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A model for integrating disability employment and mental health services

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Title: A model for integrating disability employment and mental health services


1
A model for integrating disability employment
and mental health services
  • Geoff Waghorn PhD
  • The Queensland Centre for Mental Health Research
    (QCMHR) and The University of Queensland

2
Declaration of interests
  • A vocational research program is funded by QCMHR
  • Funding applications are currently being
    considered by DEWR (a multi-site trial) and DoHA
    (to develop suitable measures)
  • The Park integrated site is funded by Qld Health
    and theAustralian Rotary Health Research Fund.
  • No other financial interests to declare

3
Acknowledgments
  • Professor Harvey Whiteford co-director of QCMHR
  • Dr David Chant, Statistician
  • Professor Gary Bond, Indiana - Purdue
    Universities, Indianapolis, Indiana.

4
Presentation Outline
  • Employment and recovery
  • Population-level studies
  • Service-level studies
  • Australian Sites
  • Challenges to implementation
  • A national multi-site trial

5
How employment facilitates recovery
  • Reduces stigma by providing access to a
    socially-valued role
  • Few other things can be done for up to 8, or
    more, hours a day
  • Strengthens self-efficacy and self-esteem
  • Increases opportunities for receiving positive
    regard from others
  • Increases opportunities for social inclusion
  • Provides time structure and a reason to stay well
  • Can reduce symptoms and health service
    utilization
  • No evidence that suitable employment causes
    adverse MH events

6
Recovery as a multidimensional term
  • Assistance with five inter-related domains may be
    needed
  • Clinical recovery and access to health care
  • Personal recovery a personal journey to reclaim
    empowerment, identity, and purpose
  • Social recovery to restore social networks,
    reduce stigma, restore leisure activities, and
    increase social inclusion in the wider community.
  • Economic recovery to reduce poverty and improve
    standard of living (housing, income support).
  • Functional recovery to restore functioning in
    socially-valued roles (worker, student, carer or
    parent, self development, independent living).

7
Restoring mental health is not enough Social
inclusion is important too
8
  • At a population level, how successful are we at
    providing access to employment for people with
    mental illness?

9
Australian population-level surveys of labour
force activity 2003 compared to 1998
10
Service-level studies
  • How effective are services that provide intensive
    assistance, at helping people obtain and keep
    employment?

11
Most people with severe mental illness when
asked, say they want to work
  • Say they want to work 55-70
  • Are currently working 21
  • Have access to EBP near 0
  • Sources Rogers, 1991 McQuilken, 2003 Mueser,
    2003 Harris 2002 Hall 2003 King et al., 2006
    West, 2005

12
DEWR statistics (Star Rating seminars 2006)
  • Of the 12 recorded disability categories,
    psychological/psychiatric have the lowest
    proportion retaining jobs.
  • On average only 25 of clients with
    psychological/psychiatric disabilities accumulate
    26 weeks of employment.
  • Approximately 35 of all DEN clients attain this
    milestone (all disability conditions).

13
Randomised Controlled Trials of IPS
  • Strongest scientific design for evaluating
    whether an intervention works
  • 16 published RCTs to date including
  • 12 in USA
  • 1 in Hong Kong
  • 1 in Canada
  • 1 in Europe (six countries, in press)
  • 1 RCT in Australia (abstract published)

14

15
Summary Randomized controlled trials of
Supported Employment (SE)
  • In 15 of 16 studies, SE had significantly better
    competitive employment outcomes than controls
  • Mean across studies of consumers working
    competitively at some time
  • 60 for supported employment
  • 24 for controls
  • Effect size (d) .74

16
What are the active service ingredients?
17
Two predictors of employment outcome in
service-level studies (for severe mental illness)
  • The person wants to work
  • The nature of the employment service provided
  • Note Severity of disability, course of illness,
    negative symptoms, education, work history,
    social skills, and comorbid disorders, do not
    consistently predict outcomes in service-level
    studies. Possibly because these disadvantages are
    overcome by intensive services. These variables
    may predict the cost of services.

18
Drake-Becker IPS7 Evidence-based principles
  • Eligibility is based on consumer choice
  • Supported employment is integrated with treatment
  • Competitive employment is the goal
  • Rapid job search (within 4 weeks)
  • Job finding is individualised
  • Follow-along supports are continuous
  • Financial planning is provided

19
Evidence-based ingredients in Australia
  • Competitive employment is the goal (usually)
  • Rapid job search is used (subject to official
    processing)
  • Job finding is individualised (usually)
  • Eligibility is based on consumer choice (not
    always, job-capacity and rights of refusal can
    exclude volunteers)
  • Follow-along supports are continuous (subject to
    program type and assessments )
  • Personalised benefits planning is provided (not
    usually proactively)
  • Disability employment is integrated with
    treatment (rarely)

20
Integrating employment with public mental health
  • Why unlike other disability groups, people
    with psychiatric disabilities may require
    continuing mental health care, and employment can
    contribute to their recovery
  • How DEN Employment specialists co-locate
    within public mental health teams.

