SUPPORTED EMPLOYMENT PROGRAM IN OCCUPATIONAL THERAPY DEPARTMENT, HSAH

Authors; Noor Emellia Jamaludin Fauzi Rihan

OCTOBER 2011

Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

ACKNOWLEDGEMENT We would like to express our utmost gratitude and appreciation to the following individuals / parties who had given us excellent cooperation and contribution in any shape or form. Without them, this audit would not have been a success. Dr Harif Fadzilah bin Che Hashim, Director of Hospital Sultan Abdul Halim Dr Mithali Abdullah @ Jacqueline Sapen, Head of the Quality and Innovation Unit, Hospital Sultan Abdul Halim and Clinical Audit Coordinator Dr. Shamsunnisah binti Abu Bakar, Head of Department Psychiatry and Mental Health, Hospital Sultan Abdul Halim Dr. Salwa binti Ramly, Psychiatrist, Hospital Sultan Abdul Halim All occupational therapists who had participated All Sisters/ staff nurses

Clinical Audit 2011

Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

ABSTRACT TITLE: Supported Employment Program in Occupational Therapy Department, HSAH AUTHOR: Noor Emellia Jamaludin; Fauzi Rihan OVERVIEW: It is a multidisciplinary program which involved Psychiatrists, Medical Officer, Occupational Therapist, Nurse and Assistant Medical Officer. Until June 2011, 43 patients were referred to undergo this program. OBJECTIVE: To determine the percentage of patients referred for supported employment program sustained in job placement for more than 6 months and the factors that inhibits patients from sustaining in job placement. At the end of the audit, the authors desire to formulate strategies for change in improving the effectiveness of the program. METHODOLOGY: This is a prospective study with cross sectional data collection of patients with mental health illness who had participated in the Supported Employment Program from 1st December 2010 untill 1st October 2011 (data collection started from the day one since Supported Employment Program was established). RESULT: 33 patients were included in the study and only 11 (33.3%) of them sustained in job placement for more than 6 months. The factor that leads to the job terminations includes family problem (2 cases), cognitive problem (1 case), behavior problem (3 cases), lack of social skill (13 cases) and lack of work skill (3 cases). STRATEGIES FOR CHANGES: To improve the situation, strategies such as promoting awareness and educate the community, Worked directly with clients in a case management approach, smart partnership - liaison and support to ensure that support needs were met, including any adjustments necessary to enable clients to retain work/education and case management meeting with Department of Psychiatry is needed. CONCLUSION: There should be a smart partnership between the Jabatan Tenaga Kerja and occupational therapist in order to assist patient with mental health problems in returning them back to work. This sort of liaison and support improved the capacity of these organizations to accommodate people with mental health problems.

Clinical Audit 2011

Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

TABLE OF CONTENTS

No. 1. 2. 3. 4. 5. Title page

Title

Page 1 2 3 4

Acknowledgement Abstract Table of content 1.0 Introduction 1.1 Background 1.2 Problem Statement 1.3 Objectives 1.4 Standard and criteria

5 6 7 8

6.

2.0 Methodology 2.1 Sampling population 2.2 Inclusion and exclusion criteria 2.3 Data collection 2.4 Data analysis 9 9 10 10

7.

3.0 Result 3.1 Demographic data 3.2 Primary outcome 3.2 Secondary outcome 3.3 Summary of findings 11 11 11 12 13 16 18 19 20

8. 9. 10. 11. 12.

Discussion Strategy for change Conclusion References Appendixes

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Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

1.0 INTRODUCTION 1.1 Background Traditionally, mental health centers have used a brokered approach to vocational rehabilitation for patients with mental health problems, referring them to state vocational rehabilitation services, which in turn have relied on rehabilitation agencies providing mostly sheltered workshops to gradually transition clients into competitive employment or extensive skill training interventions designed to develop the requisite working skill before competitive job placement. Gary R. Bond & Kikuko Campbell (2003) defined supported employment as an approach to helping people with disabilities participate in the competitive labor market, helping them find meaningful jobs and providing ongoing support from a team of professionals. Less than 15% of patients with mental illness are competitively employed at any time. There is an increasing research evidence which demonstrates that the individual placement and support (IPS) approach, also known as evidence-based supported employment, is effective in enabling a substantial proportion of people with serious mental health problems to gain and sustain open employment (Bond et al., 2001; Crowther et al,2001; Bond,2004). In psychiatric rehabilitation, work has been found to be associated with a range of benefits, including improved symptoms, greater satisfaction with finance, improved self-esteem, and improved sense of recovery. Work is important both in maintaining mental health and in promoting the recovery of those who have experienced mental health problems. Studies of supported employment focus on enabling people to gain jobs once they have lost them; however, it is equally important to prevent people from losing their jobs in the first place (Royal College of Psychiatrists, 2002; Rinaldi et al, 2004). Components of supported employment program include vocational assessment, job searching/bridging, job preparation, job placement and job coaching.

