that’s their bread and butter, that’s how they survive. A final funding tension is created when an individual does not have access to a job of interest because they are affiliated with the wrong broker and providers do not work in partnership for the benefit of the client: And technically not knowing, like your client could be looking for a, you know, post office job and it could be that one service provider actually has that job, you know, as open right now, you would never know it. They won’t tell you. . . they are more business centered as opposed to client centered. Yeah, what yeah, what I kind of mean is like it’s a business and they’re competing against each other. Instead, the individual is likely offered a job they are not interested in or do not want. One consumer participants spoke about how his friend never secured a job he wanted and how this contributed to his chronic unemployment, “he had all the lousy jobs and stuff like that and after awhile you get tired of doing the jobs that nobody else wants to do and what happens is that you quit”. 5. Discussion This paper draws upon the findings from a larger qualitative case study so as to build support for collaborative partnerships that can better serve the employment needs of people with SMI within northeastern Ontario communities. The case for collaborative partnership is strong on at least two fronts – in enabling a more effective and efficient use of limited resources, and in successfully bridging distance and geography to provide them. First, given the limited resources dedicated to employment in the case communities, working together makes sense on many levels. In fact, collaboration may provide the best way to utilize existing resources and the only way to provide evidence-based supported employment across the expansive geography of the case communities. The research literature also highlights the importance of cross-sector collaboration and partnerships to fostering employment success for

86


persons with a mental illness. In their recent review of the randomized clinical trial evidence in support of successful supported employment programs, Drake and Bond [46] reported that vocational and mental health services over most of the US continue to be dominated by antiquated models that do not encourage collaboration; financing systems that do not align with evidencebased practices; institutional resistances to change; and poor outcomes. Collaboration has been cited as important to employment success [16]. According to Drake and Bond [52], the evidence strongly supports integrating vocational and clinical services at the client level whereby the client should be able to relate to a single team of providers who provide a consistent message and help them to pursue employment as well as other goals. Non-integrated services are typically less effective because of fragmentation, poor access, inadequate communications between providers, placing the burden of integration on the client, conflicting messages about employment, and other reasons. Despite this evidence, service integration remains difficult to create, mostly because mental health and vocational services maintain separate organizations, finances, workforces, records, and regulations (p. 368). Similarly, in discussions of the critical ingredients of success, Becker and colleagues [53] underscore the importance of instituting changes at the state-level that will enhance collaboration between mental health and vocational rehabilitation. Gowdy and colleagues [16], in their exploration of organizational practices which differentiated high performing supported employment programs from low performing programs identified the importance of staff working together in partnership to help integrate diverse aspects of the system involved in employment and to simplify this process for the client. Rogers et al. [54], and more recently Cook et al. [55] have identified that integrated supported employment services are more effective in assisting clients to achieve employment success than parallel services because clinicians rather than the clients assume the burden of coordination, consistency, and coherence. Second, collaborative partnerships may be necessary to bridge the distance and geography of northeastern Ontario and the fragmentation of the mental health system in general. Collaborative partnerships facilitate linkages that bridge sectors and distances and are identified to be critical to providing services in northern places [56]. Minore and Boone [57] highlighted the need to expand the interdisciplinary education of health professionals so that it includes knowledge of collaboration and how to work with local communities. The

Mental Health Commission of Canada [51] too has commented on the lack of integration of the various health, social, political, and economic agencies funded in mental health care and advocated for better collaboration and partnership. Likewise, the Kirby Report underscored the importance of cross sectoral collaboration to reduce the current fragmentation of mental health systems across Canada [23]. Nationally speaking, the Canadian Alliance on Mental Illness and Mental Health (CAMIMH) has profiled a national mental illness and mental health action plan which includes promoting sectoral collaboration, and facilitating integration and collaboration across and within front-line service components [58]. The Canadian Community Mental Health Initiative [59] has evolved a variety of strategies to improve mental health services in the primary care setting through interdisciplinary collaboration among health care providers, consumers and caregivers and has developed a conceptual framework for use to guide the development of collaborative mental health practices in Canada that are applicable to the provision of SE. In Ontario, the local health integration networks (LHINs) are pressing for integration to improve health outcomes for Ontarians. In northeastern Ontario, the LHINs have identified integration of services, including cross-sectoral services, as a priority to address complex health care challenges facing the northeast [60]. And, given the defacto structure of mental health systems in Ontario, partnership seems to make sense – clients, providers and systems attempting to work together towards better outcomes. Poland et al. [61] commented how the lack of collaboration and cooperation within Ontario’s health system is not surprising given funding silos in Ontario were seen to promote competition for “turf” between agencies and largely discourage inter-sectoral collaboration and cooperation (p. 130). In this study, competitive funding models and separate sectors discouraged partnerships to create employment opportunities. Unsurprisingly, Poland et al. found that in every 2 of the 4 sites studied, community collaboration was seen as “a nice thing to do” if time and funds permitted; hospital motivation to engage in community collaborations had more to do with good public relations than with effecting change or promoting community or individual health (p. 131). This study underscores the challenges of collaborative practices in northeastern Ontario, and also the need for them. While policy is largely supportive of the advancement of the employment of persons with SMI, employment rates remain low in the case communities.


