Case Managers’ Perceptions of Consumer Work Readiness and Association With Pursuit of Employment

Employment is an important element of recovery for individuals with a serious mental illness (1), and community mental health centers are emphasizing the importance of work (2). Most individuals with serious mental illness desire employment (3,4), yet most remain unemployed (4,5). Research on supported employment has demonstrated that effective programs are available to help these individuals obtain work (6). Across 16 randomized controlled trials, the mean competitive employment rate for supported employment was 59%, compared with 23% for participants in control conditions that used traditional methods of employment services (7). Despite the increasing availability of supported employment programs, only a small percentage of individuals with serious mental illness participate in them (8).

Case managers are the primary conduit between consumers and vocational services. Case managers’ responsibilities include exploring and encouraging interest in work and referring clients to employment programs. They also have a role in supporting consumers to maintain employment once a job has been obtained. There is, however, wide variation among case manager caseloads in the number of consumers participating in vocational services, pursuing competitive employment, and finding a job. This variation can be seen between agencies and even between case managers on the same team.

Many studies have explored the barriers to and predictors of employment outcomes, but few have focused on case managers. Case managers’ perceptions and behaviors may be more important in determining client employment outcomes than client characteristics or other frequently studied factors. Case managers, for example, may perceive consumers as unable to work (9) and therefore may discourage them from pursuing employment or may refer them to ineffective prevocational services before supporting a decision to work (10).

The purpose of this study was to explore the effect of staff-level factors that might affect employment outcomes, most notably the perceptions of case managers who refer clients to supported employment programs. Our hypothesis was that many clients are screened out of participating in employment because of case managers’ perceptions.

We developed the following questions to help guide the research: To what degree are case managers associated with consumers’ pursuit of employment? To what degree are case managers’ perceptions of readiness to work related to consumers’ pursuit of employment?

Methods

Eight community mental health centers in Kansas with supported employment programs were recruited into the study. After approval of the study was received from the institutional review board at the University of Kansas, we asked all 113 case managers who were employed by these agencies at the time of the study to participate and report on each of their 1,556 consumers. Most of the consumers were female (54%, N=839) and Caucasian (77%, N=1,200). Further racial-ethnic representation was as follows: 232 (15%) were African American, 52 (3%) were Hispanic, 37 (2%) were Asian, 22 (1%) were Native American, and 13 (1%) were other. Slightly more than 41% (N=646) were 46 years old or older, and about 31% (N=478) were between ages 36 and 45. Approximately 42% (N=660) had a diagnosis of schizophrenia; about 22% (N=341) had bipolar disorder, and another 22% (N=334) had major depression.

A cross-sectional survey design was used to assess the role of staff perceptions on employment outcomes. Case managers were asked to complete an individual demographic questionnaire for all consumers on their caseload. They also were asked whether the consumer had expressed interest in working during the past three months. After case managers filled out the demographic questionnaire, they met with a researcher and answered questions regarding employment-related actions they had conducted in the past three months with each client on their case load. Each case manager also completed a case manager work perception scale (CMWPS) of consumers’ employability.

Active movements toward employment included any of the following activities within the three months before our site visit: the client filled out or turned in a job application, the case manager helped the client prepare for a scheduled job interview, the client interviewed for a job, the case manager referred the client to a vocational program outside the mental health center, or the case manager referred the client to a supported employment program.

We developed the CMWPS to determine how much importance case managers place on five broad areas when considering whether a consumer might be ready for work. The CMWPS uses a 5-point Likert format; case managers were asked to report on a scale ranging from 1, not at all, to 5, extremely, the level of importance they assign to five areas before referring clients to supported employment or assisting them in employment activities. The five areas rated include appropriateness of hygiene, appropriateness of social skills, whether the client is free of alcohol and drug use, adherence with medications, and whether symptoms are under control. The CMWPS has a coefficient alpha of .92.

Including case managers and their clients in the analysis resulted in a nested data structure, with data for 1,556 consumers (level 1) nested within data for 113 case managers (level 2). The mean number of consumers per case manager was 13.77, and the range of consumers per case manager was from two to 26. Failure to account for the multilevel structure by analyzing case managers’ perceptions at the same level as consumer factors could have biased the results (11). Multilevel modeling accounts for nested data structures (12). We used a hierarchical generalized linear model with a logit link function, which is a multilevel model for discrete dependent variables (13).

