Individual Placement and Support and Homelessness Stacey Teegardin, MS, CRC IPS Program Trainer PATH Grant Coordinator

Individual Placement and Support (IPS) The acronym “IPS” indicates the evidence-based approach rather than generic supported employment services.

IPS Supported Employment Approach designed for persons with serious mental illness, but has expanded to many populations and programs internationally Multiple research studies demonstrate superior outcomes People who have access to IPS are two to three times more likely to obtain a job

Who Pays for What? The Department of Health Care Policy and Financing (HCPF) funds Medicaid services and programs. OBH funds indigent services and special programs. The Division of Vocational Rehabilitation (DVR) funds specific services and programs, e.g., Supported Employment. OBH also provides matching funds to DVR for Supported Employment through an Inter-agency Agreement. Grants (like WRKE, J&J, etc.) usually pay for specific services or aspects of programs, e.g., targeted populations, special expenses, or needed positions.

IPS as a Braided Funding Program DVR pays for Vocational Exploration, Job Development/ Placement, Job Seeking Skills Training, Personal Adjustment Training, Job Coaching, and Successful Closure for DVR eligible clients (up to the contract amount). Medicaid pays for Medicaid billable services, e.g., Supported Employment and Ongoing Support to Maintain Employment (for Medicaid eligible clients). Other funding sources, e.g., grants, might pay for computers, client services, State IPS Trainer, State personnel attendance at IPS meetings and trainings, etc. (for the duration of the grant). OBH pays for other program expenses not covered by other funding sources, e.g., job development without client present, (up to the contract amount).

Eight Principles of IPS 1: Zero Exclusion: Every interested person is eligible for IPS Anyone who wants to work is encouraged to consider how work might affect his or her life, and not excluded based on diagnosis, symptoms, behaviors, or history. Colorado is now an Employment 1st State

Eight Principles of IPS 2: Job seekers obtain competitive jobs Jobs in the community paying at least minimum wage and not specified for people with disabilities

Eight Principles of IPS 3: Employment Services are Integrated with Mental Health Treatment Team Employment Specialists and mental health professionals meet weekly to provide job seekers with collaborative, professional support.

Eight Principles of IPS 4: Benefits and Work Incentives Planning is Offered Job seekers are connected with a trained benefits planner before going to work and during work to make sure they understand the implication of work on their benefits.

Eight Principles of IPS 5: The job search (community vocational exploration) occurs rapidly The employment specialist and/or job seeker meets with employers in the community within a month of joining the IPS program, rather than providing lengthy assessments.

Eight Principles of IPS 6. Employment specialists develop relationships with employers through multiple in-person visits to understand their business needs and employee preferences.

Eight Principles of IPS 7: Job supports are continuous Job supports are provided for as long as the person needs and wishes to receive IPS services. Typically about a year. Eventually, a mental health practitioner such as a case manager, or other natural supports, may be chosen to provide ongoing supports.

Eight Principles of IPS 8: Services are based on Interests, Preferences, and Choices Career profile; family; clinical team; job seeker interview… Preferences may be related to type of job, work hours, job location, etc.

Fidelity 25 Item Fidelity Scale Annual Reviews (Quality Improvement) Fidelity defined as: the degree to which a service model is implemented as intended Better implemented programs (with higher fidelity) have better outcomes

Colorado IPS Fidelity Review Scores for 2015 and 2016

Colorado IPS % Employment Rates 2017

Why IPS?

Most homeless people with mental illness: Want to work Face similar barriers as other people with mental illness Are capable of working Benefit from programs that follow IPS principles Need individualized help

…Want to work Canadian multi-city study (over 2000 homeless adults) Percentage who said they wanted to work ranged from Toronto: 64% Vancouver 82% (Poremski, 2015)

…face similar barriers Portland supported employment study of 319 homeless clients with mental illness 70% felony convictions 49% in substance abuse treatment (Herinckx, 2010)

…are capable of working if given appropriate help Portland supported employment study – 2 -year outcomes 71% gained employment 53% in full-time jobs (Herinckx, 2010)

…benefit from IPS 8 IPS principles apply well in working with homeless outreach programs Keys: Integrated of employment with housing services and treatment Outreach and engagement

Overall Findings for 23 Randomized Controlled Trials All 23 studies showed a significant advantage for IPS Mean competitive employment rates for the 23 studies: -55% for IPS -23% for controls Meta-analysis of 17 RCTs of IPS found a risk ratio of 2.40 (Modini, 2016)

18-Month Competitive Employment Outcomes in 4 Controlled Trials of IPS (Bond, Drake & Campbell, 2012)

Mean Job Tenure in Two IPS Studies Job tenure for IPS was triple that for usual services in Hoffman study.

Steady Worker Rate in 3 Long-Term Studies Hoffmann (2014): 5 year follow-up Salyers (2004): 10 year follow-up Becker (2007) 8-12 year follow-up

IPS Implementation National EBP Project IPS Learning Collaborative (McHugo, 2007) IPS Learning Collaborative (Becker. 2011)

Implementation Factors in National EBP Project After 2 years, 29 (55%) of 53 sites implemented at high fidelity Training, staff attitudes, and barriers not predictive Strongly predictive: Leadership at all levels Integration of new practices into work flow (Torrey, Bond, et al., 2011)

8 Keys to Implementing IPS End old ways of doing things (e.g., day programs) Use fidelity reviews as guide Agency directors provide resources Supervisors set firm behavioral expectations

8 Keys to Implementing IPS (continued) 5. Hire and retain staff suited for IPS 6. Provide field mentoring 7. Collaborate closely with treatment teams 8. Track indicators you want to improve (Bond et al., 2008)

Diversion from Disability Benefits Help Young Adults Avoid a life in Poverty Better for Our Country A promising area for cost savings is young adults who are experiencing early psychosis. If supported employment were available economist estimate the nation could save $368 million annually in Medicaid, Social Security and other state programs. Source: David Salkever, Ph.D

8 Follow-up Studies of Early Intervention Programs Providing IPS

Other Return on Investment for IPS Economy: Cost Savings  Each person with a SMI who becomes employed achieves an average savings in health costs of $5,000 per year (Bush et al. 2009) Mental Health Agencies and Economy: 5-Year Return on Investment for IPS and Traditional Voc Services (Hoffmann, 2014) (bar graph) Businesses: No formal studies yet, but employers have said they save by not having so much turnover, and support on the job helps retain employees and makes happier employees which helps with productivity.

A Greater Emphasis on Supported Education Most young adults have educational goals (e.g., complete high school, go to college) Lifetime earnings are associated with educational attainment. Attending school and/or working may help prevent or delay entry into the disability benefits system. The risks of dropping out of high school and college among young adults with early psychosis are high, suggesting the need for systematic help for these people.

Peers in IPS North Carolina—peer on every IPS team to augment what employment specialists do. Two agencies in Colorado are mirroring this so far and proving to be very successful. SAMHSA transforming lives 5 year grant includes peers on the teams of the new IPS states Alabama, Utah and Washington New York first-episode programs adding peer positions Some states focusing instead on hiring people lived experience to be employment specialists

Conclusions Employment is a key to recovery IPS is an effective program to achieve this goal Learning community best way to implement IPS widely

Questions???

Stacey Teegardin, MS, CRC Contact Information For more information about IPS supported employment, go to http://IPSWorks.org Stacey Teegardin, MS, CRC Individual Placement and Support (IPS) Trainer PATH Grant Coordinator P 303.866.7860 | stacey.teegardin@state.co.us