Employment as an evidencebased health intervention: Current thinking about employment for people wit

1
Employment as an evidence-based health
intervention Current thinking about employment
for people with mental illness

• Geoff Waghorn PhD
• The Queensland Centre for Mental Health Research
  (QCMHR) and The University of Queensland

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Declaration of interests

• This research is funded by Queensland Health via
  a collaboration between QCMHR and the University
  of Queensland.
• The West Moreton MHS site is partly funded by an
  Australian Rotary Health Research Evaluation
  award in 2007 and 2008.
• The Queensland multisite trial is funded by
  Queensland Health as a Council of Australian
  Governments (COAG) initiative for 2007-2009.
• Development of measures and information resources
  was funded by the Australian Government
  Department of Health and Ageing in 2007-2008.
• This visit is sponsored by Workwise Employment
  Agency.

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Acknowledgments

• Professor Harvey Whiteford co-director of QCMHR
• Dr David Chant, Mathematical Statistics
  (retired).
• Professor Gary Bond, Indiana - Purdue
  Universities, Indianapolis.

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Outline

• Labour force activity by people with psychiatric
  disorders
• Neither earning nor learning
• How employment contributes to recovery
• Traditional vocational rehabilitation
• Evidence based practices in supported employment
• Missing ingredients in Australia and New Zealand
• Australian experiences with evidence-based
  supported employment
• Advantages of integration by co-location
• Implications for policy makers
• Relevant reports

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• At a population level, how successful are we at
  restoring careers following onset of severe
  mental illness?

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Impact on labour force activity
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Neither earning nor learning by health
condition SDAC 2003, n36,088
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Possible reasons for poor LFA by people with
psychiatric disorders

• Low expectations for vocational success
• Cause of disease remains unknown, and treatments
  only partially effective for most people
• Insufficient places in suitable employment
  assistance
• Few vocational services target public mental
  health service clients
• Traditional psychiatric rehabilitation concepts
  influence service delivery (e.g. work readiness
  and non-competitive employment)
• Limited availability of evidence-based employment
  services
• Welfare traps
• Employer attitudes perceived as negative
• Past experiences of community stigma and unfair
  discrimination.
• Challenging and varied nature of psychiatric
  disorders.
• Knowledge silos Mental health and vocational
  services do not routinely share information
• Poor outcomes by traditional vocational
  rehabilitation.
• Poor employment outcomes by ACT services.

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How competitive employment facilitates recovery

• By reducing stigma and social marginalisation
• By reducing disabilities secondary to the illness
  
• By helping people reclaim a valued place in
  society
• Few other things can be done for 8 or more hours
  a day
• By strengthening self-efficacy and self-esteem
  (Maslow)
• By validating recovery progress through real
  measurable accomplishments
• Increased opportunity for positive regard from
  others
• Greater opportunity for social inclusion and
  acceptance by the wider community

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Employment can help with other problems

• People with mental illness are nearly 3 times
  more likely to be in debt
• Before employment ratio of expenses to income
  120
• After employment ratio of expenses to income 80
  (Cook, 2008)
• Employment increases housing opportunities and
  helps prevent eviction
• 66 of men under the age of 35 with mental
  illness who completed suicide were unemployed.
• Deterioration in mental health can be first
  observed at work.

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Psychiatric disabilities are the most challenging
for standard disability employment services

• Australian DEEWR unpublished data 2006
• Of the 12 disability categories assisted by the
  Disability Employment Network, psychological/psych
  iatric had the poorest job retention
• 25 of participants with psychological/psychiatric
  disabilities accumulated 26 weeks of employment
• 35 of all DEN participants attained this
  milestone

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Employment demand by people with severe mental
illness

• Say they want to work 55-70
• Are currently working 21
• Current access to evidence-based SE 0
• Most consumers of MHS are never asked about their
  employment goals.
• Sources Rogers, 1991 McQuilken, 2003 Mueser,
  2003 Harris 2002 Hall 2003 King et al., 2006
  West, 2005

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Traditional Rehabilitation

• Gradual stepwise process after clinical treatment
  and care is complete
• Usually involves prevocational training (courses
  in managing mental health, general social skills,
  independent living, self-esteem)
• Work-readiness assessments used for eligibility
• Individual and illness characteristics are used
  to assess work readiness
• Voluntary work, work experience, sheltered
  employment, and transitional employment are often
  used
• Group-based approaches often used (e.g. work
  preparation groups, Job-clubs, support groups).

