instituting market-based principles within social services for people living with mental illness

277 Pages·2010·1.93 MB·English

INSTITUTING MARKET-BASED PRINCIPLES WITHIN
SOCIAL SERVICES FOR PEOPLE LIVING WITH
MENTAL ILLNESS: THE CASE OF THE REVISED ODSP
EMPLOYMENT SUPPORTS POLICY
by
Rebecca E. Gewurtz
A thesis submitted in conformity with the requirements
for the degree of Doctor of Philosophy
Graduate Department of Rehabilitation Science
University of Toronto
© Copyright by Rebecca E. Gewurtz 2011
Instituting Market-based Principles within Social Services for
People Living with Mental Illness: The Case of the Revised ODSP
Employment Supports Policy
Rebecca E. Gewurtz
Doctor of Philosophy
Graduate Department of Rehabilitation Science
University of Toronto
2011

Abstract
Policies are shaped by social values and assumptions, and can significantly impact the
delivery of health and social services. Marginalized groups are often disadvantaged in the
political realm and reliant on publicly funded services and supports. The purpose of this research
is to consider how public policies are constructed and implemented for marginalized groups and
to increase understanding of the consequences of policy reform. It draws on a case study of the
Ontario Disability Support Program, Employment Supports (ODSP-ES) and considers the impact
of the policy revision that occurred in 2006 on employment support services for people living
with mental illness. A constructivist grounded theory approach guided data collection and
analysis. Key policy documents were analyzed and 25 key informant interviews were conducted
with individuals who were involved in: the construction and/or implementation of the policy;
developing and/or delivering employment services under the policy; or advocacy work related to
the policy.
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The findings highlight the impact of outcome-based funding on employment services and
practices, and provide lessons for the construction and implementation of public policy for
marginalized groups. The new funding system has promoted a shift from a traditional social
service model of employment supports towards a marketing model, wherein services focus on
increasing job placement and short-term job retention rates. However, the introduction of market
principles into employment services has had significant implications for people living with
mental illness. Employment programs are required to absorb increased financial risk, thereby
altering the way service providers work with clients to help them find and keep jobs; there is a
heightened focus on the rapid placement of clients into available jobs and less attention to the
quality of employment being achieved and to complex barriers that prevent individuals from
succeeding with employment. Although ODSP-ES has been somewhat successful at connecting
people with disabilities to competitive employment, it has led to secondary consequences that
compromise its overall utility. The findings highlight the complexity of constructing and
implementing public policy for marginalized groups and suggest that evaluating public policy is
an interpretative exercise that should be explored from multiple perspectives beyond the stated
objectives.

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Acknowledgments
The completion of this dissertation and my career as a graduate student would not have
been possible without the support and assistance of many people. I am particularly grateful to my
thesis supervisor Dr. Bonnie Kirsh for providing me with encouragement, guidance, wisdom, and
many valuable learning experiences over the last 7 years as I completed my master’s degree and
then my PhD. I will draw on these experiences as I embark on my career beyond graduate
studies. I would also like to thank Drs. Brian Rush and Cheryl Cott for agreeing to be on my
program advisory committee, providing helpful and timely feedback on drafts of my work, and
for sharing their insights as my research progressed. I am also grateful to Dr. Dina Brooks who
provided significant support to me throughout my PhD. I would also like to acknowledge my
colleagues in the School of Rehabilitation at McMaster University for their ongoing support,
encouragement and insight as I completed revisions on my dissertation.
I am indebted to the 28 individuals who contributed to this research by agreeing to be
interviewed and for taking time to share their insights and experiences. I would also like to
acknowledge the financial support I received from a Canadian Graduate Scholarship from the
Social Sciences and Humanities Research Council of Canada (SSHRC), the Canadian
Occupational Therapy Foundation (COTF), and the Graduate Department of Rehabilitation
Science at the University of Toronto. Without all of this support, my work as a graduate student
and this dissertation would not have been possible.
I would like to thank my family and friends who provided tremendous support and
encouragement, as well as practical assistance throughout my time as a graduate student. In
many ways my family and friends shared in the burden of completing this work by creating
space so I could work, picking up the slack in other aspects of my life, and tolerating my
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“distraction” throughout the past several years. Specifically, I want to acknowledge the love and
support I received from my husband Jeff, my parents, and my son Connor. Balancing my
multiple roles and responsibilities would not be possible without your support, understanding
(and occasional push!). Thank you very much!