Clinical Audit 2011

Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

Occupational therapists play important roles in supported employment for patients with mental health problems. Evaluation and assessments (e.g. Functional Ability Assessment (FAA), Functional Independency Assessment (FIM), Canadian Occupational Performance Measure (COPM), Comprehensive Occupational Therapy Evaluation Scale (COTE), Functional Capacity Evaluation (FCE), etc.) need to be carried out to identify the patients abilities and disabilities. Appropriate interventions (e.g. social skill training, Activity of Daily Living (ADL) retraining, communication skill training, relaxation techniques and other possible interventions) will be given to the patients in order to restore the functions affected. The occupational therapist will facilitate the patient to return to work. If the patient is not employed, the therapist will assist in job training, job bridging and job placement for that patient. In addition, the therapist should also monitor and ensure that the patient is able to sustain in the workplace. 1.2 Problem statement Rinaldi et. Al., (2004) stated that work is important both in maintaining mental health and in promoting the recovery of those who experienced mental health problems. Supported employment facilitates competitive work in integrated work setting for individuals with the most severe disabilities. Supported employment program in Hospital Sultan Abdul Halim has been established since December 2010. It is a multidisciplinary program which involved Psychiatrists, Medical Officer, Occupational Therapist, Nurse and Assistant Medical Officer. Until June 2011, 43 patients were referred to undergo this program. However, only 22% of the patients were able to sustain in job placement for more than 6 months. This study was conducted to review and revise the implementation of the program in order to improve the success rate of the program. The benefits of an effective supported employment program include improving symptoms, greater satisfaction with good financial

Clinical Audit 2011

Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

support, improved self esteem and improved sense of recovery (Bond et. al., 2001; Crowther et. al., 2001; Bond, 2005). 1.3 Objective The aim of the study is to determine the effectiveness of the supported employment program for psychiatry patients in Hospital Sultan Abdul Halim, Sungai Petani. In specific the author attempt to: 1.3.1 To determine the percentage of patients referred for supported employment program sustained in job placement for more than 6 months. 1.3.2 1.3.3 To determine the factors that inhibits patients from sustaining in job placement. To formulate strategies for change in improving the effectiveness of the program.

1.4 Standard and Criteria A study done by Rinaldi et. al., (2004) revealed that after 6 months of the intervention, employment rate of the patients with mental health problems rose from 10% to 28%. Another study conducted by Gervey et. al., (1995) claimed that 22% of their patients succeed in remaining in the job placement after 6 months period. Locally, after reviewing the percentage of patients sustain in job placement of the supported employment program, the authors found that the success rate in HSAH was the highest among the District and State Hospitals in Peninsular Malaysia (statement by Dr. Abdul Kadir Abu Bakar, President of Malaysian Psychiatry Association (MPA)). There are 3 mental health institutions in Malaysia which are (1) Hospital Permai, Johor and (2) Hospital Bahagia Ulu Kinta, Perak and (3) Hospital Mesra Bukit Padang, Sabah. Hospital Bahagia Ulu Kinta, Perak had achieved 84% of patients sustain in job placement more than 6 months period. After having a discussion with the Psychiatrist in HSAH, (Dr. Salwa binti Ramly) and considering all the aspects such as facilities and

Clinical Audit 2011

Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

technologies, numbers of bed and patients, and human resources, the authors decide to set 50% as the standard.

No. 1.

Criteria

Standard

Percentage of patients sustain in job placement for 50 % more than 6 months period.

Hospital Bahagia Ulu Kinta, Perak was chosen as our benchmark.

Clinical Audit 2011

Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

2.0 METHODOLOGY 2.1 Sampling population and sampling procedure This is a prospective study with cross sectional data collection of patients with mental health illness who had participated in the Supported Employment Program from 1st December 2010 untill 1st October 2011 (data collection started from the day one since Supported Employment Program was established). 2.2 Inclusion and exclusion criteria 2.2.1 Inclusion criteria a) Physically and mentally stable b) Referred by the Medical Officer or Psychiatrist c) Aged: above 18 and below 50 years old d) Received psychiatry service from Psychiatry and Mental Health Department and Occupational Therapy Department of Hospital Sultan Abdul Halim, Sungai Petani. e) The patient should able to use public transport independently. 2.2.2 Exclusion criteria

a) Patients with poor insight. b) Not compliance to medication and treatment.

