Results of the VENUS Project: increasing program utilization of vocational services

Results of the VENUS Project: Increasing program utilization of vocational services

Brief Project Summary

This project was organized into two major phases:

Phase One: Identifying the Obstacles

Three data sources were used to identify obstacles to VR service utilization: a review of literature that relates to delivery of vocational and educational (V/E) services; secondary analyses of a national study of clients in treatment, focussing on clients' reported V/E needs and services; and a field study in four methadone maintenance clinics[1] in New York City, which included interviews with staff and clients.

Many obstacles to the use of vocational services were identified in the literature review; these were summarized into three categories: client level obstacles, which included the impact of public assistance and client fears; program level obstacles, which included the treatment orientation of many programs and the lack of trained professionals; and societal level obstacles, which included gender related stereotypes and perceptions of employer biases.

Data from the national study of clients in treatment (Treatment Outcome Prospective Study, or TOPS, funded by the National Institute on Drug Abuse) indicate that although clients are about as likely to express the need for educational and vocational services, they are more likely to report receipt of educational services. In addition, the gap between reported need and reported receipt of V/E services in the first 6 months of treatment was between 20 and 50 percent, depending on client type. The TOPS analyses also suggests that certain client groups are more likely to report a need for services (e.g., younger clients, those without diplomas, minorities) and certain groups, including housewives and black clients, may be disproportionately underserved.

Interviews with clinical and administrative staff in the four methadone clinics focussed on the key program and staff issues affecting the utilization of services. It was found that few counsellors reported having received training in vocational rehabilitation. In addition, the critical obstacles cited by staff were understaffing, client-related problems and inadequate community service providers. There were also several indications that V/E services are given a low priority compared with other service areas. In clinics with greater V/E involvement, staff or clients indicated that there was some mechanism to engage clients in vocational services.

Interviews with a sample of clients in the four methadone clinics addressed such areas as the types of vocational services they received, their perception of obstacles to the use of vocational services and the client characteristics which may affect use of services. Although most clients reported receiving vocational counseling in their treatment programs, many desired concrete vocational services, such as training, education or job placement. Furthermore, based on client interviews, about half of the clients indicated that they had no vocational aspirations or it was determined that they had an unrealistic vocational goal. This would indicate the need for further vocational counseling. These interviews also indicated that clients believed that the primary obstacles to V/E involvement were low client motivation, typically tied to other issues (e.g., drug usage, welfare dependency and fear of work). In addition, clients receiving public assistance and working off-the-books ((undocumented, or being paid "under the table") were generally doing better financially than persons legitimately employed.

Based on the first year's findings, it became clear that a broad range of obstacles was operating. Data from these efforts were summarized and presented to a panel of experts. The panel included members from a variety of relevant perspectives local and out-of-state program administrators, fiscal experts, researchers and practitioners involved in vocational rehabilitation of substance abusers, a federal representative of the President's Committee on Employment of People with Disabilities, and an organizational psychologist). Panel members met for 2 days and were asked to select obstacles which were critical to the underutilization of vocational services, amenable to strategies or interventions which would be likely to have an impact on utilization of vocational services, and "doable" within the time and resource limitations of the project. Two classes of obstacles were identified by the panel and formed the basis for the interventions developed during Phase Two. These obstacles were:

* the presence of fiscal disincentives (and the lack of sufficient incentives) to program, staff and clients for increasing use of and involvement in vocational services; and

* the fact that vocational rehabilitation is not currently viewed as integral to treatment.

Phase Two: Implementing and Evaluating

Strategies

Based on the recommendations of the panel, the following 1-year intervention s were planned:

* Intervention 1: Removal of Medicaid Disincentive. Existing Medicaid reimbursement policies were identified as a potential disincentive for programs to providing vocational services, since Medicaid covered clients tend to generate more income for programs than non-Medicaid (e.g., employed) clients. The Medicaid intervention involved developing a contractual agreement between the New York State Division of Substance Abuse Service (DSAS) and the participating programs and committing DSAS to make up for Medicaid losses (up to a specified amount) incurred by participating programs due to increased V/E involvment of clients.

