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Effectiveness of Individual Placement and Support: Research Update

Effectiveness of Individual Placement and Support: Research Update. Gary R. Bond Dartmouth Psychiatric Research Center Troutdale, OR July 27, 2011. Presentation Outline. Theory Model description Effectiveness Cost-effectiveness Program fidelity and dissemination. Theory.

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Effectiveness of Individual Placement and Support: Research Update

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  1. Effectiveness of Individual Placement and Support: Research Update Gary R. Bond Dartmouth Psychiatric Research Center Troutdale, OR July 27, 2011

  2. Presentation Outline • Theory • Model description • Effectiveness • Cost-effectiveness • Program fidelity and dissemination

  3. Theory

  4. 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

  5. IPS:Assumption 1 • Most people with severe mental illness want to work in regular community jobs

  6. The Primary Goal in Work Arena:Competitive (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

  7. 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 • >2/3 of clients live in poverty – employment may be a way out

  8. IPS:Assumption 2 • No reason to screening for job readiness, because measures used to screen do not predict employability

  9. IPS:Assumption 3 • Employment helps people manage symptoms and control substance use, not the other way around

  10. IPS:Assumption 4 • Employment services are most effective when integrated with mental health treatment

  11. IPS:Assumption 5 • Stepwise programs (skills training, transitional employment, sheltered jobs, etc.) create dependency and lead to high dropout rates

  12. IPS:Assumption 6 • Client job preferences are the key to individualized job searches, not job market

  13. IPS:Assumption 7 • Ongoing support after job placement is crucial to successful job tenure

  14. 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 Traditional  IPS Supported Assumptions Employment

  15. Model Description Individual Placement and Support (IPS) Model of Supported Employment

  16. History

  17. IPS:8 Evidence-Based Principles • Open to anyone who wants to work • Focus on competitive employment • Rapid job search • Systematic job development

  18. IPS:8 Evidence-Based Principles (Continued) • Client preferences guide decisions • Individualized long-term supports • Integrated with treatment • Benefits counseling provided

  19. Effectiveness

  20. IPS Has… Strong and Consistent Evidence of Effectiveness in Increasing Competitive Employment Outcomes

  21. 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)

  22. Four Measurement Domains of Employment Outcomes • Job acquisition (% employed) • Job duration (weeks worked) • Job intensity (hours worked per week) • Productivity (earnings)

  23. 18-Month Competitive Employment Outcomes in 4 Controlled Trials of IPS (Bond, Drake & Campbell, submitted)

  24. 18-Month Competitive Employment Outcomes in 4 Controlled Trials of IPS (Bond, Drake & Campbell, submitted)

  25. 18-Month Competitive Employment Outcomes in 4 Controlled Trials of IPS (Bond, Drake & Campbell, submitted)

  26. Competitive Employment in 2-Year Follow-up of IPS After 1st Job (Bond & Kukla, 2011)

  27. Steady Worker Concept Suggested Criterion: Work at least half the weeks during any time period

  28. 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

  29. 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

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

  31. IPS Has… Favorable “Side Effects”

  32. Is Work Too Stressful? • As compared to what? • Joe Marrone: If you think work is stressful, try unemployment

  33. 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)

  34. 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

  35. IPS Has… Positive Long-Term Outcomes

  36. 2 Long-Term IPS Follow-up Studies (Salyers 2004; Becker, 2007)

  37. IPS Is… Adaptable to a Wide Variety of Communities and Populations

  38. 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

  39. Outcomes in 87 Urban & Rural IPS Programs (Haslett, 2011)

  40. 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?

  41. Cost-Effectiveness

  42. 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

  43. Impact of Mental Illness on Social Security (SSDI and SSI) • People with mental illness: • Comprise > 33% of disability roles • Fastest growing disability group • < .5% leave the roles in any year • Cost to US taxpayers: $2 billion per month

  44. Cost Savings: $5000/Year (Bush, 2009)

  45. 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)

  46. Program Fidelity

  47. 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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