Effectiveness of Individual Placement and Support: Research Update Gary R. Bond Dartmouth Psychiatric Research Center Troutdale, OR July 27, 2011

Presentation Outline Theory Model description Effectiveness Cost-effectiveness Program fidelity and dissemination

Theory

Six Traditional Assumptions Screen for job readiness Stabilize symptoms and curtail substance use before considering work Operate vocational program apart from mental health treatment program Provide skills training, sheltered work, or counseling to prepare for job Study job market to for possible placements End assistance once job placement made

IPS: Assumption 1 Most people with severe mental illness want to work in regular community jobs

The Primary Goal in Work Arena: Competitive (Open) Employment Regular community job Pays at least minimum wage Nondisabled coworkers Not temporary or “make work” Job belongs to the client, not to the mental health or rehabilitation agency

Why Focus on Competitive Employment? Most clients want to work Being productive = Basic human need A typical role for adults in our society Most clients see work as an essential part of recovery >2/3 of clients live in poverty – employment may be a way out

IPS: Assumption 2 No reason to screening for job readiness, because measures used to screen do not predict employability

IPS: Assumption 3 Employment helps people manage symptoms and control substance use, not the other way around

IPS: Assumption 4 Employment services are most effective when integrated with mental health treatment

IPS: Assumption 5 Stepwise programs (skills training, transitional employment, sheltered jobs, etc.) create dependency and lead to high dropout rates

IPS: Assumption 6 Client job preferences are the key to individualized job searches, not job market

IPS: Assumption 7 Ongoing support after job placement is crucial to successful job tenure

Traditional IPS Supported Assumptions Employment Traditional  IPS Supported Assumptions Employment Screen for readiness Stabilize first Stepwise prep Separate agencies Job availability Time limit support Zero exclusion Focus on client goals Rapid job search Integrated services Client choice Ongoing support

Model Description Individual Placement and Support (IPS) Model of Supported Employment

History

IPS: 8 Evidence-Based Principles Open to anyone who wants to work Focus on competitive employment Rapid job search Systematic job development

IPS: 8 Evidence-Based Principles (Continued) Client preferences guide decisions Individualized long-term supports Integrated with treatment Benefits counseling provided

Effectiveness

IPS Has… Strong and Consistent Evidence of Effectiveness in Increasing Competitive Employment Outcomes

14 Randomized Controlled Trials of High-Fidelity Supported Employment (IPS) Best evidence available on effectiveness RCTs are gold standard in medical research Bond, Drake, & Becker (in press)

Four Measurement Domains of Employment Outcomes Job acquisition (% employed) Job duration (weeks worked) Job intensity (hours worked per week) Productivity (earnings)

18-Month Competitive Employment Outcomes in 4 Controlled Trials of IPS (Bond, Drake & Campbell, submitted)

18-Month Competitive Employment Outcomes in 4 Controlled Trials of IPS (Bond, Drake & Campbell, submitted)

18-Month Competitive Employment Outcomes in 4 Controlled Trials of IPS (Bond, Drake & Campbell, submitted)

Competitive Employment in 2-Year Follow-up of IPS After 1st Job (Bond & Kukla, 2011)

Steady Worker Concept Suggested Criterion: Work at least half the weeks during any time period

6 Day Treatment Conversions to Supported Employment: Common Study Design Discontinued day treatment Reassigned day treatment staff to new positions Implemented new supported employment program Compared to 3 sites not converting Sources: Drake and Becker

Similar Results in All 6 Day Treatment Conversions Large increase in employment – No negative fallout – No increase in program dropouts, relapses, etc. Overwhelmingly positive reactions from consumers, families, & clinicians Greater community involvement regardless of whether clients worked

Mean Competitive Employment Rates in 6 Day Treatment Programs Converting to IPS

IPS Has… Favorable “Side Effects”

Is Work Too Stressful? n n As compared to what? n n Joe Marrone: If you think work is stressful, try unemployment

Negative Effects of Unemployment in General Population n n Increased substance abuse n n Increased physical problems n n Increased psychiatric disorders n n Reduced self-esteem n n Loss of social contacts n n Alienation and apathy (Warr, 1987)