* Intervention 2: Integration of Vocational Services in Treatment. It was decided that, to increase the integration of vocational services in the overall treatment process, specific personnel were needed in programs for these purposes. These people, called vocational integrators, would be responsible for working with existing program staff in analyzing current clinic policies that might affect service provision and developing methods to increase client V/E involvement. They would also provide staff with assistance in accessing technical resources and enhancing vocational counseling.

Two vocational integrators were hired, trained and placed in methadone clinics. Training dealth with such areas as review of literature regarding vocational service delivery in drug treatment, training regarding the types of services provided by local agencies, and methods of dealing with anticipated "resistance" in the clinics. The components identified as needed for integration to occur, which were the focus of the integrators' efforts, were:

* a raised sense of the importance in the clinic of V/E services as part of its overall mission;

* the development of staff skills and knowledge of resources needed to address client V/E needs; and

* implementation of clinic policies and procedures that facilitated coordination and accountability.

Four methadone maintenance clinics in New York City (who did not participated in Phase One) were recruited for a 1-year implementation and evaluation of these interventions. A 2X2 factorial design was used where one clinic just had the Medicaid disincentive removed, one just had the vocational integrator, one had both interventions, and one control clinic received no intervention.

Monthly information was collected regarding clients' Medicaid status, vocational activities and vocational status. Three times during the study year (every 4 months) a summary of the compensation to be provided by DSAS (for the two clinics in the Medicaid compensation intervention) was prepared and shared with the programs' administrative staff and members of DSAS.

Based on baseline data collected on clients in the study clinics, a new approach to categorizing the vocational status of clients was developed. This method took into account the competing factors (e.g., poor health, unstable housing, childcare needs) likely to be experienced by many clients. It was found that although most clients with "competing" factors were not engaged in full-time V/E activities, a substantial number were able to become vocationally involved at least on a part-time basis. In addition, many full-time V/E involved clients had criminal histories similar to other clients, thus indicating that this is not necessarily a major obstacle.

Results of the intervention study indicated that the vocational integrator intervention was related to an increase in client involvement in vocational activities but no significant change in vocational status. It is likely that status changes (e.g., from unemployment to employment) require a longer time period than was available in this study. The Medicaid intervention, contrary to expectations, was related to a small decline in activities and status, perhaps because staff became sensitized to the Medicaid clients.

Additional results indicated that many clients move up or down in vocational status during a 1-year period, regardless of interventions. This may be contributed to the lack of larger differences which could be attributable to the intervention. Conclusions of the intervention study were that:

* although the vocational integrator had an influence on vocational activities, the addition of a vocational counselor to provide direct services and a longer time period for intervention and subsequent assessment are needed to obtain increases in vocational status which can be sustained; and

* efforts to impact on fiscal disincentives were not simple to effect and opportunities to explore various methods to remove fiscal disincentives for programs and for clients are needed.

Conclusions and Recommendations

These conclusions and recommendations are based on all aspects of the study, including the literature review, the TOPS data analysis and the eight methadone clinics that participated in the Phase I field study and the Phase II intervention study. Because this study primarily focussed on the methadone maintenance modality, the findings and recommendations are not necessarily generalizable to other modalities.

Obstacles to Greater Utilization of

Vocational Services

Based on a literature review and field studies in methadone clinics, this project documented a wide range of obstacles to vocational service utilization operating on the clients, program and societal levels. Many of these obstacles are not unique to the drug treatment system.

Efforts to impact on these obstacles must take into account that obstacles operate on several levels and that efforts to increase utilization of vocational services are more likely to be successful if they address more than one level. Thus, efforts which undertake one initiative at a time (e.g., to simply provide more vocational information to counselors, send new policies to be implemented by programs, or place a vocational counselor on staff) are unlikely to lead to major changes by themselves. Efforts to increase client involvement in VR activities and enhance program delivery of these services require more comples interventions and the long-term commitment of funding agencies and programs.

