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This paper provides information on the experience of organisations that serve individuals with very high support needs related to a total organisational change to supported employment. While many of the recommendations developed from these experiences, together with the barriers organisations faced, relate specifically to the US political system, they are still relevant in that they call for government initiatives to provide the leadership and support to help organisations succeed in this bringing about what is a difficult task. The authors note that where the changeover to supported employment has occurred, the decision to change was driven by values. Keyword: Employment