Associated Benefits of Competitive Employment for Clients with Mental Illness Increased income Increased income Improved self esteem Improved self esteem Increased quality of life Increased quality of life Reduced symptoms Reduced symptoms Mueser, 1997; Sources: Arns, 1993, 1995; Bond, 2001; Fabian, 1989, 1992; Mueser, 1997; Van Dongen, 1996, 1998

IPS Has… Positive Long-Term Outcomes

2 Long-Term IPS Follow-up Studies (Salyers 2004; Becker, 2007) 2 Long-Term IPS Follow-up Studies (Salyers 2004; Becker, 2007)

IPS Is… Adaptable to a Wide Variety of Communities and Populations

Where and with Whom Has IPS Been Successfully Implemented? US, Canada, Europe, Hong Kong, Australia, Japan Both rural and urban communities Diverse ethnic groups Different age groups – –Key subgroup: First-episode of psychosis

Outcomes in 87 Urban & Rural IPS Programs (Haslett, 2011)

Problem and Potential Solution n n Only about 2% of people who could benefit from IPS have access in U.S. n n What if U.S. had universal access to IPS? n nHow much would services cost? n nWould fewer first episode clients apply for disability?

Cost-Effectiveness

Is IPS Cost Effective? Long-term controlled studies of IPS cost-effectiveness have not been conducted Two areas hypothesized to yield cost savings: – –Prevent entry onto disability rolls – –Reduce treatment costs after achieving employment

Impact of Mental Illness on Social Security (SSDI and SSI) People with mental illness: – –Comprise > 33% of disability roles – –Fastest growing disability group – –<.5% leave the roles in any year – –Cost to US taxpayers: $2 billion per month

Cost Savings: $5000/Year ( Bush, 2009)

Cost Offset for IPS IPS service costs: ~$5000 per client per year Clients who work have reduced mental health treatment costs Universal access to IPS could save Social Security ~ $700 million/year (Latimer, 2004; Bush, 2009; Drake, 2009)

Program Fidelity

Fidelity n n Degree to which an intervention is delivered as intended n n Working hypothesis: Better implemented programs (with higher fidelity to EBP) have better outcomes

Dartmouth Approach to Fidelity Assessment n n Relatively brief assessment by independent assessors n n Based on model principles n n Emphasizes face valid, behaviorally-anchored items n n Incorporates both research and quality improvement goals

Data Collection Procedures for EBP Fidelity Scales n n Ratings made by two independent assessors n n Day-long site visit n n Multiple data sources (interviews, chart review, observation) n n Fidelity report (with narrative + ratings) given to site leadership

Format for EBP Fidelity Items n n Items rated on 5-point behaviorally- anchored continuum: 1 = Not Implemented… 5 = Fully Implemented

IPS Fidelity Scale n 15-item scale developed to ensure adherence to IPS model n Used worldwide over last 15 years n Good evidence for validity (Bond, Becker, Drake & Vogler, 1997; Bond, Becker & Drake, 2011)

IPS Fidelity Predicts Competitive Employment

IPS Is… Relatively Easy to Implement

IPS Implementation Projects National EBP Project Mental Health Treatment Study IPS Learning Collaborative

SE Fidelity in National EBP Project (4.0 = high fidelity)

Mental Health Treatment Study: Attainment of High IPS Fidelity in 22 sites throughout US

IPS Learning Collaborative (Becker, Drake, & Dartmouth Psychiatric Research Center Staff) Begun in 2002 Supported by Johnson& Johnson Office of Corporate Contributions Includes 127 programs in 13 states Participants share fidelity and outcome data, attend annual meetings

Achievement of IPS Fidelity in 88 Sites in Learning Collaborative

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Benchmarks for Quarterly Comp. Employment Rate (Becker et al. 2011)

Factors Promoting Evolution of the IPS Model Operationally defined from the start Grounded in evidence-based medicine Commitment to ongoing research and evaluation Use of a validated fidelity scale All research conducted in field settings

Conclusions: IPS… Is well defined Is effective Has favorable “side effects” Shows long-term outcomes Generalizes across populations and settings May be cost effective Has been widely implemented with high fidelity

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