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Witness Testimony of Anthony Campinell, Ph.D., Director, Therapeutic and Supported Employment Programs, Veterans Health Administration, U.S. Department of Veterans Affairs

Chairman Johnson, Ranking Member Donnelly, and Members of the Subcommittee: thank you for the opportunity to discuss the Department of Veterans Affairs’ (VA) Compensated Work Therapy (CWT) program. I am accompanied today by my colleague Anthony Kerrigan, Ph.D., CWT Coordinator at the Houston VA Medical Center. Also accompanying me today is Mr. Sean Kayse, a U.S. Army Veteran recently hired by VA, who will discuss his experience in the CWT program in Iowa.

CWT provides Veterans whose lives have been disrupted by mental illness or coexisting physical disabilities with a supportive, stable, structured approach to help them achieve their employment goals. Currently, almost 750,000 Veterans under age 50 are not in the labor force due to various disabilities or illnesses, including serious mental illness. Employment is an important personal goal and contributes to a positive self image and a sense of purpose, and is a critical element for people recovering from mental health issues. Congress formally established CWT for VA in 1984. The program has grown substantially over these 27 years, with over 41,000 Veterans receiving CWT services at 187 locations in Fiscal Year (FY) 2011, and an additional 26,000 Veterans receiving other forms of vocational rehabilitation. In addition to its clinical benefits, CWT serves as a complement to other employment services available from the Veterans Benefits Administration, the Department of Labor, or state employment agencies.

My testimony today will begin by providing an overview of the CWT program, including its purpose and functions. It will then describe the leadership and organization of the program, and conclude with a review of some of the program’s major successes, as well as its challenges.

Overview of CWT Program

CWT programs provide vocational rehabilitation services by medical prescription to Veterans, many of whom have extensive barriers to employment. A majority of persons with a disability want to work. The core philosophy of CWT is that all persons with a disability can work when provided with the necessary supports, and thus no one should be excluded from the opportunity to participate in meaningful employment.  CWT programs serve eligible Veterans, including those with service-connected disabilities, Veterans who have been involved in the justice system, and Veterans with active addictions. Many have serious mental illness, including psychotic disorders; serious physical disabilities co-occurring with mental health diagnoses; and Spinal Cord Injury and Traumatic Brain Injury. In addition, CWT programs include homeless Veterans and Veterans who have been out of the work force for an extended period of time, in some cases, since discharge from the military. VA benefits, including service-connected compensation and VA pension, cannot be reduced, denied, or discontinued based on participation in either CWT or Incentive Therapy (IT).

CWT programs are available in both urban and rural areas, as well as in remote and difficult to access locations. For example, CWT services are provided through the Black Hills Health Care System and Rapid City VA Medical Center in South Dakota. These facilities extend access to Native American Veterans on the Standing Rock Lakota Sioux Indian Reservations in McLaughlin, SD, Eagle Butte, SD, and Pine Ridge, SD, on the Pine Ridge Indian Reservation. The CWT program and services in these remote and isolated locations offer economic stability and a recovery-based culture for the participating Veteran and his or her family alike.

CWT provides a number of options for Veterans who are looking to get back into the work force. These options include the following:

Incentive Therapy (IT): This is a pre-vocational work restoration program that authorizes the assignment of patients to various hospital work situations. IT provides a diversified work experience at those VA medical centers that choose to incorporate it for Veterans who exhibit severe mental illness or physical impairments. IT services may consist of full or part-time work with remuneration limited to the maximum of one half of the Federal minimum wage and paid on an hourly basis. IT participants provide services in various “jobs” or roles: escorting Veterans to and from appointments; delivering messages and communications; and providing a range of assistance to program areas, including light cleaning, picking up lunches, and folding items.  Hours of work may be adjusted from as little as 1 hour per day to 8 hours per day, based on the Veteran’s work stamina and treatment goals. IT also provides an opportunity for VA to assess Veterans in a more independent but clinically supportive environment.

