effectiveness of individual placement and support: research update gary r. bond dartmouth...
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Effectiveness of Individual Placement and Support:
Research Update
Gary R. BondGary R. BondDartmouth Psychiatric Research CenterDartmouth Psychiatric Research Center
USPRA ConferenceBoston, Massachusetts
June 15, 2011
Presentation OutlinePresentation Outline
Theory Model description Effectiveness Cost-effectiveness Program fidelity and
dissemination
Theory
Six Traditional AssumptionsSix 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:IPS:Assumption 1Assumption 1
Most people with severe mental illness want to work in regular community jobs
Why Focus on Why Focus on Competitive Employment?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:The Primary Goal in Work Arena:Competitive (Open) EmploymentCompetitive (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:IPS:Assumption 2Assumption 2
No reason to screening for job readiness, because measures assumed to predict employability are inaccurate
IPS:IPS:Assumption 3Assumption 3
Employment helps people manage symptoms and control substance use, not the other way around
IPS:IPS:Assumption 4Assumption 4
Employment services are most effective when integrated with mental health treatment
IPS:IPS:Assumption 5Assumption 5
Stepwise programs (skills training, sheltered jobs, etc.) create dependency and lead to high dropout rates
IPS:IPS:Assumption 6Assumption 6
Client job preferences are the key to individualized job searches, not job market
IPS:IPS:Assumption 7Assumption 7
Ongoing support after job placement is crucial to successful job tenure
Traditional Traditional IPS Supported IPS Supported Assumptions Employment Assumptions EmploymentScreen for readinessStabilize firstStepwise prepSeparate agenciesJob availabilityTime limit support
Zero exclusion
Focus on client goals
Rapid job search
Integrated services
Client choice
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:IPS:8 Evidence-Based Principles8 Evidence-Based Principles
Open to anyone who wants to work Focus on competitive employment Rapid job search Systematic job development
IPS:IPS:8 Evidence-Based Principles 8 Evidence-Based Principles
(Continued)(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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
96 NH
10 AL
07 IL
04 CT
08 HK
10 CA
08 AUST
06 SC
99 DC
08 CA
07 EUR
06 QUE
10 HOL
02 MD
IPS Control Control 2
18-Month Competitive Employment Outcomes in 4 Controlled Trials of IPS
IPS Control p d
N = 307 N = 374 Job acquisition 216 (70.4%) 91 (24.3%) <.001 0.96 Total weeks worked 20.5 5.2 <.001 0.79 Job tenure (weeks) 17.4 4.6 <.001 0.74 Total hours 417.0 105.8 <.001 0.62 Hours per week 13.3 5.4 <.001 0.64 Total wage $3,704 $1,001 <.001 0.51 Work 20 hrs/wk 128 (41.7%) 50 (13.4%) <.001 0.67 Days to first job 140.0 212 <.001 -0.58
(Bond, Drake & Campbell, in prep.)
Mean Competitive Employment Mean Competitive Employment Rates in 6 Day Treatment Programs Rates in 6 Day Treatment Programs
Converting to IPS Converting to IPS
13.4% 12.4%
37.5%
15.2%
0%5%
10%15%20%25%30%35%40%
Sites Converting toIPS (n = 317)
Control Sites (n = 184)
Percentage Employed
Before
After
IPS Has…
Favorable “Side Effects”
Is Work Too Stressful?Is Work Too Stressful?
As compared to what? Joe Marrone: If you
think work is stressful, try unemployment
Negative Effects of Unemployment Negative Effects of Unemployment in General Populationin 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 Associated Benefits of Competitive Employment for Competitive Employment for Clients with Mental Illness Clients with Mental Illness Increased incomeIncreased income Improved self esteemImproved self esteem Increased quality of lifeIncreased quality of life Reduced symptomsReduced symptoms
Sources: Arns, 1993, 1995; Bond, 2001; Fabian, 1989, 1992; Mueser, 1997; Mueser, 1997; Van Dongen, 1996, 1998
IPS Has…
Positive Long-Term Outcomes
2 Long-Term IPS Follow-up Studies 2 Long-Term IPS Follow-up Studies (Salyers 2004; Becker, 2007)(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 Where and with Whom Has IPS Been Successfully Implemented?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 Impact of Mental Illness on Social Security (SSDI and SSI)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
(Bush, 2009)
Figure 1. Cost Outpatient Services and Institution Days
8000
13000
18000
23000
28000
33000
38000
43000
48000
0 1 2 3 4 5 6 7 8 9 10
Years
Mea
n C
ost
Minimum Work
Steady Work
Cost Offset for IPSSupported 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 Dartmouth Approach to Fidelity AssessmentFidelity 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 Data Collection Procedures for EBP Fidelity ScalesEBP 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 forFormat forEBP Fidelity ItemsEBP Fidelity Items
Items rated on 5-point behaviorally-
anchored continuum:
1 = Not Implemented…
5 = Fully Implemented
IPS Fidelity ScaleIPS 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 IPS Fidelity Predicts Competitive Employment OutcomesCompetitive Employment Outcomes
Location # Sites Findings Reference
7 states 26 r = .51 (p < .01) Becker et al. (2006)
USA 32 r = .35 (p < .05) Becker & Bond (2010)
Indiana 20 r = -.07 (n.s.) McGrew (2005)
Indiana 17 r = .37 (p <.06) McGrew (2007)
Indiana 23 r = .39 (p < .05) McGrew (2008)
Maryland State-wide
Successful VR closures: IPS (60%), Non-IPS (36%)
Hepburn & Burns (2007)
Europe 6 Increased rate over usual services (p = .08)
Catty et al. (2008)
Massachusetts 21 Odds ratio = 1.24 (p < .03) Henry (2009)
USA 23 r = .50 (p< .05) Frey et al. (2011)
Vermont 10 r = .76 (p < .01) Becker et al. (2001)
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
2.8
4.24.5 4.44.6
1
2
3
4
5
Baseline 6 mo. 12 mo. 18 mo. 24 mo.
(n = 9) (n = 8) (n = 9) (n = 9) (n = 9)
SE
Fid
elit
y S
cale
Mea
n
Mental Health Treatment Study: Attainment of High IPS Fidelity
in 22 sites throughout US
Year 1 17/22 (77%)Year 2 19/22 (86%)Year 3 18/21 (86%)
IPS Learning Collaborative
(Becker, Drake, and Dartmouth Psychiatric Research Center)
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
Achievement of IPS Fidelity Achievement of IPS Fidelity in 88 Sites in Learning in 88 Sites in Learning
CollaborativeCollaborativeScore Range Fidelity Category N (%)
115-125 Exemplary Fidelity 8 (9%)
100-114 Good Fidelity 45 (51%)
74-99 Fair Fidelity 30 (34%)
73 and belowNot Supported Employment
5 (6%)
..
Average Percent of Clients Employed for All Sites
0
10
20
30
40
50
0–10 10–20 20–30 30–40 40–50 50–60 60–70
Percent of clients employed
Frequency
(si
tes)
75th percentile: 57%50th percentile: 45%25th percentile: 33%
Benchmarks for Quarterly Employment Rate (Becker et al. in press)
Factors Promoting Evolution of Factors Promoting Evolution of the IPS Modelthe 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…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