SUPPORTED EMPLOYMENTAS AN EVIDENCE-BASED PRACTICE

Presented by:

Rick DeGette, M.A., MFTricder_ricder@yahoo.com510-383-1678 cell

&Dan Chandler, Ph.D.dwchandl@yahoo.com

PART I: COMPETITIVE EMPLOYMENT

Why Focus on Employment?

• Work is the typical role for adults in our society and the source of much identity and self-esteem

• It is viewed by many consumers as an essential part of recovery

• Most consumers want to work (71%) but few do (15%)

Positive Results of Competitive Work

• Sense of meaning• Structures to the day and life• Normal adult role• Higher self-esteem• Better control of psychiatric symptoms• More satisfaction with finances and with

leisure• Enhanced social contact, relationships,

and community integration• Significantly reduced treatment costs

(Bond 2001; Becker, 2007; Drake 2009; Bond 2009)

Is Work Too Stressful?

Research shows stresses of work in Individual Placement and Support do not translate into higher rates of hospitalization or other problems of functioning

Joe Marrone, an employment trainer:

“If you think work is stressful, try unemployment.”

PART II: THE INDIVIDUAL PLACEMENT AND SUPPORT MODEL

Definition of Supported Employment

Mainstream job in community (not “protected”)

Pays at least minimum wage Work setting includes people who are not

disabled Service agency provides ongoing support Intended for people with most severe

disabilities

Evidence-Based Principles of Individual Placement and Support Model (IPS)

Eligibility is based on consumer choice Supported employment is integrated with

treatment Competitive employment is the goal Personalized benefits planning is provided Job search starts soon after a consumer

expresses interest in working Follow-along supports are continuous Consumer preferences are important

REVIEW: How Individual Placement and Support Differs from California Models

Quick entry into employment (average of about 4 months of job search until employed) (Bond 2008)

Minimum emphasis on “readiness” (many sources especially Bond 2007)

No preconditions, including substance use (though tailoring necessary, Cook 2007, Becker 2005)

Competitive rather than jobs “owned” by the agency or other protected settings (Bond 2007)

Integrated with treatment team rather than referral to a separate agency (Drake)

IPS is not Choose, Get, and Keep because of latter’s focus on prevocational career planning, which is less effective

• 2006 Choose Get Keep study: 22% competitive employment after two years (Rogers)

Individual Placement and Support Is Affordable

Costs average about $2,500 per person per year assuming a caseload of 18 per employment specialist (Lattimer 2004)

A 2008 study found per capita expenditures for “supported employment” in the state-federal vocational rehabilitation system to be less for clients with psychiatric disabilities

SECTION III: OUTCOMES

Randomized Controlled Studies

Only ACT has more randomized controlled studies showing effectiveness

Typical results in 9 studies: Average of 62% worked, range 25% to over 80% (Bond 2008)

Much better than control groups of other approaches (average of 37% more having employment in Individual Placement and Support condition) (Bond 2008)

Results from 13 Randomized Controlled Trials of SE

0%10%20%30%40%50%60%70%80%90%

96 NH (IPS)

94 NY(SE)

04 CA

(IPS)

04 IL

(IPS)

04 CT (IPS)

05 SC

(IPS)

05HK

(IPS)

99 DC (IPS)

95 IN (SE)

00 NY(SE)

05QUE(IPS)

97 CA (SE)

02 MD(IPS)

Supported Employment Control Control 2

Other Positive Findings Participating in supported employment does not worsen

clinical or social functioning--including hospitalization (Burns, 2008)

Long term results Salyers 2004: 47% of Individual Placement and Support clients

currently working 10 years later Becker 2007: 71% of Individual Placement and Support clients

currently working 10 years later Caveats: there are methodological weaknesses and not all

work in competitive settings

Head to Head with a Psychiatric Rehabilitation Model like the Village

Study looked at Thresholds, a Chicago psychiatric rehabilitation program very like The Village. A “menu approach” was compared to an Individual Placement and Support approach. (Bond 2007)

Competitive employment for Individual Placement and Support was 75% vs 37% for the diverse approach

In study, total with paid work was equal– indicating menu approach substitutes non-competitive for competitive employment.

SE Is Not a Panacea Job tenure averages 22 weeks for the first job (Bond 2008) Only 43% of persons work 20 or more hours a week (Bond 2008) Average weeks working in a year 10 – 17 (2.5 times controls)

(Bond 2008) SE has not been shown to reduce use of SSI (Drake 1998) Research rates of 60% reflect work over a 18 month or 24 month

period. Quarterly rates for high fidelity Individual Placement and Support programs range from 23% to 35%. (Drake 1998)

Many barriers to work are external: e.g., stigma and discrimination (Corrigan 2007), low wages, disincentives (Bond 2007) since income, housing, health insurance tied to disability (Cook 2006 ), “dire poverty” (Alverson 1998)

National EBP Project Findings

Compared to other evidence-based practices, IPS is easier to implement (next two slides) Achieve higher fidelity Achieve high fidelity faster

National EBP Project ImplementationSE Achieved Highest Fidelity (Bond 2008[2])

National EBP Project ImplementationHigh Fidelity in Six Months (Bond 2008[2])

SECTION IV IMPLEMENTATION

ELEMENTS OF INDIVIDUAL PLACEMENT AND SUPPORT SUCCESS THAT REFER TO PROGRAM, COUNTY, AND STATE LEVELS

TRAINING: Intensive, on-going, hands-on LEADERSHIP: Program, Agency, County, and State

levels STAFF ATTITUDES: Staff who believe in competitive

employment and have a high opinion of the abilities, talents, and spirit of their consumers

FUNDING: Continuing to fund non-evidence based vocational programs while implementing IPS

INDEPENDENT MEASUREMENT OF FIDELITY: Low fidelity programs are not effective. County and state can assess fidelity.

Getting to work!

Compatibility of SE & IPS Approaches

Supported Education1. A focus on main stream education

2. Readiness based on consumer choice,

3. Rapid enrollment into courses

4. Integration of mental health and supported education services,

5. Attention to consumer preference in course and degree choice

6. Individualized Ed supports

7. Personalized academic counseling

8. Implementation to a fidelity scale

IPS Employment1. A focus on competitive

employment,

2. Eligibility based on consumer choice,

3. Rapid job search,

4. Integration of mental health and employment services,

5. Attention to consumer preference in the job search,

6. Individualized job supports

7. Personalized benefits counseling

8. Implementation to a fidelity scale