Sheltered workshops: These activities are operated at approximately 35 VA medical centers nationally. CWT sheltered workshop is a pre-employment vocational activity that provides an opportunity for assessment and the development of work skills in a simulated work environment. Veterans participate in a wide variety of work, from advanced printing, including business cards and engraving, to furniture upholstery, with participating Veterans paid on a piece rate basis commensurate with the type of work performed.

CWT/Transitional Work (CWT/TW): This is a pre-employment vocational assessment program that operates in VA medical centers and local community businesses. CWT/TW is provided at many National Archives and Record Administration (NARA) Federal Record Centers and National Cemeteries. Participants are matched to real-life work assignments for a time-limited basis.  Services may relate to work in janitorial/housekeeping, food service, warehouse, prosthetics assistant, and grounds maintenance. Veterans are supervised by personnel of the sponsoring site, under the same job expectations experienced by non-CWT workers.  CWT/TW participants are not considered employees and receive no traditional employee benefits. Participants receive no less than the greater of Federal or state minimum wage, depending upon the type of work performed. The CWT/TW program offers real training to Veterans and provides an avenue to competitive jobs in these Federal agencies.

CWT/Supported Employment (CWT/SE): This is an evidence-based practice which has been demonstrated to assist Veterans with the most severe psychiatric disabilities to achieve competitive employment and community integration with extensive clinical supports. CWT/SE was implemented nationally in 2005 as part of VA’s recovery transformation efforts, and has since been highlighted in a RAND report as a gold standard mental health program. CWT/SE services are individualized and intensive, and are integrated as part of the Veteran’s mental health treatment. When the Veteran is able to maintain employment independently, CWT/SE services are phased out and support is provided by the clinical team and natural supports in the Veteran’s community. CWT/SE is routinely provided to Veterans with psychotic disorders. Additionally, VHA’s Therapeutic and Support Employment Services (TSES) works in partnership with VA researchers to expand SE services to a broader audience.  CWT/SE services have been provided to Veterans living with spinal cord injury and traumatic brain injury as part of VA-sponsored research.  A recently concluded 2011 study of SE for Veterans with post-traumatic stress disorder (PTSD) funded by the VA Office of Research and Development was so successful in improving rates of employment among Veterans receiving SE that a new, larger study is in the planning stages with the VA Cooperative Studies Program.

Homeless Veterans Supported Employment Program (HVSEP): This program provides vocational assistance, job development and placement, and employment support designed to improve employment outcomes among homeless Veterans. In FY 2011, VA medical centers started to receive funding for HVSEP. The program is coordinated between the CWT and Homeless Veteran Programs. VA has provided funding to hire 407 Vocational Rehabilitation Specialist positions to support this initiative.  These employees have been trained and integrated into the range of VA Homeless services, including the Health Care for Homeless Veterans (HCHV), Grant and Per Diem (GPD), Department of Housing and Urban Development -Department of Veterans Affairs Supportive Housing (HUD-VASH), Domiciliary Care for Homeless Veterans (DCHV), Healthcare for Re-Entry Veterans (HCRV), and the Veterans Justice Outreach Initiative (VJO) programs for the purpose of providing community-based vocational and employment services.  All the HVSEP Vocational Rehabilitation Specialists hired are themselves Veterans who are homeless, formerly homeless, or at risk of homelessness.

Vocational Assistance:  This CWT support provides a set of assistance, guidance, counseling, or other services that may be offered to individual Veterans or groups. These services enable Veterans to identify skills, resources, attitudes, and expectations needed when searching for employment.

CWT Leadership and Organization

The CWT program is an element of the VHA’s Therapeutic and Supported Employment Services section (TSES) in the Office of Mental Health Operations.  TSES is responsible for overseeing CWT and IT programs. These two programs are authorized by 38 United States Code, Section 1718, to integrate remunerative work restoration services and vocational rehabilitation and employment support into treatment planning for Veterans receiving care in VA’s health care system.

VHA Central Office TSES staff consists of a Director and four Program Planning Specialists, who function as liaisons and support staff for assigned Veterans Integrated Service Networks (VISN); two Supported Employment Specialists; one Program Analyst; and one staff member who works closely with both TSES and Homeless Services to support the Homeless Veterans Supported Employment initiative. TSES provides guidance for implementing CWT programs and interpreting policy in collaboration with networks and facilities.

