April 17, 2024

A total of 15 service providers participated in this study, with 10 service providers directly involved with program implementation completing surveys and 11 service providers directly and indirectly involved with program implementation participating in focus groups. Table 1 below is a summary of participants, categorised by their role and whether they were internal or external to the program. Program externals were associated with the program and provided some aspect of program support (e.g., administrative, clinical) but were not directly involved in implementation. Given the sample size, participant demographics are not disclosed beyond role and level of involvement with implementation. The participation rate was 77% and 69%, respectively, for surveys and focus groups for those eligible and invited to participate.

Table 1 Summary of service provider participants

Through survey responses and focus groups, participants discussed the range of factors impacting their ability to delivery appropriate services to support the employment goals and well-being of clients. Participant perspectives are presented as domain summaries below with quotes to highlight their typical views.

Innovation factors

The innovation in this study refers to the Links to Employment program or IPS program, as described in the “Program Design” section above. Participants identified that drawing from an evidence-based model supported implementation because others were familiar with IPS and confident in its effectiveness and approach (innovation source and evidence base), which helped give the program greater credibility and promote wider program buy-in. IPS principles also provided the implementation team with structure and guidance around best practice, especially when dealing with complex client cases or situations, although not all the principles consistently aligned with immediate client goals.

There’s other health authorities that are utilizing IPS – I had a great conversation with one of the directors of mental health and substance use and his [former workplace] had an IPS program in it. So, people know and people see the value.

Outer setting factors

The outer setting in this study refers to both the wider health, social, and employment systems that provide programs, services, and supports for individuals across BC and the individual communities in which the IPS program was operationalized.

Financing

Insecure long-term funding was identified as a barrier that directly and indirectly impacted multiple aspects of program implementation, including staff turnover, health care service provider and organizational buy-in, and program integration into existing local systems of support.

We do feel like part of the primary care clinics now but having to qualify our work on whether we will continue or not because of funding, creates a barrier between us, our clinics, and our clients. To able to say we will support our clients through challenges long term, can give [them]the stability to trust us more.

Local conditions

Economic and environmental conditions were identified as a barrier impacting community-based engagement and support from local employers, as well as other agencies and organizations providing health or social services. Residual effects from the COVID-19 pandemic have created greater demand for services while capacity and human resources have simultaneously decreased, resulting in many businesses and organizations struggling to maintain current levels of operation.

[Our community] does have quite a lot of agencies and programs but I just think everything is so strained and challenged right now due to the current economic climate, the health care system … all of those factors. So that proves to be a big challenge.

Some of the challenges have been [around] making the local connections – having an employer that’s open and excited and wants to join the program and really have [that] community-based support.

Inner setting factors

The inner setting in this study refers to the community health centres, which include primary health care services, where the IPS program is available, and the specific IPS program teams directly involved in implementation.

Information technology infrastructure

Being fully integrated into the system of electronic medical records within the primary care setting was identified as a facilitator towards promoting wider integration and collaborative care across both the program team and their associated health care service providers. An integrated system allowed both teams to independently stay up to date with all aspects of a client’s well-being, whether related to health or employment, allowing client needs to be met more quickly and with less repetition. Where the infrastructure was not in place to allow for a shared system of records, participants identified that it created multiple barriers.

Our lack of current integration with primary care is actually causing a barrier to clients because if they had a full network of support and integrated supports, then some of these challenges would be better solved or better supported and would just aid in [the] longevity of employment.

Work infrastructure

Staffing levels were identified as a continuous barrier to implementation. Not being able to find and/or retain highly qualified staff (e.g., occupational therapists) at each of the three program sites decreased program capacity and slowed program development. Gaps in staffing structure and supervision also limited the support available to the program team in areas such as overall program management and organization administration or reporting (e.g., waitlist management, funder reports, presentations), creating additional tasks and responsibilities outside the scope of employment-based service delivery.

More training and supervision was needed, especially in the early days of the program.

Participants also reported that staff turnover and capacity within their associated health care teams was a challenge, which often resulted in their clients being disconnected from health services or added to waitlists for health services. This required participants to shift their focus from traditional IPS or employment services to address critical health care needs.

There’s a lot of people in our community that need support and not a lot of resources for people to access at the moment. There’s been scope creep because there’s no support to refer people to in some cases.

