Job Retention and Vocational Rehabilitation for People with Mental Health Problems.

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Job Retention and Vocational Rehabilitation for
People with Mental Health Problems.

• Fife Pilot

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Aims of this Presentation

• To give a description of the Job retention Pilot
  Study.
• To introduce participants to a process applicable
  to job retention for mental health issues,
  illustrated through composite case studies
• To describe some of the learning encountered
  during intervention.
• To give an overview of the interim results from
  the evaluation

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The Context

• Average length of time taken off work for mental
  health related problems is estimated at 29 days
  compared to 19 days for musculoskeletal
  disorders.( Jones et al. 2001/2002 Self Reported
  Work Related Illness in 2001/2002 Results from a
  household Survey. SW 101/102 www.hse.gov/statist
  ics/causdis/swi0102pdf )
• As many as 117,000 people with mental health
  problems, aged between 18 and 65 years currently
  registered unemployed are capable of work and
  want to work. ( Scottish Executive Health
  Department (1997) A Framework for mental health
  services in Scotland 1997)
• Constructive Employment can have a positive
  impact on mental health and well-being.
  (Schneider J. (1998) Work interventions in Mental
  Care, Some Arguments and recent evidence. Journal
  of Mental Health, 7 81-94)

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Drivers for the Project

• The National Programme for Improving Mental
  Health and Well- Being.
• The Framework for Mental Health Services in
  Scotland
• The Mental Health and Employment Policy for
  Scotland
• The Mental Health (Care and Treatment) (Scotland)
  Act 2003
• Fifes Multi-agency Mental Health Strategy
  Group-Employment Strategy Group

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2 Strands to the Project

• Job Retention
• Workplace assessment
• Meet with Employee and manager
• Short term assistance for mental health issues
• Referral on to specialist services.

• Support into Work
• Anyone who applies to Fife Council or NHS Fife.
• Application packs contain a flyer offering
  confidential service.
• FEAT offer support through application process
  and into employment

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Rehabilitation Consultants Role

• Workplace assessment.
• Meet with employee and manager to identify what
  changes might be made to assist the employee in
  returning to or remaining at work.
• Formulate a plan to overcome identified problems.

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Inclusion/ Exclusion Criteria

• Participants must
• Have work-related issues that are affecting their
  mental health or mental health issues affecting
  their work.
• Have reduced performance or increased sickness
  absence.
• Have worked for their organisation longer than
  six months, usually. If involved with the support
  into work strand this may indicate earlier
  inclusion.
• Have consented and be willing and able to
  co-operate with the rehabilitation consultant.

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Referral from OHSAS
Self Referral
Eligibility Screening
Participant Consent Obtained
Pre-intervention Assessement CORE, GHQ12,EQ-5D
Pre-intervention Assessment COPM
Allocation to Rehabilitation Consultant Assessment
and workplace visit
Action Plan agreed with client
Intervention as agreed in plan
Post-Intervention Assessement
Clients/Managers Perceptions
Objectively derived data
Post Intervention Assessment (OT)
Exit
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Structure of the model

• Aim of the project is to develop and evaluate a
  model which can be rolled out across Scotland.
• Need for a structured approach which allows the
  model to be accepted and applied to the context
  of other areas.

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3 models- Kortman

• Professional Model- a wide description of role
  and practice across many client groups and
  situations.
• Delineation- The favoured approach to be used
  with a particular client or group.
• Application- Specific intervention techniques
  used during client contact.
• Kortman B (1995)The Eye of the Beholder, Models
  in Occupational Therapy. British Journal of
  Occupational Therapy.58, 532-536

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Model of preference- Professional Model

• Model of Human Occupation- Considers the
  individual in terms of Motivation, Roles and
  Habits, Skills and the environment the individual
  moves in.

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Model of Preference- Delineation

• Approach Specific to the clients needs e.g.
• Cognitive approach
• Behavioural approach
• Rehabilitative approach
• Symptom management

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Application

• The specific activities and techniques used in
  the intervention e.g.
• Relapse prevention plans.
• Target setting.
• Support in positively reframing client situation.

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Job Retention Pilot Intervention

• Personal contact with the employee and manager.
• Workplace assessment.
• Formulate an action plan.
• Liaison with employee and manager.
• Short term interventions and referral on

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The Model. Schematic
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Learning.
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Referrals

• The majority of referrals are for individuals
  with Anxiety and depression.
• The demand for assistance with job retention
  issues appears to outweigh supply.
• People presenting with major mental illnesses
  usually require a more rehabilitative approach.

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Each Case a Minimum of 4 People

• The index client.
• The manager.
• The HR officer.
• The OH physician or nurse.
• Other (e.g.CPN)

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The Index Client

• Each case is unique and the rehab agent should
  consider the following
• The mental health problem the client is
  presenting with.
• The clients personality.
• The clients motivation, roles and habits and
  skills associated with their worker role.