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EB-SE7 Evidence-based principles

• 1. Eligibility is based on consumer choice
• 2. Supported employment is integrated with
  treatment
• 3. Competitive employment is the goal
• 4. Rapid job search (within 4 weeks)
• 5. Job finding, and all assistance, is
  individualised
• 6. Follow-along supports are continuous
• 7. Financial planning is provided.
• 2 7 most likely to be missing in Australia
• Others can be weak in practice
• Evidence for each principle as well as for the
  model as a whole (Bond, 2004 Bond et al, 2008
  Psychiatric Rehabilitation Journal).

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Evidence for what works best

• Most effective approach is now known as
  evidence-based supported employment for people
  with psychiatric disabilities. Previously called
  the Drake-Becker Individual Placement and Support
  (IPS) approach.
• Evidence includes 6 day treatment conversions and
  16 RCTs.
• RCTs are the strongest scientific design for
  evaluating whether an intervention works.
• 16 published and qualifying RCTs (See recent
  edition of PRJ)
• 12 in USA
• 1 in Hong Kong
• 1 in Canada
• 1 in Europe (six European countries)
• 1 in Australia (in press with BJP).
• 11 RCTs involve services with high fidelity to
  EB-SE.
• This approach is most similar to the Disability
  Employment Network program in Australia.

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Day treatment conversions to IPS Common study
design

• Discontinue day treatment (usually group training
  in managing medication or social skills)
• Reassign day treatment staff to new positions
• Replace group-based programs and sheltered work
  with IPS

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Mean competitive employment rates in 6 day
treatment conversions
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Similar results in all 6 day treatment
conversions

• Large increase in employment rates
• No negative outcomes (e.g., relapses)
• Consumers, families and staff all liked the
  change
• Overall, all former day treatment clients got out
  into the community more
• Resulted in cost savings

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Other employment outcomes

• 11 of 16 RCTs compared high fidelity services to
  the best available local services (EB-SE vs.
  controls).
• More participants commenced competitive
  employment (11 studies, 62 vs. 25)
• More participants worked 20 or more hours per
  week (4 studies, 43.6 overall, 66 vs. 14.2 at
  control sites).
• Less days to first job (6 studies, 144.5 vs.
  214.0 days).
• Similar accumulated employment following
  commencement of first job (11 studies, 24.5 vs.
  25.0 weeks).
• More weeks worked at longest job (11, studies,
  22.0 vs 16.3 weeks).
• Time to first job and job retention are major
  challenges.

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EB-SE changed the way we think

• Not a gradual stepwise process, goal is immediate
  competitive employment. Aim is to commence job
  searching within 4 weeks.
• Employment service is closely coordinated with
  health treatment and care.
• No prevocational training. All training is highly
  individualised and linked to a particular job
  Place then train, not Train then place.
• No assessments of work-readiness. Main inclusion
  criteria are that applicants have a severe mental
  illness and are requesting assistance.
• Assessments are ongoing once a job commences.
  Employers are provided with similar support.
• Intensive one-one assistance is available at
  every step
• Service characteristics rather than individual
  characteristics, predict employment outcomes
• Individual preferences guide every aspect of
  assistance. These preferences are not modified
  and all assistance is provided on a one-one
  basis.
• Voluntary work, work experience, sheltered
  employment, transitional employment, wage
  subsidies, and temporary jobs are rarely used
• Job tryouts at casual rates are the preferred
  method to obtain career-learning experiences.
  These are often negotiated on behalf of clients.
  
• Continuing support not arbitrarily discontinued.

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Missing ingredients in Australia and New Zealand

• Integration of vocational assistance with mental
  health treatment and care.
• Financial planning
• to work out the cost-benefits of going to work
  and reduce the stress of financial uncertainty.
• to clarify motivation to seek employment in those
  who have not yet volunteered.
• Intensity, continuity, and individualised
  approach also need to be strengthened
• With the support of a mental health team all
  volunteers can be assisted.

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A key ingredient Integrating employment with
community mental health services

• Why
• People with psychiatric disabilities can require
  extended periods of mental health care which
  needs to be coordinated with any vocational
  services provided.
• Employment services can facilitate engagement in
  mental health treatment and care
• Employment outcomes can demonstrate the efficacy
  of a recovery orientated mental health service
• Discharge plans can be linked to real world
  milestones such as stable housing and employment.

