Effectiveness of Individual Placement and Support: Research Update Gary R. Bond Dartmouth Psychiatric Research Center USPRA Conference Boston, Massachusetts June 15, 2011

Presentation Outline  Theory  Model description  Effectiveness  Cost-effectiveness  Program fidelity and dissemination

Theory

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 and counseling to prepare for job  Study job market to for possible placements  End assistance once job placement made

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

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

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

IPS: Assumption 2  No reason to screening for job readiness, because measures assumed to predict employability are inaccurate

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

IPS: Assumption 4  Employment services are most effective when integrated with mental health treatment

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

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

IPS: Assumption 7  Ongoing support after job placement is crucial to successful job tenure

Traditional  Assumptions Employment Screen for readiness IPS Supported Zero exclusion Stabilize first Focus on client goals Stepwise prep Rapid job search Separate agencies Integrated services Job availability Client choice Time limit support Ongoing support

Model Description

Individual Placement and Support (IPS) Model of Supported Employment

History 1980s Supported employment model developed in vocational rehab field 1993

A Working Life

(Becker & Drake) 1994 First IPS demonstration study published 1996 First IPS RCT published 1997 IPS fidelity scale published 2008 11 RCTs of high fidelity IPS published

IPS: 8 Evidence-Based Principles

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

IPS: 8 Evidence-Based Principles (Continued)

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

Effectiveness

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

Recognition of IPS as an Evidence-Based Practice  RWJ Conference of 1998  New Freedom Report (2003)  Cochrane Review (Crowther, 2000)  Schizophrenia PORT (2010)  Unanimous conclusion from every systematic review  No effective alternative models (Bond et al., 1999)

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)

Competitive Employment Rates in 14 Randomized Controlled Trials of High-Fidelity Individual Placement and Support

90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 96 NH 10 AL 07 IL 04 CT 08 HK 10 CA 08 AUST 06 SC 99 DC 08 CA 07 EUR IPS Control Control 2 06 QUE 10 HOL 02 MD

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

IPS Control p d

Job acquisition Total weeks worked Job tenure (weeks) Total hours Hours per week Total wage Work • 20 hrs/wk Days to first job

N = 307

216 (70.4%) 20.5

17.4

417.0

13.3

$3,704 128 (41.7%) 140.0

N = 374

91 (24.3%) 5.2

4.6

105.8

5.4

$1,001 50 (13.4%) 212 <.001

<.001

<.001

<.001

<.001

<.001

<.001

<.001

0.96

0.79

0.74

0.62

0.64

0.51

0.67

-0.58

(Bond, Drake & Campbell, in prep.)

Mean Competitive Employment Rates in 6 Day Treatment Programs Converting to IPS 37.5% 40% 35% 30% Percentage Employed 25% 20% 15% 10% 5% 0% 13.4% 12.4% 15.2% Before After Sites Converting to IPS (n = 317) Control Sites (n = 184)

IPS Has… Favorable “Side Effects”

Is Work Too Stressful?

 As compared to what?

 Joe Marrone: If you think work is stressful, try unemployment

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)

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

IPS Has… Positive Long-Term Outcomes

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

Steady Workers (> 50% Follow-up) 52% Length of Follow-up 10 years Sample Size 74

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

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

QuickTime™ and a decompressor are needed to see this picture.

Cost-Effectiveness

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

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?

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

Cost Savings: $5000/Year

Figure 1. Cost Outpatient Services and Institution Days

Minimum Work 48000 43000 38000 33000 28000 23000 18000 13000 8000 Steady Work 0 1 2 3 4 5 Years 6 7 8 9 10 ( Bush, 2009)

Cost Offset for IPS

Supported employment costs: ~$4000 per client per year  Clients who work have reduced mental health treatment costs  Universal access to supported employment could save Social Security at least $700 million/year (Latimer, 2004; Bush, 2009; Drake, 2009)

Program Fidelity

Fidelity

 Degree to which an intervention is delivered as intended 

Working hypothesis:

Better implemented programs (with higher fidelity to EBP) have better outcomes

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

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

Format for EBP Fidelity Items

 Items rated on 5-point behaviorally anchored continuum: 1 = Not Implemented… 5 = Fully Implemented

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)

IPS Fidelity Predicts Competitive Employment Outcomes

Location # Sites Findings Reference

Vermont 7 states USA Indiana Indiana Indiana Maryland Europe Massachusetts USA 10 r = .76

(

p

< .01) Becker et al. (2001) 26 32 20 r = .51

(

p

< .01) r = .35 (

p

< .05) r = -.07 (n.s.) Becker et al. (2006) Becker & Bond (2010) McGrew (2005) 17 r = .37 (

p

<.06

) McGrew (2007) 23 State wide 6 21 r = .39 (

p

< .05

) Successful VR closures: IPS (60%), Non-IPS (36%) Increased rate over usual services (

p

= .08

) Odds ratio = 1.24 (

p

< .03

) McGrew (2008) Hepburn & Burns (2007) Catty et al. (2008) Henry (2009) 23 r = .50 (p< .05) Frey et al. (2011)

IPS Is… Relatively Easy to Implement

IPS Implementation Projects

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

SE Fidelity in National EBP Project 5 2 1 4 3

2.8

4.2

Baseline (n = 9) 6 mo.

(n = 8)

4.6

4.5

4.4

12 mo.

(n = 9) 18 mo.

(n = 9) 24 mo.

(n = 9)

Mental Health Treatment Study: Attainment of High IPS Fidelity in 22 sites throughout US

Year 1 Year 2 Year 3 17/22 (77%) 19/22 (86%) 18/21 (86%)

IPS Learning Collaborative

 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 (Becker, Drake, and Dartmouth Psychiatric Research Center)

Achievement of IPS Fidelity in 88 Sites in Learning Collaborative

Score Range Fidelity Category

115-125 100-114

Exemplary Fidelity Good Fidelity

74-99 73 and below

Fair Fidelity Not Supported Employment N (%)

8 (9%) 45 (51%) 30 (34%) 5 (6%)

.

20 10 0 Benchmarks for Quarterly Employment Rate (Becker et al. in press) Average Percent of Clients Employed for All Sites 50 40 75th percentile: 57% 50th percentile: 45% 25th percentile: 33% 30 0–10 10–20 20–30 30–40 40–50 Percent of clients employed 50–60 60–70

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

Conclusions: IPS…  Is well defined  Is client-centered  Is consistent with societal goals   Is effective Has favorable “side effects”  Shows long-term outcomes  Has reasonable costs  Is easy to implement  Generalizes across populations and settings