Employment remains limited by the lack of substantive funding that considers the influence of context and by any standard implementation plan to make it work. Until such time as collaboration is financially rewarded over competition and existing financial disincentives to working with individuals who require greater support are removed, it is unlikely that employment rates will improve. The consequences of more of the same will continue to plague the provision of employment services in northeastern Ontario so that people with SMI and their providers will remain stuck in the mud. Partnership may be the best way to improve the employment prospects for persons with SMI in northeastern Ontario. Nevertheless, entrenched jurisdictional boundaries that challenge working together, as well as funding models that encourage (and financially reward) competition over collaboration complicate the formation of employment partnerships.

6. Conclusions This paper draws upon the findings of a larger qualitative study [1] and describes how collaborative partnerships represent a huge departure from the current provision of employment services by mental health and vocational service providers. It also identifies how a shift towards collaboration may not be wholly embraced by services currently enjoying uncontested jurisdiction and whose funding models are competitive. Nonetheless, the findings of this study underscore the need for collaborative partnership as a necessary mechanism to raise the bar in northeastern Ontario where the effects of limited resources and vast geography challenge the provision of employment services and supports for persons with SMI. Accordingly, partnership is a recommended strategy to advance the employment success of persons with SMI in northeastern Ontario. Policy development must promote, reward and fund collaboration over competition; create environments that are conducive to relationship building; and remove punitive measures that discourages context-specific solutions to SE practices outside of large urban centers. For persons with SMI in northeastern Ontario, collaborative partnership may indeed be the most effective mechanism to build community capacity, to lessen the muddiness of employment services, and to improve their chances for work.

87

Acknowledgements The first author would like to acknowledge the support of the Canadian Institutes of Health Research for financial support of this research. References [1] [2]

[3] [4]

[5] [6]

[7]

[8] [9] [10]

[11]

[12] [13]

[14] [15]

Rebeiro Gruhl K. Access to competitive employment for persons with serious mental illness in northeastern Ontario: An exploration of the influence of place. In progress. Razzano LA, Cook JA, Burke-Miller JK, Mueser KT, PickettSchenk SA, Grey DD, et al. Clinical factors associated with employment among people with severe mental illness: Findings from the employment intervention demonstration program. The Journal of Nervous and Mental Disease 2005; 193(11): 705-713. Kirby M. Mental health in Canada: Out of the shadows forever. CMAJ: Canadian Medical Association Journal 2008; 178(10): 1320. Perkins DV, Raines JA, Tschopp MK, Warner TC. Gainful employment reduces stigma toward people recovering from schizophrenia. Community Mental Health Journal 2009; 45: 158-162. NE LHIN. Population profile at a glance: NE LHIN. 2008; Available at: http://www.nelhin.on.ca/Page.aspx?id=4024. Accessed 13/05, 2009. Drake RE, Fox TS, Leather PK, Becker DR, Musumeci JS, Ingram WF, et al. Regional variation in competitive employment for persons with severe mental illness. Administration and Policy in Mental Health 1998; 25(5): 493. Drake RE, Bond GR, Rapp C. Explaining the Variance Within Supported Employment Programs: Comment on “What Predicts Supported Employment Outcomes?” Community Mental Health Journal 2006 Jun; 42(3): 315. Statistics and Analysis Unit, Policy Analysis and Research Branch. Characteristics of ODSP Adult Beneficiaries with mental disorders in northern Ontario; 2009. Lurie S, Kirsh B, Hodge S. Can ACT lead to more work? The Ontario experience. Canadian Journal of Community Mental Health 2007; 26(1): 161-171. Koegl C, Durbin J, Goering P. Mental health services in Ontario: How well is the province meeting the needs of persons with serious mental illness? Analysis of data collected during the Provincial Psychiatric Hospital and Community Comprehensive Assessment Projects 2004; 2923/03-04. Crane-Ross D, Roth D, Lauber BG. Consumers’ and case managers’ perceptions of mental health and community support service needs. Community Mental Health Journal 2000; 36(161): 178. Goering P. Making a difference: Ontario’s community mental health evaluation initiative; 2006; p. 34. Ministry of Health and Long Term Care (MOHLTC), Northeastern Ontario Mental Health Implementation Task Force. The time for change is now: Building a sustainable system of care for people with mental illness and their families in the northeast region. Employment and education 2002: 201-217. SEEI Coordinating Centre. Moving in the Right Direction: SEEI Final Report; 2009; 1-52. Gowdy EL, Carlson LS, Rapp CA. Practices differentiating high-performing from low-performing supported employment programs. Psychiatr Rehabil J 2003 Winter; 26(3): 232.