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A key ingredient Integrating employment with
community mental health services

• How
• Co-locating by formal partnership with an
  existing employment service (e.g. Qld trial)
• Attachment model (visiting and cross-training,
  South Auckland)
• Rehab. staff provide enhanced inter-sectoral
  links (Newcastle)
• MHS employs employment specialists and obtains
  MSD contract (CCDHB)
• MHS employs employment consultant using own funds
  or research funds (ORYGEN Youth Health,
  Melbourne).

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Integration by co-location

• Employment specialists
• Hosted by one or two clinical teams
• Share office space with clinical team to access
  shared clients
• Communicate informally with team members about
  progress of individual clients
• Conduct joint interviews with clients
• Discuss vocational progress at weekly case
  reviews.
• Clinical team benefits from the input of the
  employment specialist.
• Employment specialist benefits from knowledge and
  support of the clinical team.
• Clients benefit from not having to coordinate
  services
• Clients work performance issues are more likely
  to be solved
• Services become more effective
• The employment service trains and supports the
  employment specialist who regularly attends the
  home vocational service.

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Problems with segregated employment services

• Breakdowns in communication
• Referral process works poorly (delays in take-up,
  right of refusal)
• Meetings hard to schedule
• Clients perceived differently
• Treatment and housing get out of step with job
• Responsibility for follow-up unclear
• Employment staff may get caught up in crisis work
  (care manager role).

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Advantages of co-location

• More efficient use of existing resources
• Knowledge and expertise flow to both sectors
• Changes in resource allocation, funding
  arrangements, or staff duties, not usually
  required
• Health staff implement a recognised
  evidence-based practice
• Health staff benefit from seeing more individual
  recovery
• Health staff develop new skills and expertise in
  psychosocial rehabilitation
• Help with risk assessment and contingency
  planning
• Help with personal information management
• Link treatment and care goals to
  clientsemployment goals.
• Mental health exit strategies can be linked to
  employment milestones
• Employment specialist can facilitate re-access to
  mental health services if needed
• Forensic services, substance use, and acute care
  teams can participate
• Employment specialist can assist clients most in
  need of this assistance and build more expertise
  compared to segregated services.

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Employers best understand psychiatric disorders
in terms of work restrictions
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Advantages of service integration

• Mental health service accepts importance of
  return to real-world functioning as a key outcome
  indicator for MHS
• Mental health teams refine treatment plans to
  optimise work performance
• MHS staff (RHD students) help design add on
  programs to improve employment service
• Work-related problem solving skills
• Job-specific social skills
• Motivational interviewing to delineate
  work-motivation.
• CBT and other interventions to reduce employment
  restrictions.
• Integrated MH service find no downside to
  integration in the medium term.
• Employment service assists more challenging
  clients and increases employment outcomes.

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Financial planning

• Perceptions of welfare as more stable and
  dependable. Fear of loss of income support and
  loss of fringe benefits.
• Financial planning important to assess in advance
  the real costs and benefits of going to work
• Identify job location and likely earnings (after
  tax)
• Identify actual value of fringe benefits
• Identify all welfare and tax implications (income
  support, fringe benefits, taxation, housing
  subsidies)
• Apply for all applicable incentives
• Clarify notification obligations
• Calculate costs of going to work (travel, meals,
  clothing, tools)
• Plan a budget for the first four weeks.

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Australian experiences with evidence-based
supported employment

• Queensland Multisite trial (12 sites)
• Mental Illness Fellowship Victoria (5 of 6 sites
  similar to Qld trial)
• Hunter Valley and New England MHS trial ( 1 site)
  2 MH staff dedicated to monitor referrals to
  local services).
• ORYGEN Youth Health (1 site) EC employed directly
  as part of YMHS, no links to federal employment
  system.

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Qld multi-site trial
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Support for other sites

• Australia
• Launceston Choice Employment and Tasmania MHS
• Hobart CRS Australia and Tasmania MHS
• Rockingham MHS WA, and Ruah Workright
• Canberra
• Sunshine Coast Mental Health Service
• NZ
• Capital and Coast DHB, research support.
• Workwise, implementation and research support.

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Major challenges to integration by co-location

• Need sufficient funded places (25 per FTE) for
  sustainability
• An experienced employment specialist with a new
  case-load capacity
• Employment service can have lower performance
  during set-up
• Organizational culture differences need to be
  monitored
• Need for proactive change management by MHS
• Need training for MH staff to generate referrals
  as quickly as possible and to promote acceptance
  of the EC
• Need to accommodate the increased demand for
  employment services by other clients of the MHS.
  Need an enhanced care plan.