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Table of Contents
ABSTRACT .................................................................................................................................................... II
ACKNOWLEDGMENTS .................................................................................................................................IV
TABLE OF CONTENTS ...................................................................................................................................VI
LIST OF TABLES .......................................................................................................................................... XII
LIST OF FIGURES ........................................................................................................................................ XIII
LIST OF APPENDICES ................................................................................................................................ XIV
CHAPTER 1: INTRODUCTION ........................................................................................................................ 1
1.1. PURPOSE AND RELEVANCE OF RESEARCH .................................................................................................... 2
1.2. PUBLIC POLICY ....................................................................................................................................... 4
1.3. PERSONAL REFLECTION ............................................................................................................................ 5
1.4. POPULATION OF FOCUS ........................................................................................................................... 6
1.5. TERMINOLOGY ....................................................................................................................................... 7
1.5.1. People Living with Mental Illness ............................................................................................ 8
1.5.2. Service Providers, Employment Programs, Policy Programs ................................................... 8
1.6. ORGANIZATION OF THESIS ........................................................................................................................ 9
CHAPTER 2: LITERATURE REVIEW ............................................................................................................... 11
2.1. EMPLOYMENT AMONG PEOPLE LIVING WITH MENTAL ILLNESS ...................................................................... 11
2.1.1. Benefits of Employment ........................................................................................................ 12
2.1.2. Unemployment and Underemployment ................................................................................ 14
2.1.3. Barriers to Employment ......................................................................................................... 15
Environmental and contextual factors................................................................................................................ 17
2.1.4. Summary of Knowledge about Employment among People Living with Mental Illness ........ 20
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2.2. SOCIAL CONSTRUCTIONISM AND THE STUDY OF PUBLIC POLICY ..................................................................... 21
2.2.1. The Social Construction of Target Population Framework .................................................... 22
2.2.2. Mental Illness and Public Policy ............................................................................................. 27
2.3. RESEARCH ON PUBLIC POLICY REFORM AND IMPLEMENTATION ..................................................................... 29
2.3.1. Neoliberalism and Public Policy Reform ................................................................................ 29
2.3.2. Policy Implementation Research ........................................................................................... 33
The study of policy implementation: The search for comprehensive theories................................................... 34
Future directions for policy implementation research: An interpretative, case study approach ....................... 37
2.4. FUNDING FOR EMPLOYMENT SUPPORTS ................................................................................................... 38
2.4.1. Fee-for-Service Funding ......................................................................................................... 39
2.4.2. Capitated Managed Care ...................................................................................................... 39
2.4.3. Outcome-based Funding ....................................................................................................... 40
Research evaluating outcome-based funding ..................................................................................................... 42
How does outcome-based funding influence service provision? ....................................................................... 46
Concerns about outcome-based funding............................................................................................................ 47
Outcome-based funding and evidence-based employment supports ................................................................ 49
Outcome-based funding: Implications for employment services for people living with mental illness in Ontario
............................................................................................................................................................................ 50
2.5. SUMMARY OF LITERATURE REVIEW .......................................................................................................... 50
CHAPTER 3: THEORETICAL FRAMEWORK, METHODOLOGY AND METHODS ............................................... 52
3.1. THEORETICAL FRAMEWORK .................................................................................................................... 52
3.2. RESEARCH OBJECTIVES .......................................................................................................................... 54
3.3. METHODOLOGICAL APPROACH ............................................................................................................... 54
3.4. DATA SOURCES .................................................................................................................................... 56
3.4.1. Document Review .................................................................................................................. 57
3.4.2. Key Informant Interviews ...................................................................................................... 58
Sampling strategy ............................................................................................................................................... 60
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Recruitment strategy .......................................................................................................................................... 61
3.5. DATA ANALYSIS .................................................................................................................................... 65
3.5.1. Coding Procedures ................................................................................................................. 66
3.5.2. Document Review .................................................................................................................. 67
3.5.3. Analysis of Key Informant Interviews .................................................................................... 68
3.6. STRATEGIES FOR ENSURING TRUSTWORTHINESS ......................................................................................... 69
3.6.1. Reflexivity .............................................................................................................................. 70
3.7. ETHICAL ISSUES .................................................................................................................................... 71
3.7.1. Privacy and Confidentiality .................................................................................................... 71
3.7.2. Compensation ........................................................................................................................ 71
3.7.3. Risks and Benefits .................................................................................................................. 72
CHAPTER 4: CONSTRUCTING ODSP EMPLOYMENT SUPPORTS ................................................................... 73