Relationship connections

Although there was consensus around the importance of working relationships, there was a large disparity in relationship connections across the two levels of the inner setting and across both community sites. Working in collaboration, both through formal and informal pathways, with a health care team, which includes primary care providers, within the community health centre was identified as one of the key strengths supporting program implementation. An existing connection facilitated a more seamless transfer and sharing of clients between health and employment services and reinforced the important role that employment has in shaping an individual’s overall well-being. Additionally, being connected with a clinical team provided added support to clients with higher needs during times of immediate crises and for maintenance of overall health, which allowed program staff to focus more exclusively on employment related goals and work sustainment. Conversely, where there were not strong working relationships, integration was low or absent and IPS teams struggled to secure time with individual clinical staff to discuss shared clients and as a larger team to discuss program structure, referrals, and overall supports.

All referral sources should be from integrative health care teams; otherwise, clinical support and supervision is lacking.

Across the inner level of the inner setting (i.e., within the program team), relationship connections were consistently identified as a key strength for implementation. Built on shared values and working norms, the strong personal and professional relationships within the program team enabled sharing of difficult tasks, collective brainstorming, and collaborative troubleshooting and outreach. The team-based approach utilizes individual strengths to collectively support the diverse employment goals and well-being needs of clients across all program sites.

Culture (human equality and recipient-centredness)

Many of the guiding IPS principles, notably zero exclusion, time unlimited supports, individual preferences, and integration with mental health [25], were reported as aligning well with the needs of the population served, as well as with the existing client-centred values of each local community health centres and CMHA BC. This enabled the program to fit as a natural addition to existing services.

Focus[ing] on individualized support has been a great strength. The team has been able to work with clients who have a vast array of preferences and needs to develop goals that align with their desires.

Individual factors

This domain highlights the roles and/or characteristics across various groups involved with the IPS program, as well as those that may impact or be impacted by its implementation.

High- and mid-level leaders

In this study, high-level leaders refer to those within the provincial government and/or provincial non-profits that hold decision-making power related to funding allocation and policies for health or social services and service delivery. Mid-level leaders refer to those responsible for making decisions and/or overseeing services at the local community level. Support at each of these levels was considered a vital component in securing buy-in to allow for the program to be operational and sustainable. Challenges at these levels created trickle-down implementation barriers for the IPS team.

If we could find the right person in the chain – I know we’ve had meetings with quite high-level health people, and they’re really enthusiastic … and we’ve had meetings with frontline staff, and they’re really enthusiastic. It’s sort of that mid mid-level management.

Integration into the clinics was also a long and arduous process that was greatly hindered by lack of communication from upper management.

Other implementation support

This role refers to all other health care service providers that support the program in various ways. Their support for the program was identified as the key factor for promoting integration between health and employment services, not only for incoming referrals, but also for continued communication and collaborative care. Where program support and buy-in from clinical teams was lacking, program staff struggled to build working relationships and ensure their clients had sufficient access to a range of other health resources.

[There’s] enthusiasm and support from partner clinics and the recognition of vocational rehabilitation as an important aspect of a person’s overall well-being. Clinicians have always been receptive and appreciative of the work that the team has been doing and are always open to consult with.

Implementation or program team

This role refers to those directly involved with implementing the IPS program and delivering IPS services to clients. Participants reported that the program team’s skills and experience, along with motivation and commitment to supporting clients, were critical components for successful implementation.

[There are] strong and diverse team members who are all devoted to serving the demographic we work with.

While most participants felt they had the tools and resources to implement the program, some reported inconsistent messaging and conflicting priorities across various levels of leaders and decision makers, including those internal and external to the program/community health centre. For example, during the early phases of implementation there was confusion around program requirements (e.g., inclusion criteria), service expectations (e.g., scope of services offered, IPS model), and operational logistics (e.g., where/how to document). Some participants also felt that additional training, especially for those without a clinical background, would be beneficial to ensure that complex client needs could be appropriately met.

The start to the program required education and courses on IPS, development of resources and program policies, and community networking. The time that it took to do these things were useful to ensure [there was] a solid base for the program to grow from.

There were many clients in our program with suicidal ideation. Additional training on this would be extremely necessary. Clients were much more complex and had much more trauma than we were prepared to address.