88 [16]


Gowdy EA, Carlson LS, Rapp CA. Organizational Factors Differentiating High Performing from Low Performing Supported Employment Programs. Psychiatric Rehabilitation Journal 2004 Fall; 28(2): 150. [17] Ryan-Nicholls KD, Racher FE. Investigating the health of rural communities: Toward framework development. Rural and Remote Health 2004; 4(244): November 7, 2007. [18] Twohig PL. Written on the Landscape: Health and Region in Canada. Journal of Canadian Studies 2007 Fall; 41(3): 5-17. [19] DesMeules M, Pong R, Lagacé C, Heng D, Manuel D, Pitblado R, et al. How healthy are rural Canadians? An assessment of their health status and health determinants; 2006. [20] Davidson A. Dynamics without change: Continuity of Canadian health policy. Canadian Public Administration 2004; 251(29). [21] The Standing Senate Committee on Social Affairs, Science and Technology. A healthy productive Canada: A determinant of health approach; 2009. [22] Raphael D, Bryant T, Rioux M editors. Staying alive: Critical perspectives on health, illness, and health care. Toronto, ON: Canadian Scholars’ Press Inc.; 2006. [23] Rioux M, Crawford C. Poverty and disability: Toward a new framework for community mental health. Canadian Journal of Community Mental Health 1990; 9(2): 97. [24] Creswell JW, Plano Clark VL. Designing and conducting mixed methods research. Thousand Oaks, CA: Sage Publications Inc.; 2007. [25] Kirby M, LeBreton M. Chapter 10: Rural Health (pp. 159169), In, The health of Canadians: The Federal Role (Report of the Standing Senate Committee on Social Affairs, Science and Technology, 6 volumes); 2002. [26] Pong R. Rural health research in Canada: At the crossroads. Aust J Rural Health 2000; 8: 261-265. [27] Becker DR, Drake RE. A working life: The Individual Placement and Support (IPS) Program; 1993. [28] Kirsh B, Cockburn L, Gewurtz R. Best practice in occupational therapy: Program characteristics that influence vocational outcomes for people with serious mental illnesses. The Canadian Journal of Occupational Therapy 2005 Dec; 72(5): 265. [29] Corbière M, Bond GR, Goldner EM, Ptasinski T. The Fidelity of Supported Employment Implementation in Canada and the United States. Psychiatric Services 2005 November; 56(11): 1444-1447. [30] Crowther R, Marshall M, Bond G, Huxley P. Vocational rehabilitation for people with severe mental illness. Cochrane Database of Systematic Reviews 2007; 4. [31] Latimer EA, Lecomte T, Becker DR, Drake RE, Duclos I, Piat M, et al. Generalizability of the individual placement and support model of supported employment: results of a Canadian randomised controlled trial. British Journal of Psychiatry 2006; 189: 65. [32] Becker DR, Xie H, McHugo GJ, Halliday J, Martinez RA. What predicts supported employment program outcomes? Community Mental Health Journal 2006; 42(3): 303. [33] Bond GR. Supported Employment: Evidence for an EvidenceBased Practice. Psychiatric Rehabilitation Journal 2004 Spring; 27(4): 345. [34] Bond GR, Drake RE, Becker DR. An Update on Randomized Controlled Trials of Evidence-Based Supported Employment. Psychiatric Rehabilitation Journal 2008 Spring; 31(4): 280. [35] Standing Senate Committee on Social Affairs, Science and Technology. Out of the shadows at last: Transforming mental health, mental illness and addictions services in Canada; 2006.

