Individuals with serious mental illness (SMI) face considerable challenges in educational attainment and employment. Supported education (SEd) presents a promising approach to address the educational goals of individuals with mental illness. The goals of SEd are for individuals with SMI to successfully be able to: (1) set and achieve an educational goal (e.g., training certificate or degree); (2) improve educational competencies (literacy, study skills, time management); (3) navigate the educational environment (e.g., applications, financial assistance); and (4) improve educational attainment.
The current project was designed to characterize the current state of knowledge about SEd as a way to assess the feasibility of conducting a demonstration of SEd for individuals with SMI. This project sought to identify key considerations in planning and preparing for a larger-scale demonstration of SEd by compiling evidence on SEd programs, identifying gaps in the knowledge base about SEd, and describing possible approaches for addressing unanswered questions about SEd. The project focused on answering a series of research questions about SEd program composition, implementation, service context, the experiences of individuals involved in SEd programs, available SEd data sources and ongoing evaluations, SEd policies, financing, and gaps in the SEd knowledge base.
Three key tasks were associated with this project: (1) a literature review; (2) an environmental scan of SEd researchers, program managers, and other key informants; and (3) site visits to three programs implementing SEd service delivery models. This final project report includes chapters describing the results from each task, as well as a final synthesis chapter that identifies future SEd needs and opportunities.
The current policy and practice landscape makes a focus on SEd interventions and supporting evidence particularly timely. The negative functional impact of SMI, particularly among young adults, is receiving increased public attention. There are several recent SEd program development and evaluation efforts, especially for individuals with first-episode psychosis. Institutions of higher education have also noted a burgeoning student population with mental health conditions. In addition, two recent policy and practice opportunities provide new possibilities for SEd program funding: the Workforce Innovation and Opportunity Act (WIOA) and the early intervention for SMI set-aside in the Substance Abuse and Mental Health Services Administration Block Grants. These policy and funding opportunities for SEd are complemented by the increased experimentation with SEd practices in the field. Consequently, findings from the current project suggest that SEd is on the cusp of widespread and sustained implementation.
1.1. Supported Education Program Model Development
Our findings suggest that the practice of SEd includes common core strategies to support individuals with mental health conditions to choose, keep, and obtain an educational goal. The literature review, environmental scan, and site visits shed light on principal issues concerning development of a model of service to support the educational goals of individuals living with mental health conditions. Findings include recognizing that variability among SEd program models is largely due to differences in service context. SEd program service settings can range from specialty mental health settings (e.g., hospitals, clubhouses, community mental health centers) to primary and post-secondary education settings and to state vocational rehabilitation (VR) agencies. Despite differences in settings and specific program characteristics, a shared set of core SEd service array components is also present across SEd efforts. Environmental scan and site visit findings demonstrate that widely different settings can successfully practice the core elements of providing educational supports. Findings also show that SEd is often integrated and delivered in tandem with supported employment (SE) services, but this integration can be beneficial and disadvantageous. Post-secondary campus settings can offer particularly unique opportunities, distinct from traditional mental health system-focused SEd services, to support students with mental health conditions directly in a college environment.
Results of the literature review, environmental scan, and site visits indicate the following needs and opportunities for the development of a fully specified, replicable, and testable model for SEd:
Specifying SEd Core Components: Specification around the core components of SEd should be increased. This could include matching specific components to SEd activities and to measureable outcomes. A first step could include examining existing program-specific SEd manuals and various SEd efforts being implemented across the country to further operationalize components and activities.
Identifying SEd Staffing Requirements: Staffing requirements should be further elucidated to reflect the range of education, disciplines, and training that contribute to skilled SEd staff. This should include an emphasis on specified skill sets and the capacity to support individuals with educational goals. Staffing requirements should also include developing and routinizing training supports coupled with ongoing coaching and mentoring.
Defining SEd Specialist Tasks: The role of an education specialist needs to be clearly defined, not only specific to a standalone SEd program, but also when integrated with SE. This includes defining discrete tasks and activities associated with supporting educational goals, while also emphasizing inter-personal and relational skills that facilitate the strong relationships that are the foundation of the work between a SEd participant and a SEd specialist.
Operationalizing SED/Individual Placement and Support (IPS) SE Integration: Strategies on how to integrate SEd and IPS SE need to be further defined and operationalized. This should include defining measurable goals and outcomes specific to educational goals and milestones, as well as strategies for staff on how to balance and integrate education and employment goals.
Operationalizing Campus Best Practices Supporting Student Mental Health: A set of best practice guidelines should be developed to highlight successful strategies for improving campus-based supports for students with mental health conditions. Specifics should include how to secure administrative and leadership buy-in and how to partner with key campus departments (e.g., disability services), as well as more ancillary departments (e.g., travel abroad) to address student mental health. Additionally, strategies to normalize mental illness and decrease stigma on campus should be considered.
1.2. Supported Education Funding
Funding challenges to support SEd program services were commonly described within the published literature and by environmental scan and site visit participants. Environmental scan participants, in particular, noted the lack of one centralized funding strategy for SEd services. Consequently, SEd programs relied on different funding vehicles (municipal, federal, state, collegiate, and/or private corporations) that varied in terms of their stability and ultimate sustainability. Creative braiding of funding will likely be the solution to the absence of a clear funding stream, and guidance on how to properly utilize funding opportunities to meet individual client needs will aid provider organizations.