A major effort of the TSES program is conducting fidelity reviews of the CWT/SE program. These reviews follow a standardized procedure to assess SE program implementation barriers and successes. TSES uses the results of these reviews to assist programs in their ongoing quality improvement efforts through recommendations and technical assistance to the CWT Program Management as well as facility and service line leadership. In FY 2011, 68 fidelity site visits were conducted, and the results of these reviews showing strengthened levels of employment implementation were disseminated nationally through the VA Northeast Program Evaluation Center’s reporting system.

In addition, TSES organizes national conferences to train CWT staff, participates in monthly conference calls to address local and national issues, and conducts onsite training visits upon request. VHA provided five training visits to approximately 175 staff in FY 2011 in response to requests from facilities for consultation.

In accordance with VHA Handbook 1163.02, Therapeutic & Supported Employment Services Program, each facility is responsible for appointing a TSES Vocational Program Manager. The facility program manager is responsible for implementing the policy and procedures for establishing and operating a TSES program in accord with the VHA Handbook guidance. CWT program implementation occurs at the local level to include CWT hiring decisions, staffing levels, and program manager duties. In addition, each individual facility makes decisions regarding the use of Transitional Workers.

CWT’s Successes and Challenges

Collectively, these efforts are making a difference. All told, TSES programs provide paid work experience, competitive employment, and vocational assistance services to almost 70,000 Veterans each year, approximately 11 percent of whom are Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans. In FY 2011, the IT component of TSES served over 7,000 Veterans; the CWT/TW component served over 29,000 Veterans; and the CWT/SE component served over 14,000 Veterans, a 12 percent increase over FY 2010. An additional 29,300 Veterans received vocational assistance services. Veterans in TSES programs earned in excess of $60 million as a result of their work. Earnings generated through IT, CWT/Workshops, and CWT/TW are also tax exempt and excludable as income for Social Security Supplemental Security Income (SSI) program purposes. This exemption enables Veterans who receive disability income to take advantage of the skills learned at TSES programs and develop these work skills without fear of losing their benefits.

In FY 2011, TSES provided CWT services at 187 program locations and 90 IT program locations. Of 11,267 Veterans who were discharged from CWT/TW and CWT/SE Programs who were entered into the VA Northeast Program Evaluation Center program evaluation database, 27 percent were placed in community-competitive employment at discharge, with an additional 8 percent leaving CWT to pursue formal training, higher education, or volunteer work. Forty-six percent remained unemployed,

13.8 percent retired, and information is unavailable on the remainder. Since May 2011, the Homeless Veterans Supported Employment Program has served 2,564 Veterans, 27 percent of whom have been placed in community employment.

The Commission on Accreditation of Rehabilitation Facilities (CARF) has accredited VA outpatient mental health services for over 15 years. All CWT programs with 4.0 Full-time Employee Equivalents or more (86 total) have received a 3-year CARF/Employment and Community Services accreditation, the highest level score for quality rehabilitation services. CARF accreditation recognizes that CWT programs are providing efficient, effective services that result in high levels of stakeholder satisfaction. Smaller programs are not required to be CARF accredited at this time.

Notwithstanding these successes, the CWT program faces several challenges. TSES staff has received reports about staff and funding variations across local programs that sometimes result in delays in patient enrollment. We also understand from CWT program staff that there is growing demand for CWT services.  Funding for CWT programs comes from both national sources (for TSES staff) and from VA facility budgets (for local programs). Funding is also received at the local level from employers who contract with CWT programs to hire Veterans enrolled in CWT. We are exploring new opportunities to standardize and simplify the funding stream, which will also provide VA greater oversight of how revenues are used across the system.

Conclusion

Thank you again for the opportunity to share information about VA’s efforts to provide vocational rehabilitation services to Veterans. VA is dedicated to improving Veterans’ overall quality of life through a vocational rehabilitation experience in which Veterans learn new job skills, strengthen successful work habits, and regain a sense of self-esteem and self-worth. My colleagues and I are prepared to answer any questions you may have.