[36] [37] [38] [39] [40] [41] [42]

[43] [44]

[45] [46] [47]

[48] [49] [50] [51] [52] [53]

[54]

[55]

Cook JA. Executive Summary of findings from the employment intervention demonstration program; 2006. Kirsh B. Factors associated with employment for mental health consumers. Psychiatric Rehabilitation Journal 2000 Summer; 24(1): 13. Ministry of Health and Long Term Care (MOHLTC). Making it Work: Policy framework for employment supports for people with serious mental illness; 2001; Cat.# 7610-4232419. Ontario Technical Advisory Panel. 2005/06 Ontario ACT data outcome monitoring report; 2007. Stake R. The art of case study research. Thousand Oaks, CA: Sage; 1995. Stake R. Multiple case study analysis. New York, NY: The Guilford Press; 2006. Israel BA, Eng E, Schulz AJ, Parker EA. Introduction to methods in community-based participatory research for health. In: Israel BA, Eng E, Schulz AJ, Parker EA, editors. Methods in community-based participatory research for health. San Francisco, CA: Jossey-Bass; 2005; pp. 3-26. Israel BA, Eng E, Schulz AJ, Parker EA editors. Methods in community-based participatory research for health. San Francisco, CA: Jossey-Bass; 2005. Westhues A, Ochocka J, Jacobson N, Simich L, Maiter S, Janzen R, et al. Developing Theory From Complexity: Reflections on a Collaborative Mixed Method Participatory Action Research Study. Qual Health Res 2008 May 1; 18(5): 701-717. Creswell JW. Research Design: Qualitative, quantitative, and mixed methods approaches. Second Edition ed. Thousand Oaks, CA: Sage Publications; 2003. Morse JM. Mixing Qualitative Methods. Qual.Health Res. 2009 November 1; 19(11): 1523-1524. Bond G, Campbell K, Bond GR, Gervey R, Pascaris A, Tice S, et al. Does type of provider organization affect fidelity to evidence-based supported employment? Journal of Vocational Rehabilitation 2007 08; 27(1): 3-11. Bond GR, Salyers MP, Rollins AL, Rapp CA, Zipple AM. How evidence-based practices contribute to community integration. Community Mental Health Journal 2004; 40: 569-588. Becker DR, Drake RE. A working life for people with severe mental illness. 2nd ed., NY, NY: Oxford University Press Inc; 2003. K. Campbell. Consumer predictors of competitive employment outcomes in supported employment. United States – Indiana: Purdue University; 2007. Mental Health Commission of Canada. Towards recovery and well-being: A draft framework for a mental health strategy for Canada; 2009. Drake RE, Bond GR. Supported Employment: 1998 to 2008. Psychiatr Rehabil J 2008; 31(4): 274-276. Becker D, Whitley R, Bailey EL, Drake RE. Long-term employment trajectories among participants with severe mental illness in supported employment. Psychiatric Services 2007 Jul; 58(7): 922. Rogers ES, Drake RE, Becker DR, Bond GR, Mueser KT. A process analysis of integrated and non-integrated approaches to supported employment. Journal of Vocational Rehabilitation 2003; 18(1): 51. Cook JAPD, Lehman AFMD, Drake RMD, McFarlane WRMD, Gold PBPD, Leff HSPD, et al. Integration of psychiatric and vocational services: A multisite randomized, controlled trial of supported employment. Am J Psychiatry 2005 October; 162(10): 1948-1956.

K.L. Rebeiro Gruhl et al. / The case for collaborative partnerships [56]

[57]

[58] [59]

Boone M, Minore B, Katt M, Kinch P. Strength through sharing: interdisciplinary teamwork in providing health and social services to northern native communities. Canadian Journal of Community Mental Health 1997; 18(2): 15-28. Minore B, Boone M. Realizing potential: improving interdisciplinary professional/paraprofessional health care teams in Canada’s northern aboriginal communities through education. Journal of Interprofessional Care 2002 05; 16(2): 139-147. Canadian Collaborative Mental Health Initiative (CCMHI). About this initiative. 2008; Available at: http://www.ccmhi. ca/en/who/initiative.html. Accessed 05/12, 2009. Canadian Collaborative Mental Health Initiative (CCMHI).

[60] [61]

89

Strengthening collaboration through interprofessional education: A resource for collaborative mental health care educators. 2008; Available at: http://www.ccmhi.ca/en/products/ toolkits/documents/EN Strengtheningcollaborationthrough interprofessionaleducation.pdf. Accessed 05/12, 2009. NE Lhin. Integrated Health Service Plan (IHSP) 2010-2013; 2009. Poland B, Graham H, Walsh E, Williams P, Fell L, Lum JM, et al. Working at the margins or leading from behind?: A Canadian study of hospital-community collaboration. Health and Social Care in the Community 2005; 13(2): 125-135.