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The Manager is Key

• Their sensitivity to mental health issues.
• Their specialist knowledge of the job e.g. what
  might be a reasonable adjustment.
• Their power to implement a plan.
• Their knowledge of the client.
• The possibility of their being a contributing
  factor in the clients difficulties.

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HR, OH and Other Agents.

• HR are remote from the process of the
  intervention but are central to the case in terms
  of attendance management and organisational
  policy.
• OH may have continued contact with the client and
  require some level of communication.
• Existing services already giving support should
  be factored into planning as they may be doing
  work pertinent to the return to work programme.

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The Job Task Components

• Physical
• Cognitive
• Social
• Emotional
• Environmental

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Case Study

• Mrs CStudie
• 44 yrs old
• Class and Admin assistant
• 3 year history of Anxiety, including panic
• Still attending work but performance much
  diminished.
• Supportive manager has accommodated difficulties
  but needs action taken

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Worker Role Interview

• Showed clients level of motivation supported a
  return to her role
• Continued reporting for work carrying out reduced
  duties had maintained her work routines
• Client was able to engage with the children in
  her care on a one to one basis
• Client perceived her work environment as
  supportive.

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Job site visit

• Although client continued to attend work she was
  not fulfilling her role, concerns within the
  organisation that this was unsustainable.
• Manager was sensitive to mental health issues,
  had made adjustments already and was keen to see
  a return to full capacity

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Job Task Analysis

• Used Valpar Profile Analysis Guide to describe
  the level of demands in a variety of component
  areas e.g. temperaments, aptitudes, educational
  development
• Identified what tasks had been lost and level of
  perceived difficulty in re-engagement.

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Meeting with both Manager and Client

• Facilitated communication between the two parties
• Agreed the plan together- identified tasks not
  being carried out, in order of ease and set time
  scales and targets to re-introduce these.
• Agreed need for specialist help and time to
  utilise this to ensure maintenance of progress in
  future.
• Agreed Review date.

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Result

• Client returned to almost full working capacity
  by review date. Discharged at this point.

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Case Study

• Anne Awnimuss
• 35 years old
• Technical Officer, Science Department
• 15 year history of Schizophrenia
• 11 month sickness absence
• Fractured relationships within department

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Worker Role Interview

• Showed client had a strong identification with
  her worker role and specialised skills.
• Illustrated an absence of routines in work role
  and during period of sickness absence.
• High lighted symptoms of the illness impacting on
  ability to fulfill role.

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Job Site Visit and meeting with manager

• Reinforced that client was considered to have
  specialist skills valuable to the organisation.
• Changes had occurred during clients absence
  introducing increased level of IT equipment
• Organisation willing to accommodate issues around
  symptoms and medication.

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Plan included

• Phased return over 6 week period.
• Hours altered to accommodate hours of daylight
  throughout the seasons.
• Break times organised to accommodate onset of
  drowsiness caused by medication.
• Client provided with work space to minimise
  contact with IT equipment.

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Result

• Client did not cope well with the early stages of
  the phased return.
• Client resigned but this was declined by the
  organisation. Resigned whilst ill.
• Same plan implemented at a lower key site.
• Client resigned.

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Some Unsolicited Comments

• advice was helpful and we put several things in
  place to change his routine. The transformation
  in him has been quite remarkable.- Gs manager.
• .it has been very stressful for me but I have
  been able to make decisions where needed. A (a
  client)

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Evaluation Overview

• Pre and post intervention assessments conducted
  independently of intervention.
• Range of measures covering
• Occupational performance and satisfaction
• Psychological distress
• Quality of life and general functioning
• Client and managers perspectives

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Evaluation Overview Pre Post Intervention
Measures

• Non-standardised measures
• Clients Perception Questionnaire
• Managers perception Questionnaire
• Standardised measures
• Canadian Occupational Performance Measure
• CORE
• GHQ-12
• European Quality of Life 5D

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Interim Findings Group overview

• Subgroup of 11 completed cases.
• Analysis of pre and post-intervention scoring on
  standardised measures using non-parametric
  statistics (Wilcoxen Signed Ranks tests).
• Demographic Information
• Gender 6 males and 5 females
• Age mean 42.09, range 28 to 56

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Interim Findings Employment Status

• Pre-intervention employment status
• Absent from work and receiving sick pay 8
• Absent from work no sick pay 1
• Length of absence mean26.2 weeks (range 1-72
  weeks)
• At work performing restricted duties 2
• Post-intervention employment status
• All 11 individuals were at work at the point of
  discharge (some restricted duties).

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Interim Findings- Occupational Group
Council Total9 NHS Total2
Local office network 2 Nursing -1
Comm leisure services 2 Estates -1
Education 3
Childcare strategy 1
Finance -1
Development services-1
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Interim Findings Diagnostic group
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The Canadian Occupational Performance Measure
(COPM)Law et al (2000)

• Designed for use by Occupational Therapists to
  detect self-perceived change in occupational
  performance problems over time.
• Performance and satisfaction scores based on
  ratings for 5 individually relevant occupational
  performance problems.