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Minor challenges to integration by co-location

• 3-6 months may be needed for a new co-located
  service to run smoothly
• Most issues are practical such as IT access,
  parking, car access, confidentiality agreements,
  shared interview rooms, job search facilities for
  clients.
• It helps if a single coordinator and a small
  steering committee are appointed in the host
  service. This way all issues can be quickly
  resolved.

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Implications for policy makers

• Australian Disability Employment services
  characterized by
• Segregation from mental health treatment and care
  
• Difficulty with zero exclusion
• Difficulty with rapid job search
• Financial counselling ad hoc
• Demand often exceeds places available
• Otherwise a highly suitable type of service for
  people with severe mental illness
• Another benefit to MHS is demonstrating
  successful implementation of evidence-based
  practice
• EBP in SE much easier to implement than ACT or
  Family Psycho-education.
• EBP in SE should have no long term costs to
  either service.
• Approach informs inter-sectoral issues in
  education and housing.

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Relevant Reports

• Killackey, E., Waghorn, G. (2008). The
  challenge of integrating employment services with
  public mental health services in Australia
  Progress at the first demonstration site.
  Psychiatric Rehabilitation Journal, 32(1), 63-66.
  
• King, R., Waghorn, G., Lloyd, C., McMah, T.,
  McCloud, P., Leong, C. (2006). Enhancing
  employment services for people with severe mental
  illness the challenge of the Australian service
  environment. Australian and New Zealand Journal
  of Psychiatry, 40, 471-477.
• Lloyd, C., Waghorn, G. (2007). The importance
  of vocation in recovery for young people with
  psychiatric disabilities. British Journal of
  Occupational Therapy. 70(2), 50-59.
• Porteous, N., Waghorn, G. (2007) Implementing
  evidence-based employment services in New Zealand
  for young adults with psychosis Progress during
  the first five years. British Journal of
  Occupational Therapy, 70(12), 521-526.
• Waghorn, G., Collister, L., Killackey, E., and
  Sheering, J. (2007). Challenges to the
  implementation of evidence-based employment
  services in Australia. Journal of Vocational
  Rehabilitation, 27, 29-37.

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Relevant reports continued

• Lloyd, C., Waghorn, G., Best, M., Gemmell, S.
  (2008). Reliability of a composite measure of
  social inclusion for people with psychiatric
  disabilities. Australian Occupational Therapy
  Journal, 55(1), 47-56.
• Lloyd, C., Waghorn, G., McHugh, C. (2008).
  Musculoskeletal disorders and comorbid
  depression Implications for practice. Australian
  Occupational Therapy Journal, 55(1), 23-29.
• Lloyd, C., Waghorn, G, Williams, PL. (in
  press). Conceptualising recovery in mental health
  rehabilitation. British Journal of Occupational
  Therapy.
• Lloyd, C., Waghorn, G., Williams, PL., Harris,
  MG, Capra, C. (in press). Early psychosis
  Treatment issues and the role of occupational
  therapy. British Journal of Occupational Therapy.
  
• Rampton, N., Waghorn, G., Lloyd, C., De Souza,
  T. (in press). Employment service provider
  knowledge of service user assistance needs.
  American Journal of Psychiatric Rehabilitation.
• Waghorn, G., Lewis, S. (2002). Disclosure of
  psychiatric disabilities in vocational
  rehabilitation. Australian Journal of
  Rehabilitation Counselling, 8 (2), 67-80.
• Waghorn, G., Lloyd, C. (2005). The employment
  of people with mental illness. Australian
  e-Journal for the Advancement of Mental Health,
  4(2) Supplement, 1-43.
• Waghorn, G., Lloyd, C. Mackenzie-Ross, A.,
  Schembri, S. (in press). Generalizability of a
  measure of work-related subjective experiences
  for people with psychiatric disabilities. Journal
  of Rehabilitation.
• Waghorn, G. Lloyd, C., Abraham, B., Silvester,
  D., Chant, D. (2008). Comorbid physical health
  conditions hinder employment among people with
  psychiatric disabilities. Psychiatric
  Rehabilitation Journal, 31(3), 243-246.

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Contact details

• geoff_waghorn_at_qcmhr.uq.edu.au
• Tel. [phone]
• Fax. [phone]
• Postal QCMHR, The Park, Centre for Mental
  Health. Locked Bag 500, Sumner Park BC,
  Queensland 4074 Australia