4.1. DESCRIPTION OF SAMPLE ....................................................................................................................... 73
4.1.1. Documents ............................................................................................................................. 73
4.1.2. Interview Informants ............................................................................................................. 77
4.2. SITUATING ODSP-ES WITHIN THE ONTARIO POLICY CONTEXT ...................................................................... 79
4.2.1. Mental Health Services in Ontario ......................................................................................... 80
4.2.2. Employment Supports for People Living with Mental Illness in Ontario ................................ 81
4.2.3. Funding for Social Assistance in Ontario ............................................................................... 83
4.3. THE ONTARIO DISABILITY SUPPORT PROGRAM ........................................................................................... 85
4.3.1. Critiques of ODSP ................................................................................................................... 85
4.4. PERSPECTIVES ON ODSP-ES .................................................................................................................. 86
4.4.1. ODSP-ES 1999-2006 ............................................................................................................... 90
4.4.2. Problems with the former ODSP-ES policy ............................................................................. 91
Poor employment outcomes .............................................................................................................................. 91
Inefficient processes ........................................................................................................................................... 94
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Disincentives to employment ............................................................................................................................. 95
4.5. THE REVISED ODSP-ES POLICY .............................................................................................................. 95
4.5.1. Formulating the Revised Policy: Consultation and Research ................................................. 96
4.5.2. The Focus of ODSP-ES: Self-Sufficiency and Independence.................................................... 99
4.5.3. Funding for ODSP-ES ............................................................................................................ 100
The single milestone system ............................................................................................................................. 101
The funding level .............................................................................................................................................. 103
Transitional funding .......................................................................................................................................... 104
4.5.4. Changes to ODSP Income Support ....................................................................................... 106
4.6. DISCUSSION OF FINDINGS IN RELATION TO EXTANT KNOWLEDGE: DRIVING FORCES ASSOCIATED WITH POLICY
CONSTRUCTION ................................................................................................................................. 108
CHAPTER 5: IMPLEMENTING AND OPERATIONALIZING THE REVISED ODSP-ES POLICY ............................ 112
5.1. FROM PRE-EMPLOYMENT TO JOB PLACEMENT SERVICES ............................................................................ 112
5.1.1. Funding for Training ............................................................................................................ 115
5.1.2. Skills and Beliefs of Service Providers .................................................................................. 119
5.1.3. Program Responses to the Revised Policy ........................................................................... 121
5.2. DECREASED CAPACITY TO ADDRESS BARRIERS TO EMPLOYMENT .................................................................. 123
5.2.1. Perceived Challenges of Mental Illness: Instability and Unpredictability ............................ 124
5.2.2. The Challenge of Stigma: The Image of People Living with Mental Illness as Deficient ...... 126
5.2.3. The Importance of Motivation ............................................................................................. 129
5.2.4. Social and Material Resources as Determinants of Employment ........................................ 132
5.2.5. Income Support as a Barrier to Employment ....................................................................... 133
5.3. CONSTRAINED COLLABORATION AND INCREASED COMPETITION BETWEEN PROGRAMS AND SERVICE PROVIDERS .. 139
5.3.1. The Potential of Collaboration ............................................................................................. 141
5.3.2. Challenges to Collaboration ................................................................................................ 143
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5.4. DISCUSSION OF FINDINGS IN RELATION TO EXTANT KNOWLEDGE: RELYING ON MARKET FORCES TO IMPLEMENT AND
OPERATIONALIZE POLICY ...................................................................................................................... 146
CHAPTER 6: ANALYSIS OF CONSEQUENCES OF THE REVISED ODSP-ES POLICY ......................................... 149
6.1. IMPACT OF THE FOCUS ON JOB PLACEMENTS ........................................................................................... 149
6.1.1. Quality of Employment ........................................................................................................ 151
6.1.2. The Need for Marketing Capacity ........................................................................................ 157
6.1.3. Whose Needs are Being Met?: Employers versus Clients .................................................... 159
6.1.4. Target Population of ODSP-ES ............................................................................................. 160
6.2. IMPACT OF DECREASED CAPACITY TO ADDRESS BARRIERS TO EMPLOYMENT .................................................. 165
6.2.1. Prioritizing Personal Barriers to Employment ...................................................................... 165
6.2.2. Addressing Complex Barriers to Employment ..................................................................... 169
6.3. IMPACT OF CONSTRAINED COLLABORATION AND INCREASED COMPETITION ................................................... 174
6.3.1. Accountability and Innovation ............................................................................................. 174
6.3.2. Small Organizations and Employment Programs ................................................................ 176
6.3.3. Implications for Employment Programs: Assessing and Managing Risks ........................... 178
6.4. DISCUSSION OF FINDINGS IN RELATION TO EXTANT KNOWLEDGE: CONSEQUENCES OF THE POLICY – COMPROMISED
JOB QUALITY, HEIGHTENED COMPETITION AND COMPETING PRIORITIES ....................................................... 182
CHAPTER 7: DISCUSSION .......................................................................................................................... 188
7.1. THE PROCESSES AND CONSEQUENCES INVOLVED IN IMPLEMENTING THE REVISED POLICY ................................. 188
7.1.1. The Marketing Model and Neoliberalism ............................................................................ 191
7.2. DISCUSSION OF LESSONS LEARNED ......................................................................................................... 195
7.2.1. Understanding the Problem of Unemployment ................................................................... 195
Contextual barriers to employment ................................................................................................................. 198
7.2.2. Understanding the Consequences of ODSP-ES .................................................................... 201
Rapid placement as an evidence-based approach ............................................................................................ 202
7.2.3. Outcome-Based Funding Models ......................................................................................... 203
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