This project identified several needs and opportunities that could help sustain funding for SEd programming:
Braided Funding Case Studies: Those working in the SEd field need to better understand how various programs across the country have and are currently braiding funding to support their SEd program activities. Published case studies that demonstrate successful braided funding strategies in support of SEd services could be widely used to help program administrators circumvent the funding challenges noted in stakeholder discussions across this project.
Medicaid Billing Code: The availability of an SE Medicaid billing code has helped to disseminate and sustain SE approaches for individuals with psychiatric disabilities across the United States. A similar Medicaid billing option could support and extend the availability of SEd services to complement employment supports. The availability of this type of billing option would directly benefit young adults with mental illness who are highly likely to have both educational and employment goals.
Guidelines for SE/SEd Medicaid Billing: Programs described using the SE Medicaid billing code to support the activities of SE/SEd specialists' time; however, procedures for billing joint SE/SEd program activities vary. SE/SEd program administrators could benefit from guidelines that describe how to bill SEd activities that occur as part of IPS or other SE services.
Increased Clarity Around Medicaid Waiver Option Processes: Program administrators implementing SEd programs could benefit from enhanced clarity around the availability of Medicaid funding to support education services through the 1915(c) Home and Community-Based Services waiver option. This guidance could come in the forms of a state Medicaid director letter, program guide, frequently asked questions document, or fact sheet.
WIOA Expansion: The recent WIOA expansion offers an opportunity for SEd program implementation and support through VR. The expanded emphasis on WIOA to address career needs of 15-21-year-olds will certainly involve supporting their education attempts. VR dollars, with their high federal match for state dollars, can incentivize SEd services for this population. There is also an opportunity to braid the dollars associated with WIOA with Medicaid to provide the rehabilitation services that are concomitantly needed.
1.3. Supported Education Research and Evaluation
The published literature on SEd research demonstrates the promise of SEd interventions to affect education enrollment among individuals with mental illness. Suggestive evidence from noncontrolled studies also indicates that individuals improve their employment and educational attainment after participating in a SEd program. However, there is a lack of controlled comparative evidence to suggest that participating in a SEd program explicitly leads to gains in educational attainment. SEd intervention research and evaluation are limited by the predominance of nonexperimental study designs, small sample sizes, and few long-term follow-up assessments of program participants. A rigorous and comparative demonstration project to determine the impact of SEd programs on educational enrollment, attainment, and ultimately employment is clearly needed.
Project results indicate the following research and evaluation needs and opportunities:
Rigorous Evaluation and Research Designs: SEd programs demonstrate a strong ability to support evaluation studies and data collection efforts; however, existing evaluation efforts are not systematic. Rigorous evaluation and research designs are needed that capitalize on the existing SEd program infrastructure and data collection readiness.
Randomized Controlled Trials (RCTs): Rigorous research designed to understand the impact of SEd on core outcomes of interest is needed. In particular, a well-designed RCT could help establish the evidence base necessary to move SEd from a "promising" to an "evidence-based" practice.
Follow-Up Data Collection for 3-5 Years (minimum): Any future SEd research or evaluation trial must be designed with follow-up data collection that extends a minimum of 3 years and ideally 5 or more years from baseline to adequately capture longer-term educational degree attainment and ultimately job sustainability outcomes. Most SEd studies are limited by 1-2-year follow-ups (or less), which is an insufficient amount of time for most individuals to complete a full degree requirement.
Large Sample Size: Larger sample sizes in SEd outcome studies are needed to analyze differences in outcomes by demographic characteristics and mental illness/symptomology. Larger sample sizes are also needed to allow sufficient power to disentangle the additional benefit of SEd to IPS approaches, separate from their impact on employment outcomes. This would not be feasible in a multisite design.
1.4. Supported Education Demonstration Project
A central goal of this study was to determine the feasibility of a SEd demonstration project. Results from our literature review, environmental scan, and site visits clearly suggest that a SEd demonstration project is needed and that the SEd field would be ready to support such a project. The implementation of many different SEd programs are described in the published literature. The environmental scan and site visit results demonstrate that several provider organizations are well poised to conduct systematic data collection on SEd processes and outcomes. Work is under way to develop SEd intervention model fidelity tools, program training manuals, and implementation guides. Also, there is general consensus in the field about what outcomes are important to measure in order to best assess SEd program impact.
Given the methodological limitations of existing SEd research, an optimally designed demonstration project would have two sequential and complementary stages. Stage 1 (6-12 months) would focus on refining and testing existing fidelity and implementation guides to support a high-quality process evaluation. Stage 2 (3-5 years or more) would include conducting a multisite RCT with long-term follow-up of program participants for 3 or more years. The field could benefit from a demonstration that is explicitly focused on the impact of a SEd-specific intervention, separate from an intervention that emphasizes employment supports. Such a demonstration project would provide the platform necessary to generate the type of evidence needed to move SEd programs from a promising practice to an evidence-based practice, thus encouraging future funding and widespread adoption.