The study evaluated the Integrated Scaling Approach, or ISA, across agencies operating within a state supported employment system. It used a concurrent mixed-methods design: descriptive quantitative measures tracked implementation and service reach, while 12 focus groups and two individual interviews with 25 participants explored facilitators and barriers to scaling and sustainment. Participants included frontline staff, supervisors, program managers and a representative from the state Mental Health Authority. The Vocational Rehabilitation agency withdrew from active participation during implementation and did not participate in the interviews.

Thinking Skills for Work, or TSW, was the evidence-based practice selected for the trial. It is a cognitive remediation intervention designed to improve employment outcomes among people with serious mental health conditions by targeting cognitive functioning. TSW also had a defined intervention manual and training guide, which the researchers treated as criteria for dissemination readiness. The field trial was conducted in Georgia, which had 23 high-fidelity Individual Placement and Support programs serving more than 4,000 people annually at recruitment. The state Mental Health Authority and Vocational Rehabilitation agency initially expressed interest in the initiative.

ISA was organized into preparation, implementation and sustainment phases. Preparation activities included engaging state administrators, introducing TSW to participating agencies, adapting a marketing toolkit, creating agency- and system-level implementation teams, and providing a 10-week online, self-paced training program. During implementation, technical assistance focused on integrating TSW into billing, documentation and workflow. Providers then completed a five-month certification program with remote supervision emphasizing skill development, fidelity and case-based problem-solving. The sustainment phase emphasized a 10-week Train-the-Trainer program and periodic technical assistance.

Nine of the 23 supported employment agencies enrolled, representing 39% of the state’s active programs, and the participants operated 12 sites. Eight of the nine agencies completed all three ISA phases. During implementation, 18 of 20 program managers, or 90%, participated in monthly technical assistance sessions, while 19 of 34 staff members across the agencies completed training and became certified in TSW. Providers approached 61 clients during implementation; 57, or 93%, enrolled and received TSW. Another 28 clients enrolled during sustainment, bringing the total to 85 supported employment clients served during the field trial. All nine agencies had 16 staff complete Train-the-Trainer certification.

Interviews and focus groups identified several features associated with implementation. Participants described TSW as flexible enough to fit different agency contexts and individual client needs. Structured hybrid training combined didactic instruction with extended practice-based supervision, which respondents associated with greater staff confidence and perceived competence. Implementation-team meetings supported cross-agency learning, accountability and problem-solving, while regular technical assistance kept TSW visible amid competing service demands. State endorsement also supported participation by signaling the legitimacy and potential value of the intervention.

Long-term sustainment was not achieved. Pandemic-related funding reductions and workforce disruptions produced staff shortages, with some agencies reporting losses of one-third to one-half of their supported employment staff. Staff were redeployed to other services, some training was interrupted, and agencies did not use the TSW marketing toolkit because they were concerned they could not meet demand. Clients also faced barriers to engagement, including prioritizing personal health over work, reluctance to begin a new intervention and avoidance of in-person services. The state’s Vocational Rehabilitation system lost 75% of its staffing as funding shifted to COVID-19 relief.

System-level changes were also associated with weaker sustainment incentives. Leadership and staffing changes at the Mental Health Authority and Vocational Rehabilitation agency disrupted plans to reimburse TSW as part of supported employment services, reducing agencies’ incentives to maintain the practice. These changes also halted proposed modifications to supported employment fidelity measures that would have recognized TSW as a service component, making integration more difficult for some agencies. The study therefore associated the failure to sustain TSW with unstable funding, policy support, reimbursement mechanisms and staffing rather than with a complete absence of agency interest. Participants also described the tension between supported employment expectations for rapid placement and the time required to deliver TSW.

The study establishes short-term implementation outcomes, not the intervention’s effectiveness in improving employment, and it does not show that the ISA caused long-term sustainment. Eight of nine agencies completed all phases, staff certification and internal training capacity were achieved, and 85 clients received TSW, but adoption and sustainment were distinct outcomes and early implementation did not predict maintenance. The authors concluded that integrated workforce, organizational and system strategies can facilitate uptake, even during substantial disruption, but they argued that durable policy and funding support are needed for sustained scale-up. Because the trial covered one state under exceptional pandemic conditions, future assessment of ISA with other evidence-based practices and in more stable systems remains necessary.

Subject of Research: A mixed-methods field trial of the Integrated Scaling Approach for implementing Thinking Skills for Work in Georgia supported employment programs

Article Title: Outcomes of the Integrated Scaling Approach: scaling an evidence-based employment intervention in public mental health systems

Article References: Farkas, M., Trolley-Hanson, A., McGurk, S. R., Burke-Miller, J. K., Braverman, D., Khare, C., & Mueser, K. T. (2026). Outcomes of the Integrated Scaling Approach: scaling an evidence-based employment intervention in public mental health systems. Frontiers in Psychiatry, 17, Article 1867975. https://doi.org/10.3389/fpsyt.2026.1867975

Image Credits: AI Generated

DOI: 10.3389/fpsyt.2026.1867975

Keywords: implementation science, supported employment, Thinking Skills for Work, cognitive remediation, mental health systems, scale-up, workforce capacity, implementation sustainability, COVID-19 disruptions, Georgia, Outcomes, Integrated