Effectiveness of Individual Placement and Support: Research Update

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Effectiveness of Individual Placement and
Support Research Update

• Gary R. Bond
• Dartmouth Psychiatric Research Center
• Troutdale, OR
• July 27, 2011

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Presentation Outline

• Theory
• Model description
• Effectiveness
• Cost-effectiveness
• Program fidelity and dissemination

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Theory

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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

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IPSAssumption 1

• Most people with severe mental illness want to
  work in regular community jobs

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The Primary Goal in Work ArenaCompetitive
(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

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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
• gt2/3 of clients live in poverty employment may
  be a way out

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IPSAssumption 2

• No reason to screening for job readiness, because
  measures used to screen do not predict
  employability

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IPSAssumption 3

• Employment helps people manage symptoms and
  control substance use, not the other way around

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IPSAssumption 4

• Employment services are most effective when
  integrated with mental health treatment

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IPSAssumption 5

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

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IPSAssumption 6

• Client job preferences are the key to
  individualized job searches, not job market

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IPSAssumption 7

• Ongoing support after job placement is crucial to
  successful job tenure

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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

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Model Description

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

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History

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IPS8 Evidence-Based Principles

• Open to anyone who wants to work
• Focus on competitive employment
• Rapid job search
• Systematic job development

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IPS8 Evidence-Based Principles (Continued)

• Client preferences guide decisions
• Individualized long-term supports
• Integrated with treatment
• Benefits counseling provided

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Effectiveness

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IPS Has

• Strong and Consistent Evidence of Effectiveness
  in Increasing Competitive Employment Outcomes

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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)

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Four Measurement Domains of Employment Outcomes

• Job acquisition ( employed)
• Job duration (weeks worked)
• Job intensity (hours worked per week)
• Productivity (earnings)

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18-Month Competitive Employment Outcomes in 4
Controlled Trials of IPS

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

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

(Bond, Drake Campbell, submitted)
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Competitive Employment in 2-Year Follow-up of IPS
After 1st Job

(Bond Kukla, 2011)
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Steady Worker Concept

• Suggested Criterion
• Work at least half the weeks
• during any time period

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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

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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

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

• Favorable
• Side Effects

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Is Work Too Stressful?

• As compared to what?
• Joe Marrone If you think work is stressful, try
  unemployment

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Negative Effects of Unemployment in General
Population

• Increased substance abuse
• Increased physical problems
• Increased psychiatric disorders
• Reduced self-esteem
• Loss of social contacts
• Alienation and apathy
• (Warr, 1987)

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Associated Benefits of Competitive Employment
for Clients with Mental Illness

• Increased income
• Improved self esteem
• Increased quality of life
• Reduced symptoms
• Sources Arns, 1993, 1995 Bond, 2001
  Fabian, 1989, 1992 Mueser, 1997 Van
  Dongen, 1996, 1998

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IPS Has

• Positive Long-Term Outcomes

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

• Adaptable to a Wide Variety of Communities and
  Populations

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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

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Outcomes in 87 Urban Rural IPS Programs
(Haslett, 2011)
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Problem and Potential Solution

• Only about 2 of people who could benefit from
  IPS have access in U.S.
• What if U.S. had universal access to IPS?
• How much would services cost?
• Would fewer first episode clients apply for
  disability?

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Cost-Effectiveness

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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

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Impact of Mental Illness on Social Security
(SSDI and SSI)

• People with mental illness
• Comprise gt 33 of disability roles
• Fastest growing disability group
• lt .5 leave the roles in any year
• Cost to US taxpayers
• 2 billion per month

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Cost Savings 5000/Year

• (Bush, 2009)

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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)

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Program Fidelity

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Fidelity

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

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Dartmouth Approach to Fidelity Assessment

• Relatively brief assessment by independent
  assessors
• Based on model principles
• Emphasizes face valid, behaviorally-anchored
  items
• Incorporates both research and quality
  improvement goals

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Data Collection Procedures for EBP Fidelity
Scales

• Ratings made by two independent assessors
• Day-long site visit
• Multiple data sources (interviews, chart review,
  observation)
• Fidelity report (with narrative ratings) given
  to site leadership

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Format forEBP Fidelity Items

• Items rated on 5-point behaviorally-anchored
  continuum
• 1 Not Implemented
• 5 Fully Implemented

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IPS Fidelity Scale

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

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IPS Fidelity Predicts Competitive Employment
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IPS Is

• Relatively Easy to Implement

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IPS Implementation Projects

• National EBP Project
• Mental Health Treatment Study
• IPS Learning Collaborative

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SE Fidelity in National EBP Project(4.0 high
fidelity)
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Mental Health Treatment Study Attainment of High
IPS Fidelity in 22 sites throughout US
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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

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Achievement of IPS Fidelity in 88 Sites in
Learning Collaborative
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.
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Benchmarks for Quarterly Comp. Employment Rate
(Becker et al. 2011)
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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

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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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My email

• gary.bond_at_dartmouth.edu