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Customized Employment Supports

Customized Employment Supports (CES, formerly known as Comprehensive Employment Supports) was developed to help methadone treatment patients, who are likely to have irregular work histories, attain rapid placement in paid jobs and increase their legitimate earnings. CES counselors work intensively with a small caseload of unemployed and underemployed patients (15-18 in the initial period) to help them overcome the barriers that hinder their employment. This intervention extends to an addiction population the principles of the Individual Placement and Support (IPS) model of vocational counseling for persons with disabilities. CES has six stages of service delivery: assessment, engagement, enhancement of self-efficacy to reduce barriers, focused employment skills teaching, preparation for interviewing, and job retention. CES is implemented in two settings: first in the program/clinic to practice interviewing and prepare a resume, and then in the community to help the individual secure and retain a job. Sessions in the community involve active engagement techniques to build a therapeutic alliance with the patient. Vocationally relevant learning activities take place in the community on "neutral turf" to promote the development of patient trust and openness. Master's-level vocational rehabilitation counselors meet with patients individually up to three times per week during an intensive phase of up to 6 months until employment is obtained, followed by continuing job retention support.

Descriptive Information

Areas of Interest Substance abuse treatment
Outcomes Review Date: March 2008
1: Paid employment
Outcome Categories Employment
Ages 26-55 (Adult)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Settings Outpatient
Other community settings
Geographic Locations Urban
Implementation History Since 2001, CES has been implemented at two sites with a total of 78 individuals participating. Evaluations were conducted and completed at both sites. Funding for this intervention research was received through a grant from the National Institute on Drug Abuse.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: March 2008

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Magura, S., Blankertz, L., Madison, E. M., Friedman, E., & Gomez, A. (2007). An innovative job placement model for unemployed methadone patients: A randomized clinical trial. Substance Use and Misuse, 42(5), 811-828.  Pub Med icon

Outcomes

Outcome 1: Paid employment
Description of Measures Paid employment (any paid employment, including informal and competitive) was measured through self-report in interviews as well as through vocational activity logs, employment documentation (e.g., pay stubs, letters from employers, permission to call employers), and/or direct observation.
Key Findings During the 6- and 12-month follow-up periods, the percentage of patients with any paid employment was higher among the CES group than among the group receiving standard vocational counseling (41% vs. 26%, p < .05). CES participants were 2.3 times more likely than standard counseling participants to find any paid employment (p < .05), a difference associated with a small effect size (odds ratio = 2.3).

During the same follow-up periods, the percentage of patients with informal (e.g., part-time or short-term) employment was also higher among the CES group than among the group receiving standard vocational counseling (27% vs. 14%, p < .05). CES participants were 2.8 times more likely than standard counseling participants to find informal employment (p = .02), a difference associated with a medium effect size (odds ratio = 2.8).

There was no statistically significant difference between the two groups in competitive employment.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.8 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 58% Male
42% Female 		43% Black or African American
32% Hispanic or Latino
25% White

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Paid employment 2.5 3.0 2.5 3.0 2.0 3.5 2.8

Study Strengths

The researchers used multiple measures of employment, such as interviews with participants; vocational activity logs; and employment documentation, including pay stubs, letters from employers, and permission to call employers. The data analyses were appropriate for the uncontrolled categorical findings and the covaried logistical regression analyses.

Study Weaknesses

Fidelity of implementation was a weakness in that CES was not delivered consistently over the course of the trial. For example, because some counselors were lost midstudy, participants often received abbreviated versions of the treatments, and replacement counselors provided a less intensive level of service than their predecessors did. In addition, a large number of subjects assigned to both conditions failed to receive any counseling. This weakness affected the power of the study because the authors chose to exclude these participants from the analysis rather than conduct a more conservative intent-to-treat analysis. Finally, although the researchers successfully dealt with many potential confounds, they failed to track participants' alcohol use during the study period. Drinking may have affected the participants' ability to obtain and retain employment, a likely possibility given their substance use history.
Readiness for Dissemination
Review Date: March 2008

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Items available from http://www.ndri.org/ctrs/itsr/ces.html:

  • Blankertz, L., Magura, S., Madison, E., & Spinelli, M. (2007). Comprehensive Employment Supports (CES) training manual. New York: National Development and Research Institutes.
  • Comprehensive Employment Supports (CES) Fidelity Scale
  • Comprehensive Employment Supports (CES) Vocational Outcomes Interviews--Baseline and Follow-Up
  • Comprehensive Employment Supports (CES) Weekly Vocational Activities Log

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
2.5 1.5 2.5 2.2

Dissemination Strengths

Implementation materials explain the theoretical foundation and principles of this intervention, with special attention to the process involved in providing vocational rehabilitation services. Clinical support consultants who provide technical assistance are accessible through the program developer. Outcome and fidelity measures are provided to support quality assurance.

Dissemination Weaknesses

Materials focus on the theory supporting the intervention and omit specific implementation details that would be beneficial to clinicians and organizations using this intervention. The training manual lacks clear direction for implementers and actual instructional tasks to guide training, making it seem more like a program overview than a manual. No guidance is provided for the administration and use of quality assurance tools.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
CES training manual Free Yes
On- or off-site training $100 per hour plus travel expenses No
On- or off-site consultation $100 per hour plus travel expenses No
CES Fidelity Scale Free No
CES Vocational Outcomes Interviews: Baseline and Follow-Up Free No
CES Weekly Vocational Activities Log Free No

Additional Information

The program should be implemented by a master's-level vocational counselor. The approximate annual cost of employing such a counselor in the public sector ranges from $39,900 to $59,850, including benefits, depending on geographic area (2007 estimates). Since it is recommended that no more than 36 new patients be accepted per year, with each patient being served intensively for 6 months, the cost per patient for direct counseling ranges from $1,108 to $1,663. Additional costs include those associated with clinical supervision for the counselor as well as facilities and administration costs for the parent agency.
Replications

No replications were identified by the developer.
Contact Information

To learn more about implementation, contact:
Elizabeth Madison, M.A., CRC
(917) 282-5195
eomadison@msn.com

Laura Blankertz, Ph.D.
(610) 353-3309
blankertz@aol.com

To learn more about research, contact:
Stephen Magura, Ph.D., CSW
(269) 387-5895
stephen.magura@wmich.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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