Based on the first year's literature review and field study, a panel of experts identified fiscal disincentives (and lack of incentives) to programs and clients as one of the two most important classes of obstacles.

In the research, the concern about the loss of Medicaid and welfare benefits to clients was cited by many clients and staff. In addition, clients who were on welfare and engaged in unverified employment were among the most stable workers and had the highest net incomes.

Impacting on this obstacle, which has been inherent in the welfare system, appears needed to enhance client ability to move toward legitimate employment. The recently passed welfare reform legislation may help to reduce this disincentive for clients. In addition, programs may also be able to reduce this disincentive by developing vocational service capability which would motivate and enable clients to obtain higher salaried positions.

Treatment staff did not identify fiscal disincentives to programs as one of the important obstacles, and the method used to reduce a potential fiscal disincentive for programs did not have the anticipated effect. Fiscal concerns are no doubt important to all service agencies, but it may be that providing incentives to programs, with or without directly addressing any potential disincentives, may be a more useful strategy.

Data from the first year's study indicate tha vocational services are not integrated into drug treatment. This lack of integration was the other important class of obstacles which emerged from the blue-ribbon panel deliberations. The panel identified several elements as indicative of this lack of integration, and the clinic studies repeatedly came accross examples of this obstacle.

The three major areas used to define integration were:

* a sense of importance and emphasis on the V/E function;

* skills of counselors and knowledge of resources to address client VR needs; and

* policies and procedures that facilitate accountability and followup of VR service delivery.

It is recommended that efforts to integrate vocational activities in programs take these three areas into account. The types of activities undertaken in each of these areas can include, respectively, the establishment of a "Vocational Committee" within a clinic, developing linkages with local vocational service agencies, and review of existing clinic procedures to develop those that promote VR activities.

Vocational Services Provided in

Treatment Programs

The majority of clients reported receiving vocational services (most frequently, vocational counseling). However, many clients reported that they wanted other types of services (more concrete vocational services, such as training and education). In addition, there were indications that counseling staff were not sufficiently familiar with vocational services delivery to provide adquate services (e.g., few used resources available, assessments were not done properly or systematically).

Even when vocational services are provided, the quality of services may need upgrading. Efforts are needed to monitor programs, not only for the existence of V/E services, but also for the quality of service provision. In addition, program administrators may need training to recognize quality vocational services and to hold their staff accountable for providing them. Additional efforts to train staff in vocational service delivery and resource development is recommended.

Clients' Likelihood of Vocational

Improvement

Although the majority of clients who were involved in full-time documented jobs and those who were uninvolved vocationally (with some explanation) tended to be in the same category 1 year later, the majority of those who were marginally involved or not involved (with no explanation), did move vocationally and were almost as likely to go up as to go down in vocational status. this indicates a certain fluidity of vocational status among many clients and, thus, the potential of directed movement, with assistance. In addition, even clients in the more stable category (full-time documented job) may need vocational assistance to keep from falling back in vocational status.

Clients Who Can Become

Vocationally Involved

It was found that clients with various types of competing factors (e.g., current drug abuse, primary caretaker) could also be involved in vocational programming and employment. Analyses from a nationwide study indicated that there was a substantial discrepancy between the percentage of clients in treatment who identified vocational services as a need and the percentage of clients and population were blacks, older clients and females - populations which may be stereotypically seen as less likely to benefit from vocational services.

Whole categories excluded from vocational assessment and planning. Instead, planning should be individualized based on client needs. In addition, assessments should be undertaken at various intervals: clients who may not be able to engage in vocational services at one point in treatment may be more amenable to these services at a later time.

Increasing Utilization of

Vocational Services

As with most efforts to change how systems operate, efforts to impact on how a clinic functions in terms of vocational service delivery is likely to meet with resistance. This is even more likely to occur if staff is asked to take on what are perceived as additional duties, if staff feel overburdened and stressed with current duties.