2.3 Data collection and clinical outcome The following information was collected and documented in Data Collection Table (in Appendix) a) Patients identification number b) Date of referral to supported employment program c) Date of job placement d) Duration of sustained job placement e) Factor that leads to job termination

Interview session also being done by the authors in order to explore the inhibit factors that lead to job termination.

Clinical Audit 2011

Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

2.4 Data analysis All the data will be analyzed by using Microsoft Excel 2007

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Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

3.0 RESULT

3.1 Demographic data

Table 1: Sample Distributions (Gender) Male 25 75.8% Female 8 24.2%

3.2 Primary outcome Table 2: Percentage of patients who sustained in job placement for more than 6 months Total patients Number of patients sustained in job placement > 6 months 33 11 (33.3%)

3.3 Secondary outcome

Chart 1: Factor that leads to job termination

14%

9% 5%
Family Problem

14%

Cognitive Problem Behavior Problem Personal skill/ scosial skill problem Lack of work skill

58%

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Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

3.4 Summary of audit findings 33 patients were included in the study and only 11 (33.3%) of them sustained in job placement for more than 6 months. The factor that leads to the job terminations includes family problem (2 cases), cognitive problem (1 case), behavior problem (3 cases), lack of social skill (13 cases) and lack of work skill (3 cases).

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Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

4.0 DISCUSSION 4.1 Stigmatization and discrimination at workplace Thornicroft (2006) stated that people with mental ill health face stigma and discrimination when trying to find work or retaining their jobs. Many people in employment feel isolated and ostracized by colleagues who do not know how to support them. In a survey of public attitudes, only two-thirds of people agreed that People with mental health problems should have the same right to a job as anyone else (TNS Global, 2007). Similar issues may also happened In Malaysia. Not all employers are willing to employed patient with mental health problems. Patients with mental health problems usually appear to be dangerous and could harm themselves or others. Recently, there were a few of criminal and amok cases that involved individuals with mental health problems causing injuries and even death. These cases influence the publics and the communitys perception towards person with mental health problems (15 August 2011, Harian Metro) More awareness programs need to be conducted in order to improve the community awareness and knowledge about individuals with mental health problems. The awareness program may also help in early detection of mental health problems in the community. 4.2 Family Support Based on Kumpfer K.L. & Alvarado R. (2003), strong family support is essential to positive development including avoiding problems such as academic failure and mental disorders that may have implications for life-long functioning. The family exerts a powerful influence on the developing child and this impact continues into adolescence to a greater degree than previously believed (Joronen K. & Astedt Kurki P., 2005). In this study, the author found out that family problem contributes to the termination in job placement. Family support includes moral support and financial support. Patients with mental health problems require both supports from their family. Moral support from family members is important to built trust, confidence and feeling valued by family. The authors have found that family of two patients has failed to provide both moral support and financial

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Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

support. Both patient has been abandoned by the family. He or she has no money to travel to the hospital and workplace. Therefore, he or she was terminated. In such situation, the occupational therapist or medical officer could refer the patient to the appropriate agencies that may help the patient such as Jabatan Kebajikan Masyarakat (JKM), Social Welfare Department, or others related non-government organization (NGOs). On of top of that, the occupational therapist needs to educate the family on the importance of their involvement in patients intervention program in mental health. 4.3 Cognitive impairment Midin et. al., (2011) claimed that cognitive impairment is also associated with broader functional outcomes among patients with mental health problems. Green M. (1996) found strong and consistent associations between cognitive functions and functioning in schizophrenia. Verbal memory, executive functioning and vigilance were found to be associated with different aspects of functional outcome. In this study, there was one case of cognitive impairment in which the patient has problem in attention and concentration. Patient also has problem in educational skill such as reading, calculating and writing. It is a challenge for the therapist to help such patient. Intensive cognitive retraining is required for this patient before he or she can undergo job placement. 4.4 Lack of interpersonal skill and social skill and behavior problems. Interpersonal skill can be defined as mental and communicative algorithms applied during social communications and interaction to reach certain effects or results. Good interpersonal skills allow others to perceive us as more confident and having more charisma, qualities that are often endearing. Meanwhile, social skill is any skill facilitating interaction and communication with others. Social rules and relations are created, communicated, and changed in verbal and nonverbal ways. The process of learning such skills is called socialization. Midin et. al., (2011) stated that personal and vocational functioning, social skills were also found to be dependent on certain intact cognitive domains. Most of the patients in this study who were unable to sustain in job

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Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

placement for more than 6 months demonstrated lack of motivation. Social skill training and interpersonal skill training can be used in developing confidence, motivation and communication skill. Occupational therapist can use these interventions in treating patients with low motivation in job placement.