21
Organisation
  • Employment specialists
  • Each join one or two treatment teams
  • Share office space with treatment team
  • Communicate frequently with treatment team
    members about progress of individual job seekers
  • Discuss vocational progress at team meetings
  • The treatment team help coordinate employment,
    benefits counseling, case management, psychiatric
    services, housing, education and training, dual
    diagnosis treatment, disability support and
    income support
  • The treatment team goals broaden to include
    functional recovery
  • The employment service continues to support the
    employment specialist

22
Problems with brokered employment services
  • Breakdowns in communication
  • Referral process works poorly (delays in take-up
    and 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
    (case manager role)

23
Advantages of integration
  • Work performance as an early warning sign of
    illness
  • Knowledge and expertise flow across sectors
  • Health outcomes are measured objectively
  • Clinical team assist with assessments
  • Employment goals lever engagement in treatment
  • Clinical team helps solve work-performance
    problems
  • Public mental health exit strategies linked to
    employment milestones
  • Employment staff facilitate re-access to mental
    health services
  • Acute care teams can help prevent job loss at
    first admission

24
Australian sites implementing integration
  • Orygen Youth Health, Melbourne (completed 12
    month RCT), and MIFV
  • Hunter Valley and New England MH, and Castle
    Personnel
  • Mental Illness Fellowship Victoria (2 sites),
    Worktrainers Shepparton, St Vincents Hospital
  • WA Mental Health in Perth (2 sites), and Ruah
    Workright
  • West Moreton Heath Service, and Workline
  • Total 7 sites, none were formally integrated
    prior to 2006.

25
Australian sites planning integration
  • Sydney (3 sites)
  • Coffs Harbour and Yamba (2 sites)
  • Mental Illness Fellowship Victoria (2 more sites)
  • WA Mental Health Perth (1 more site)
  • Queensland Health (4 South East Qld sites)
  • Cairns
  • Townsville
  • Hobart
  • Albury Wodonga
  • Total 16 sites (all must involve a DEN partner)

26
Major challenges to integration by co-location
  • Access to sufficient capped and un-capped DEN
    places is needed (25 ) to create a new caseload
  • Part-time co-location is insufficient for service
    integration (some sites cannot manage full-time)
  • Health partners may need to insure service
    viability in the short term to enable full-time
    co-location
  • Organizational culture differences hinder
    cooperation and take time to work through

27
Minor challenges to integration by co-location
  • Overall demand for employment services increases,
    hence the need for an enhanced usual care plan
  • Confidentiality, legal, resource and insurance
    issues need to be identified
  • Staff recruitment difficult to coordinate with
    project commencement.
  • It may take 3-6 months to get the service running
    smoothly.

28
A national multi-site trial
  • A national 3-year trial is near agreement, funded
    by DEWR and QCMHR.
  • On-site support, training, and data collection at
    up to 10 sites to commence in July 07.
  • Off-site support for five additional sites
  • Coordinated data collection, with each site
    providing a controlled study, an RCT if possible
  • Benchmarking against national and regional DEN
    outcomes
  • Development of functional recovery measures
  • Cost effectiveness assessed
  • Access to DEWR programs to be investigated.

29
Site selection
  • Interested sites will be invited to apply, and
    assisted to prepare a brief proposal.
  • Sites will be selected on key criteria
  • Access to sufficient DEN capped or uncapped
    places
  • Evidence of strength of parnership and viability
  • Scientific design and a suitable control group
  • Ability to achieve good fidelity to IPS
  • Willingness to collect data (sponsored)
  • Geographic location (preferred)

30
So why is employment so important to people with
mental illness?
31
With evidence-based employment assistance people
with mental illness have a chance to enjoy life,
just like other folk.
32
Recent reports
  • 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.
  • Waghorn, G., Collister, L., Killackey, E., and
    Sheering, J. (in press). Challenges to the
    implementation of evidence-based employment
    services in Australia. Journal of Vocational
    Rehabilitation.
  • Waghorn, G., Lloyd, C. (2005). The employment
    of people with mental illness. Australian
    e-Journal for the Advancement of Mental Health,
    4(2) Supplement.
  • Killackey, E., Waghorn, G. The challenge of
    integrating employment services with public
    mental health services in Australia Progress at
    the first demonstration site. Submitted to
    Psychiatric Rehabilitation Journal
  • Porteous, N., Waghorn, G. Implementing
    evidence-based employment services in New Zealand
    for young adults with psychosis Progress during
    the first five years. Submitted to the British
    Journal of Occupational Therapy.

33
Contact detailsfor further information
  • geoff_waghorn_at_qcmhr.uq.edu.au
  • Tel. 61 07 3271 8673
  • Fax. 61 07 3271 8698
  • Postal QCMHR, The Park, Centre for Mental
    Health. Locked Bag 500, Richlands, Queensland
    4077, Australia
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