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COPM findings Performance scores

• This difference was statistically significant
• (T(11)0, plt.01)

N Group Mean Std Dev
Pre 11 3.19 1.30
Post 11 6.69 1.96
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COPM findings Satisfaction scores

• This difference was statistically significant
• (T(11)0, plt.05)

N Group mean Std Dev
Pre 11 3.18 1.79
Post 11 5.92 2.81
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Evaluation Overview

• Pre and post intervention assessments conducted
  independently of intervention.
• Range of measures covering
• Occupational performance and satisfaction
• Psychological distress
• Quality of life and general functioning
• Client and managers perspectives

45
Evaluation Overview Pre Post Intervention
Measures

• Non-standardised measures
• Clients Perception Questionnaire
• Managers perception Questionnaire
• Standardised measures
• Canadian Occupational Performance Measure
• CORE
• GHQ-12
• European Quality of Life 5D

46
Interim Findings Group overview

• Subgroup of 11 completed cases.
• Analysis of pre and post-intervention scoring on
  standardised measures using non-parametric
  statistics (Wilcoxen Signed Ranks tests).
• Demographic Information
• Gender 6 males and 5 females
• Age mean 42.09, range 28 to 56

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Interim Findings Employment Status

• Pre-intervention employment status
• Absent from work and receiving sick pay 8
• Absent from work no sick pay 1
• Length of absence mean26.2 weeks (range 1-72
  weeks)
• At work performing restricted duties 2
• Post-intervention employment status
• All 11 individuals were at work at the point of
  discharge (some restricted duties).

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Interim Findings- Occupational Group
Council Total9 NHS Total2
Local office network 2 Nursing -1
Comm leisure services 2 Estates -1
Education 3
Childcare strategy 1
Finance -1
Development services-1
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Interim Findings Diagnostic group
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The Canadian Occupational Performance Measure
(COPM)Law et al (2000)

• Designed for use by Occupational Therapists to
  detect self-perceived change in occupational
  performance problems over time.
• Performance and satisfaction scores based on
  ratings for 5 individually relevant occupational
  performance problems.

51
COPM findings Performance scores

• This difference was statistically significant
• (T(11)0, plt.01)

N Group Mean Std Dev
Pre 11 3.19 1.30
Post 11 6.69 1.96
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COPM findings Satisfaction scores

• This difference was statistically significant
• (T(11)0, plt.05)

N Group mean Std Dev
Pre 11 3.18 1.79
Post 11 5.92 2.81
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General Health Questionnaire GHQ-12 (Goldberg,
1992)

• Well-established measure of psychological
  distress.
• Change in scores from pre to post intervention
  highly statistically significant (T(11)0, plt.01).

N Group mean Std Dev
Pre 11 19.82 10.55
Post 11 9.82 8.99
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CORE Outcome Measure (CORE System Group)

• Provides a measure of global distress in addition
  to subscales
• Subjective well-being
• Problems/symptoms
• Life/social functioning
• Risk to self and others

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CORE Outcome Measure Interim Findings

• Significant change in scores from pre to post
• Global Distress (T(11)0, plt.01)
• Problems/Symptoms (T(11)0, plt.005)
• Risk (T(11)0, plt.05)
• No significant change pre to post at this stage
• Well-being
• Life/social functioning

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European Quality of Life 5D Scale (EuroQuol
Group, 1990)

• Respondents indicate presence and degree of
  problems in
• Mobility
• Self-care
• Activities
• Pain
• Anxiety/Depression
• Make an overall rating of current quality of life
  using a visual-analogue scale.

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EQ-5D Interim Findings 1

• Group not characterised by physical health
  problems - pre intervention ratings for problems
  with mobility, self-care, activities and pain
  were therefore largely absent and no significant
  change was present in these scores pre to post.

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EQ 5D Interim Findings 2

• Ratings of problems with anxiety/depression
• This change achieved statistical significance
  (T(11)4.5, plt.05)

N Group Mean Std Dev
Pre 11 1.27 0.79
Post 11 0.55 0.52
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EQ 5D Interim Findings 3

• Ratings of current overall quality of life
• This change from pre to post-intervention
  achieved statistical significance (T(10)1,
  plt.01).

N Group Mean Std Dev
Pre 10 45.70 27.16
Post 11 73.91 20.57
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Summary of Interim Findings

• Small subgroup of completed cases N11
• Statistically significant changes on a range of
  relevant standardised measures of
• Occupational performance and satisfaction
• Psychological distress, problems and symptoms
• Quality of life
• Effect sizes substantial
• Aim to establish whether findings are replicated
  in larger group
• Caveat post intervention completers