4.5 Lack of Work skills Work skill and work habit is important in helping the patient with mental health problems in sustaining in their job placement. Work skill includes time management, leadership, teamwork and interaction with other workers. Meanwhile work habits includes punctuality, obey to the rules and regulations and responsibility. Occupational therapist should conduct assessment of employment readiness of the patient before proceeding with other components of supported employment. It is important for the therapist to identify the interest and readiness of the patient to work. Adequate work skills and work habits also need to be developed during job training session before sending the patient with mental health problems to job placement.

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5.0 STRATEGIES FOR CHANGE No. 1. Strategies for change Promote awareness Implementation Responsibilities Progression

and a) Talk on mental health to students at a) Occupational Therapist, In Progress Medical and Officer 1) 24 August 2011 staff talk at Klinik

educate the community on school (once a year).

mental health problems in b) Kumpulan Sokongan Keluarga (Psychiatric) Kuala Muda district. Education on Psychiatric condition nurses. Medical involving government, non government b) year)

Kesihatan Kupang Officer 2) 28 September 2011 SP Inn (to Medical Assistant Officer, and other health care providers as

agencies and patients family (twice a (Psychiatric), Occupational talk at Therapist and staff nurses. b) Talk on mental health involving the c) Staff nurses at Klinik such community at Kuala Muda,Yan and Kesihatan Kuala Muda,Yan Officer, Baling (twice a year) and Baling. Medical Nurses

Occupational Therapists). 2. Worked directly with clients a) Proactively helping them to gain and a) Occupational Therapist in a case management retain work/educational courses, provide welfare benefits advice (in relation to work). approach. In progress Occupational therapist starts to involve the family discussion in the before

sending the patient to

Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

job placement. 3. Smart partnership - liaison a) Jabatan Tenaga Kerja - talk about and support to ensure that job that is potential for psychiatric support needs were met, patients to the employers. including any adjustments b)Teach patient how to use on line job necessary to enable clients street to retain work/education. a) Occupational Therapist Done 18 August 2011 met the person in charged in Jabatan Tenaga Kerja to discuss about job vacancies in Kuala Muda District. 4. Case management meeting with Department Psychiatry To discuss about the patients who were a) patients (twice a month). Psychiatrist and A schedule has been made (please refer to the appendix).

of employed will help in monitoring the Occupational Therapist

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6.0 CONCLUSION The effectiveness of supported employment appears to be generalizable across a broad range of client characteristics and community settings. There should be a smart partnership between the Jabatan Tenaga Kerja and occupational therapist in order to assist patient with mental health problems in returning them back to work. This sort of liaison and support improved the capacity of these organizations to accommodate people with mental health problems.

7.0 REFERENCES

Occupational Therapy Department Hospital Sultan Abdul Halim (HSAH), Sungai Petani, Kedah.

1. Gary R. Bond & Kikuko Campbell (2003). Supported Employment. Retrieved on 27 September 2011 from http://schizophrenia.com/family/SuppEmpl.html 2. Anynomous (2010). Community-Based Treatment of Schizophrenia: Supported Employment. Retrieved on 27 September 2011 from http://medscape.com/viewarticle/430529_5 3. William Anthony (2006). Supported Employment. The National GAINS Center for Systemic Change for Justice-Involved People with Mental Illness: Boston University, Center for Psychiatry Rehabilitation. 4. Deborah R. Becker et. al., (2011). Supported Employment for People with Severe Mental Illness: A Guideline developed for the Behavioral Health Recovery Management Project. University of Chicago Center for Psychiatry Rehabilitation. 5. Midin M. et. al., (2011). Clinical and Cognitive correlates of employment among patients with schizophrenia: a cross sectional study in Malaysia. Retrieved on 14 September 2011 from http://www.ijmhs.com/content/5/1/14 6. Anonymous (2011). What is supported employment?. Retrieved on 23 September 2011 from http://affnet.ucp.org/ucp_channeldoc.cfm/1/17/107/107107/1701 7. Anonymous (2011). Supported Employment. Retrieved on 23 September 2011 from http://en.wikipedia.org/wiki/Supported_employment 8. Anonymous (2011). What parents need to know about supported employment? Retrieved on 26 September 2011 from http://www.afb.org/Section.asp?SectionID=7&TopicID=269&DocumentID=3118 9. (2009). Overcoming unemployed and mental illness. Retrieved on 23 September 2011 from http://www.cbsnews.com/stories/2009/01/04/eveningnews/main4697774.shtml

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