Implementation process factors

In addition to sharing experiences and discussing the range of factors impacting program implementation, the focus group discussions provided opportunities for collective brainstorming around implementation strategies, suggested actions, and potential program adaptations to strengthen current implementation processes.

Assessing needs (program team)

Participants reported wanting clearer standards, guidelines, and tools for daily operation to increase consistency across messaging and operations and to minimize the time spent on administrative responsibilities. Where possible, participants wanted to reduce documentation and eliminate process redundancy. Participants also suggested developing an information resource that would provide a current list of available health programs, services, and supports within their community to ensure access to the existing network of health services. This type of resource would include local services offered within each community health centre (e.g., pain management, substance use support), as well as those available at the provincial level.

I had a lot of trouble directing [clients] to a place within primary care. Kind of like if they had addictions issues, directing them to a place where they can be supported – it’s not just the need to integrate, it’s also navigation, help navigating to specific services.

Lastly, participants noted that their perspectives and opinions should have greater weight in the decisions made around program practices and policy. Many reporting feeling that routinely incorporating service provider feedback and moving towards a bottom-up leadership structure could benefit program design, ensure ongoing fit with client needs, and support timely solutions to address implementation challenges.

Assessing needs (program clients)

Participants suggested additional program-based wraparound supports to help meet the complex and dynamic needs of the program clients. Specific suggestions included adding peer support and opportunities for more community connection, workshops focused on basic life and job skills (e.g., money management, basic computer literacy, communication), and integration of other psychosocial rehabilitation practices aimed at promoting recovery and wellness. Additionally, participants suggested greater integration and use of allied health support. In BC, the allied health workforce consist of multiple regulated health providers such as dieticians, social workers, massage therapists, music therapists, kinesiologists, etc., that provide a range of preventative, diagnostic, technical, and therapeutic health services considered outside the scope of primary health care [26].

Client cases are quite complex and require much more support outside of vocational activities – Clients often require outside referrals and resources to support their day-to-day.

Tailoring strategies

Participants identified the need for different program sites to focus on different implementation strategies based on their unique barriers. For sites struggling with referrals and program integration, participants suggested increasing visibility to spread awareness and promote the program. Suggested strategies included developing program advertisements (e.g., brochures, posters) and securing co-location within a dedicated space. In addition, frequent opportunities to share client outcomes and successes with broader clinical teams would highlight the value of the program to overall client well-being, helping to foster relationship connections across various partners and levels of management, particularly those identified as mid-level leaders.

Continuing just to connect as much as possible, to go over to that site – I think that lack of presence is a real contributing factor to the challenges that the team is experiencing.

For sites struggling to build community-based employer relationships, participants suggested ongoing resources and educational opportunities for employers to help address stigma in the workplace and to create an inclusive and flexible working environment (e.g., creating lower barrier jobs to meet hiring demands).

Support for employers to know how to hire and accommodate those with multiple barriers.

Engaging (program team)

Participants suggested options to build existing staff and team capacity and capability by providing additional resources, training, and supports. In addition, participants felt that the program team should include an occupational therapist at each site and an integrated counsellor at each community health centre dedicated specifically to program clients. This would ensure low-barrier and consistent access to mental health services in addition to primary care services.

Adapting

Participants identified the need for program flexibility as a key component for supporting ongoing implementation. This included extending the scope of services provided beyond traditional IPS to help support clients in other areas of their life that would bolster transferable skills and indirectly increase work readiness. For example, including peer support opportunities for being mentored and/or offering mentorship.

A lot of the time that mental health aspect is lacking because a lot of people have become quite isolated and then they actually don’t have that peer connection and that can be a limiting factor, so maybe expanding that peer support.

Participants also discussed adapting core IPS principles to better meet the specific needs of their clients. For example, where IPS exclusively promotes competitive employment and discourages the use of sheltered or temporary work placements [27], participants described clients with higher needs were interested in volunteering or engaging in temporary work placements to build confidence and gain “low-risk” experience.

Some sort of work experience placement that could help with community buy-in with employers, while at the same time, providing clients who maybe don’t have education or experience with real experience [to] you know, help them with some skills. And also provide references and things like that for jobs that they want to do in the future.

Implementation barriers are present in all five CFIR domains described above. Barriers within the innovation and process domains were identified as easiest to address; however, there was recognition of the importance of addressing key barriers and/or influential barriers, for example those centered on upstream factors.

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