Policy and practice: An analysis of the implementation of supported employment in Nebraska

Supported employment (SE) is an evidence-based practice (EBP) for persons with severe mental illness (SMI) aimed at competitive employment. SE has a large evidence base, demonstrating outcomes across settings and populations. SE has been promoted by the Centers for Medicare and Medicaid Services (in the U.S. Department of Health and Human Services) and widely disseminated through the internet via a community tool-kit sponsored by the Substance Abuse and Mental Health Services Administration. The SE literature expresses the opinion that state governments can successfully implement SE. Researchers have developed implementation guidelines and identified stages of statewide implementation; however, most SE implementation studies have taken place with generous funding, full-time training/consultation from foremost SE experts, and supportive, knowledgeable top-level administrators. Much less is understood about EBP implementation in the absence of such resources. This is a critical issue: state mental health systems profess the delivery of evidence-based psychiatric rehabilitation services; yet most persons with SMI fail to receive evidence-based care. To address these questions, the present study examines one state mental health system to determine the populations served, fidelity to the evidence-based model, outcomes, relevant contextual factors, and comments on current problems surrounding the implementation of recovery-oriented, evidence-based services for SMI into everyday settings. Seven of the 9 Nebraska SE programs did not meet SE fidelity. Employment outcomes achieved were characteristic of traditional vocational rehabilitation programs. Over time, programs served a decreasing proportion of individuals with schizophrenia-spectrum disorders, the population for which this EBP has been validated. Assessment and treatment plan review procedures were driven by the reimbursement structure rather than the principles of psychiatric rehabilitation and recovery. Programs demonstrated limited understanding of EBP, recovery and psychiatric rehabilitation. The implementation of SE occurred within the greater context of a statewide trend of closing nearly all inpatient hospital units--despite recognition that effective mental health systems for persons with SMI must successfully implement EBPs and provide a comprehensive continuum of care to adequately address the multiple needs of this population. Careful consideration of implementation factors should be included in further research and policy pertinent to dissemination of EBPs to adequately address the research-practice gap