1. 1 Intensive and irregular service use as possible barriers to employment for people with psychiatric and other disabilities Kathleen Thomas, PhD Alan R. Ellis, MSW Mona Kilany, MPH Joseph Morrissey, PhD 2009 Annual meeting of the American Public Health Association November, 2009 Supported by a contract from the North Carolina Department of Health and Human Services Division of Vocational Rehabilitation Services

2. 2 Service use as a barrier to employment: Presenter Disclosure Kathleen Thomas The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose

3. 3 Service use as a barrier to employment: Background Employment among people with disabilities is low o 37% o Compared to 80% among those without a disability Among people with disabilities who are not working o Most (63%) want to work

4. 4 Service use as a barrier to employment: Background Employment among people with disabilities has been associated with individual characteristics o Personal: male gender, absence of co-morbidity, and disability type o Service: high educational level, receipt of vocational services => These don’t serve well as policy levers

5. 5 Service use as a barrier to employment: Background People with disabilities cite two important barriers to work o Fear of loss of benefits (income support and health insurance) o Health => We don’t really know what ‘health’ means in this context

6. 6 Service use as a barrier to employment: Study goals o Exploratory examination of the association between intensive or irregular patterns of service use and work o Enhance our understanding of enrollment in North Carolina’s new Medicaid buy-in and how to target resources to remove barriers to work

7. 7 Service use as a barrier to employment: Data North Carolina Medicaid claims o Fiscal years 2002-2007 o Adults with disabilities o Eligible for Medicaid through receipt of Supplemental Security Income or section 1619b o n=127,431

8. 8 Service use as a barrier to employment: NC Medicaid SSI/1619b recipients CharacteristicsMedianMeanStd DevPercent Age44.042.114.6 Male43.3 White43.7 Psychiatric Disability58.0 Cognitive Disability16.6 Significant work15.0

9. 9 Service use as a barrier to employment: NC Medicaid SSI/1619b recipients Service useMedianMeanStd Dev Days23.042.561.4 Consistency0.300.390.34

10. 10 Service use as a barrier to employment: NC Medicaid SSI/1619b recipients Days ConsistencyLowMediumHigh ---1.481.08 Medium1.481.000.74 Low1.390.730.47 Logit of work as a function of service use, controlling for personal characteristics Odds Ratios Overall model and construct fit significant, p<0.0001

11. 11 Service use as a barrier to employment: NC Medicaid SSI/1619b recipients Personal CharacteristicsOdds Ratios95% CI Age1.000.99-1.00 * Male1.361.32-1.40 * White1.171.14-1.21 * Psychiatric Disability0.840.81-0.87 * Cognitive Disability0.670.64-0.70 * Logit of work as a function of service use, controlling for personal characteristics Overall model fit significant, p<0.0001

12. 12 Service use as a barrier to employment: Summary Among people with disabilities enrolled in Medicaid o Low number of service use days and high consistency in patterns of use are associated with employment o Both days and consistency are important, neither outweighs the other

13. 13 Service use as a barrier to employment: Limitations o Service use data do not capture sick days spent at home o People may need more services than they receive o Claims data provide limited contextual information

14. 14 Service use as a barrier to employment: Implications o People who are struggling with illness do not have the resources to work o Sometimes, poor access to and continuity of care may limit people’s ability to work o Findings call for attention to scheduling health care use to accommodate work commitments o Investment in advocacy skills that address negotiating scheduling appointments may help to support work