National Dissemination of an EvidenceBased Practice: Supported Employment in VHA

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National Dissemination of an Evidence-Based
Practice Supported Employment in VHA
Sandra G. Resnick, Ph.D.

• VA Northeast Program Evaluation Center, New
  England MIRECC,
• and Yale University School of Medicine

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Supported Employment

• Principles
• Goal is competitive employment
• Zero-exclusion
• Rapid, individualized job search
• Long-term follow along support
• Integration with Mental Health Team
• Considered an EBP
• Consistent findings in RCTs
• Well defined model
• Validated fidelity scale

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VACO NEPEC Partnership

• Legislation passed/money allocated in 2003
• Funds provided to VACO
• Clinical initiative
• NOT research
• NEPEC
• CWT monitoring since 1995
• Experience in dissemination of innovative
  practices
• Decisions made in partnership
• VACO all sites will have SE (130 sites)
• NEPEC centrality of fidelity monitoring
• VACO supportive of QUERI grant application

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Implementation Plan Phase 1

• Mentor-trainer sites
• One per VISN (21)
• Money for a total of 3 4 FTEE
• 1 Mentor Trainer (MT)
• Non-MT sites
• 1 FTEE
• Trained by MT
• National consultants
• Train 21 sites (not MTs)
• Rich Toscano
• Mary Sperrazza (local)

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Good Day Assumptions

• MTs from good sites will provide good training
• (corollary MTs will do what Rich does)
• Fidelity will be used as a QI tool
• MTs will learn fidelity assessment
• Programs will benefit from telephone supervision

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Bad Day Assumption

• Impossible, unfeasible plan doomed for failure

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What happened?
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Activities 21 MT Sites

• Kick-off meetings
• Louisville - September 2004
• Palo Alto - March 2006
• most between June November 2005
• Fidelity every six months
• All sites (no refusals)
• Complete data for 2 years

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MT Fidelity November 20089 of 21 sites at full
implementation
Consistent with SE
Fair SE Implementation
Not SE
52.2
64.6
60.8
64.8
64.2
63.5
n 17
n 20
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Any Competitive Work at 21 MT sites (last 90
days)
n 745 M 46 SD 22
n 456 M 45 SD 24
n 563 M 40 SD 25
n 45 M 39 SD 22
n 241 M 41 SD 29
number of days worked
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What did we learn?
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Not an impossible, unfeasible plan doomed for
failure

• Some MT sites are implementing SE well
• 9 sites at full implementation
• Mean fidelity score around 65
• Veterans are getting jobs
• Some sites hiring extra CWT/SE staff
• but faulty assumptions

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1. Good sites will provide good training

• Implementation and training are different skill
  sets
• Giving feedback
• Earning respect
• Assessment
• Good MTs have good supervisors
• Role models?
• Hire better people?

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2. Fidelity will be used as a QI tool3. MTs will
learn fidelity

• Fear factor
• Teaching to the score
• Where are the principles?
• Implementation, training AND fidelity assessment
  are all different skill sets
• Asking open-ended questions
• Assessing not teaching
• Content
• Unrealistic expectations?

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4. Sites will use telephone supervision (3 years)
number of calls
site
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What now? Phase 2

• Train the MTs
• West Haven
• New application of MI (Instructional
  Interviewing?)
• How to teach SE principles
• Focus on positives
• With Rich
• Fidelity
• Technical assistance
• What leads to sustainability?