Any plans to impact on vocational services must take this resistance into account. Methods of reducing resistance may include eliciting staff assistance in developing the intervention and ensuring that there is full administrative support before undertaking the intervention. In addition, to maintain the continuation and quality of an intervention, followup, technical assistance and monitoring mechanisms must be developed.

Clinics with more clients involved in vocational services were found to have clear, enforced policies regaring the involvement of clients in vocational services. In addition, it was found that even if one staff persoon is interested and committed to vocational service delivery and is encouraged and supported by the administration an impact on all clients' utilization of vocational services can be attained.

Program administrative efforts to identify and encourage the development of current staff with interest in vocational service delivery would be helpful in increasing vocational service utilization. Furthermore, as indicated in the section on integration, the establishment of clear and enforced program policies encouraging clients' involvement in vocational services is also recommended.

Recommendations for Future

Interventions

It is recommended that some combination of the vocational integrator model (working to integrate vocational services into the treatment system) and a vocational counselor (to provide direct services) would be a desirable intervention. The vocational integrator focuses on clinicwide issues regarding vocational services and would provide methods to increase the emphasis on vocational services; help develop the skills of counselors regarding vocational assessement, planning and counseling; and recommend needed changes in clinic policies and procedures. The vocational counselor would provide direct services to clients(e.g., testing, referral, etc.) as well as outreach to hard to reach clients. This model could provide the short-term immediate activities attainable by a vocational counselor working directly with clients, deal with staff concerns regarding the need for vocational staff assistance and provide for planning and developing methods to impact on the clinic's longterm ability to further VR services delivery.

Dr. Deren formerly was Chief of Evaluation, New York State Division of Substance Abbuse Services; currently, she is Principal Investigator with Narcotic and Drug Research, Inc., 11 BEach Street, New York, New York 10013. Ms. Randell is Assistant Deputy Director for Program Services, New York State Division of Substances Abuse Services.

Project Research staff consisted of Dr. Deren and Ms. Randell, Co-Principal Investigators; Lorinda Arella, Ph.D., Project Director; and Vincent Brewington, M.A., Research Assistant.

This project was funded by Grant No. DA03407 from the National Institute on Drug Abuse, U.S. Department of Health and Human Services, awarded to Narcotic and Drug Research, Inc., and conducted in cooperation with the New York State Division of Substance Abuse Services. Requests for more detailed information on the project should be addressed to Dr. Deren.

The opinions expressed herein do not necessarily represent the views of the Department of Education, the Department of Health and Human Services, the New York State Division of Substance Abuse Services, or Narcotic and Drug Research, Inc.

Footnotes

(1) The methadone maintenance modality is based on an outpatient medical model. Methadone is a synthetic opiate prescribed for daily consumption by clients with an established history of opiate addiction. Methadone maintenance is considered long-term or lifetime treatment for most clients entering this modality.

Bibliography

[1] Brewington, V., Arella, L., Deren, S. and Randell, J. Obstacles to Vocational Rehabilitation: An Analysis of the Literature, International Journal of the Addictions, 1987,22, 1091-1118.

[2] Arella, L., Deren, S. and Randell, J. Issues Affecting the Utilization of Vocational/Educational Services in Drug Treatment.

[3] Brewington, V., Deren, S., Arella, L. and Randell, J. Obstacles to Vocational Rehabilitation: The Clients' Perspectives.

[4] Arella, L., Deren, S., Randell, J. and Brewington, V. Vocational rehabilitation: Obstacles for treatment programs. Presented by the Annual Meetings of the American Psychological Association, Washington, D.C., August 1986.

[5] Arella, L., Deren, S. and Randell, J. Vocational Functioning of Clients in Drug Treatment: Exploring Some Myths and Realities.

[6] Randell, J., Arella, L., Deren, S., Lyles, C. and Winfield, M. Integrating Vocational Rehabilitation Into Treatment Programs: Two Case Studies.

[7] Arella, L., Deren, S., Randell, J. and Brewington, V. Increasing Utilization of Vocational Services: Results of a 1-year Intervention Study.

COPYRIGHT 1989 U.S. Rehabilitation Services Administration
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