Several federal agencies also offer sources of funding that may be used to directly provide SE to individuals with mental illness or otherwise encourage them to work. These include various block grants, VR and special education programs, VA services, and other demonstrations.
1. SAMHSA's Community Mental Health Services Block Grant
CMHS Block Grant funds, administered by SAMHSA, can be used to pay for aspects of SE programs, including mental health treatment and vocational services, for individuals with SMI (Bazelon Center 2010; Karakus et al. 2011). Block Grant funds can be used to establish new mental health programs and services, build on existing programs, increase access to community-based services, and leverage additional funding from state or community sources (Altarum Institute 2010b). Each state must submit an application detailing how it will use the funds to create an organized, community-based system of care for individuals with mental illness. Block Grant funds are extremely flexible and can be used to pay for aspects of SE that cannot be paid for by other funding sources. For example, they can be used to pay for indirect services, such as clinical supervision, fidelity assessments, training, and integrated staff meetings that are necessary for maintaining fidelity to the evidence-based SE model that cannot be covered through Medicaid (which can pay only for direct services to the beneficiary). All 50 states and the District of Columbia receive Block Grant funding (SAMHSA 2012).
2. RSA's VR Services Program and SE State Grants (VI-B State Grants)
RSA provides several types of grants to states to fund employment programs for individuals with disabilities. This source of employment support may be important for individuals who are ineligible for Medicaid. In addition to the VR services described in Chapter III, the RSA provides grants to state VR agencies specifically for SE services. These grants are intended to supplement VR state grants. Known as Supported Employment for Individuals with the Most Significant Disabilities Title VI-B State Grants, they are meant to help states develop collaborative programs with various entities to provide SE services to individuals with severe disabilities.19 SE must be determined to be an appropriate rehabilitation objective for that individual based on a comprehensive rehabilitation-needs assessment.20 Services covered include: (1) any additional assessment needed; (2) development of job placements; and (3) provision of services needed to support individuals in their jobs, such as intensive on-the-job skills and other training needed to maintain job stability, follow-up, and such post-employment services as job-station re-design.21 However, funds "cannot be used to provide the extended services necessary to maintain individuals in employment after the end of SE services, which usually do not exceed 18 months" (U.S. Department of Education n.d. a).
3. Individuals with Disabilities Education Act Funding for SE
The Individuals with Disabilities Education Act requires that an Individualized Education Program (IEP) be developed for students in special education if it is needed to help the student participate to his or her maximum potential. The IEP specifies the services that must be provided and funded by the school district and must be tailored to the individual's needs, as identified through an evaluation process. Transition services must be provided to help the student move from school to employment or further education. SE may be specified in the IEP as a transition service. However, we were unable to identify the extent to which SE is provided to individuals with SMI through IEPs.
4. Employment and Training Administration's America's Job Center Network
The America's Job Center Network (formerly called One-Stop Career Centers) was established under the Workforce Investment Act to provide comprehensive assistance to job seekers. Services offered by these centers include training referrals, career counseling, and access to job listings. Because America's Job Centers offer general support services rather than services that are specific to mental health or disability, they may be more appealing to young people or others for whom stigma is an issue. They are also especially useful for people with mental illnesses who are not yet disabled or do not qualify for disability benefits. America's Job Centers have been used by some states to provide employment assistance to people with disabilities, though questions remain about whether they are equipped to provide services to individuals with SMI (Karakus et al. 2011). In a 2009 survey of One-Stop Career Center staff in several states, respondents reported seeing a greater number of customers with mental health issues during the recession years of 2007-2009 (Heidkamp & Mabe 2011). To better serve these individuals, center staff in several states said they were connecting their services to mental and behavioral health systems.
5. U.S. Department of Veterans Affairs' VR, Compensated Work Therapy, and Homeless Veterans Supported Employment Programs
The VA provides a number of employment services for qualifying veterans through the Vocational Rehabilitation and Employment (VR&E) program, Compensated Work Therapy, and the Homeless Veterans Supported Employment Program. The VR&E program offers employment supports to veterans who have service-connected disabilities. Services available under this program include an evaluation to determine skills, abilities, and interests; vocational counseling and planning for employment services; various employment services, such as job training and development of job-search skills and resumes; assistance finding and keeping a job, including incentives to employers and special job accommodations; on-the-job training and apprenticeships; training at a college, vocational, or technical school; and case management, counseling, and medical referrals.
Through Compensated Work Therapy, the VA offers VR programs, including SE, which seek to place veterans in jobs (U.S. Department of Veterans Affairs 2009). The SE Program helps veterans with disabilities identify and obtain jobs based on individualized preferences and then provides ongoing support and vocational assistance (Resnick & Rosenheck 2007). The Homeless Veteran SE Program offers SE to homeless veterans and those who are at risk of homelessness (U.S. Department of Veterans Affairs n.d.).
6. SSA's TTW Program
The TTW program, also described in Chapter III, enables any state VR agency, America's Job Center, or mental health provider (including a consumer-operated or peer-service provider) to become an employment network (EN) and provide employment-support services. An EN receives payments if it helps the beneficiary achieve earnings high enough to reduce or eliminate SSA cash benefits (Altshuler et al. 2011). TTW funds, therefore, can be used to fund any aspect of SE programs. However, few ENs provide the intensive support that beneficiaries with significant disabilities need to sustain the level of employment required for the EN to receive payment.
TTW funds can be used concurrently with 1915(c) waiver funds to create more comprehensive SE programs. Because TTW payments are made based on employment-related outcomes and milestones achieved by beneficiaries (rather than on a cost-reimbursement basis), CMS has determined that using them together with waiver funds does not constitute an overpayment of federal dollars (HHS 2011).
Work Incentives Planning and Assistance programs, also authorized by the Ticket Act, advise Social Security disability beneficiaries on how to use work incentives available through Social Security disability benefits programs. Work incentives counseling is now one of the core components of SE, and many SE providers have become certified work incentives counselors.
7. Employer-Sponsored Employment-Support Services
Employers fund DM through their own funds, or through private insurance carriers that provide workers' compensation or short-term or long-term disability insurance. The companies that have successfully reduced costs take an active role in managing their work-injury cases. Companies use this case management function--formally or informally--whether they are commercially insured and receive claim management assistance from its carrier or they use a medical management group to provide RTW services.
SE is not typically covered under private health insurance, but some employers may include some aspects of it under short-term or long-term disability insurance, DM, or company-sponsored employment assistance programs. However, access to employee-sponsored DM programs is important for individuals who are not covered by Medicaid, because their income is too high or because they do not meet the eligibility criteria for Social Security disability benefits.