Results

We investigated the impact of case managers on consumers’ steps toward employment. We used Luke’s (11) suggestion for building multilevel models and estimated three models. The first model, the unconditional (null) model, was a one-way random-effects analysis of variance (ANOVA). One-way random-effects ANOVAs are used to investigate the effects of level 2 units (case managers in this study) on the dependent variable (12). We found that case managers explained a significant amount of variance in clients’ pursuit of employment (χ²=301.45, df=112, p<.01). The intraclass correlation for the null model was .17. Case managers explained 16% of the variance in consumers’ pursuit of employment. Approximately 31% of the clients of the typical case manager were pursuing employment, and 11% to 77% of clients were actively taking steps toward their employment goals.

Next, the researchers estimated a model that included all level 1 variables (gender, race-ethnicity, education, age, diagnosis, substance abuse or dependence, clients’ interest in employment, and clients’ hospitalization within the past three months). We estimated a random-effects analysis of covariance. Using the McKelvey and Zavoina pseudo-R²_mz statistic (12) to estimate variance, we found that the model explained 34% (R²_mz=.34) of the variance in the probability of pursuing work.

We estimated a random-intercepts model in which the intercept was set to vary by case manager and CMWPS scores. However, the slopes for each of the client-level variables were fixed. The CMWPS variable (odds ratio [OR]=.47) was a significant and negative predictor of pursuit of employment (Table 1). This model explained an additional 4% of the variance in the probability of pursuit of employment (R²_mz=.038), and the addition of the CMWPS variable accounted for 5% of variance explained at level 2. Clients of case managers with a low CMWPS score (1.8) had a 316% improvement in the odds of taking steps toward employment, and clients of case managers with a high CMWPS score (5.0) had a 63% decrease in the odds of pursuing employment. The clients of case managers with less stringent criteria for pursuing employment were more likely to take positive steps toward employment. Other predictors of the probability of pursuing employment were having a high school education (OR=1.67) and interest in employment (OR=11.04), which increased probability, and hospitalization within the previous three months (OR=.66), which decreased probability. A noteworthy finding is that age, substance abuse or dependence, gender, and being in a racial-ethnic minority group were not significant.

Discussion

This study is noteworthy in that we attempted to determine whether case managers’ perceptions influenced consumers’ pursuit of employment. However, the interpretations of this study must be made with caution because of the limitations associated with using a descriptive design. For instance the study had no control group or randomization, and the analysis was not done across time. Cross-sectional analyses preclude causal assertions, and therefore the results could be explained by other factors related to case manager or client characteristics.

A further caveat in interpreting these results is that the CMWPS was designed specifically for this assessment. Although we explored the face-content validity and internal consistency reliability of the scale, the content of validity of the CMWPS has not been established. More research is needed to establish the construct validity of the CMWPS.

Even with these limitations in mind, our findings indicate that the case manager factor (not having overly stringent perceptions of work readiness) may be an important component of consumers’ pursuit of employment. If case managers or other staff members hold negative stereotypes or perceptions about consumers’ ability to work, they may be less likely to help consumers reach their employment goals and may even impede achievement. Similarly, O’Connell and Stein (14) found that case managers’ expectations were associated with the number of days a consumer was employed.

Because employment is an important element of recovery for many consumers, barriers to their pursuit of gainful employment should be removed. High-fidelity supported employment programs have demonstrated positive outcomes for employing consumers once they are referred to these programs (6). Mental health agencies should pay attention to staff attitudes related to consumers’ ability to work, because these attitudes seem to be a significant predictor of whether a person is referred to a supported employment program and whether steps are taken to help a person attain employment. Such attention could include case manager training, focused supervision, case manager job descriptions that include responsibilities in regard to clients’ employment, monthly monitoring of each case manager’s referrals and employment rates, and so on. The results of this study have implications for mental health centers that aim to ensure that all clients who want to work are getting access to programs that will help them do so.

Conclusions

This study may be a launching point for further understanding the role of case managers’ perceptions in consumer employment and for future investigations into interventions that have the potential to change stereotypical perceptions of employability. Addressing staff negativity with regard to the ability of consumers to work may lead to consumers’ pursuit of employment, to gainful employment of more consumers, and ultimately to more consumers entering recovery.