1. Updated 2/12/14 by Gary Bond Evidence for the Effectiveness of Individual Placement and Support Model of Supported Employment

2. Presentation Outline  Role of work in recovery  Core principles of Individual Placement and Support (IPS)  Evidence for effectiveness  Implementation strategies

3. Why Focus on Work?  Most clients want to work!  Most clients see work as an essential part of recovery  Being productive = Basic human need  In most societies, typical adult role  Most clients live in poverty  Working may prevent entry into disability system

4. Most Clients Want Jobs in 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

5. Expressed Interest in Employment Reported in 8 Surveys

6. The Gap Between Need and Access  2/3 want to work  1%-2% have access to evidence- based employment services (SAMHSA, 2009; Brown, 2012, Twamley, 2013)  15% employed at any time (Lindamer, 2003; Pandiani, 2012; Perkins, 2002; Rosenheck 2006; Salkever, 2007)

7. Core Principles of the Individual Placement and Support (IPS) Model

8. Traditional  IPS Assumptions Assumptions

9. IPS Principles 1.Open to anyone who wants to work 2.Focus on competitive employment 3.Rapid job search 4.Systematic job development 5.Client preferences guide decisions 6.Individualized long-term supports 7.Integrated with treatment 8.Benefits counseling included

10. Research Evidence for Effectiveness

11. 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

13. Cumulative Employment Rates for 6 Sites Converting to IPS vs. 4 Control Sites

14. Similar Results in All Day Treatment Conversions  Large increase in employment rates  No negative outcomes (e.g., relapses)  Clients, families, staff liked change  Overall, all former day treatment clients got out into community more  Resulted in cost savings

15. 20 Randomized Controlled Trials (RCTs) of Individual Placement and Support (IPS)  Best evidence available on effectiveness  RCTs are gold standard in medical research: Random assignment = Participants assigned by a flip of a coin

17. Competitive Employment Rates in 20 Randomized Controlled Trials of Individual Placement and Support

18. Overall Findings for 20 RCTs  All 20 studies showed a significant advantage for IPS  Mean competitive employment rates for the 20 studies: –57% for IPS (Median = 60%) –24% for controls (Median = 26%) (Each study weighted equally in calculating mean rates)

19. Four Measurement Domains of Employment Outcomes  Job acquisition (% employed)  Job duration (weeks worked)  Hours worked per week  Total hours worked/earnings (Bond,Campbell, & Drake, 2012 )

20. 18-Month Competitive Employment Outcomes in 4 Controlled Trials of IPS (Bond, Campbell, & Drake, 2012)

21. Competitive Employment Duration 2-Year Follow-up After IPS Job Start (Bond & Kukla, 2011)

22. IPS for SSDI Beneficiaries Mental Health Treatment Study (MHTS) (Drake et al. submitted)  Large multi-site controlled trial  Recruited SSDI beneficiaries with mental illness –Most were not receiving community mental health services –Unemployed at baseline

23. MHTS Design  Study population: Cold calls to SSDI beneficiaries on SSA rolls  23 communities throughout US  Randomized controlled trial –Intervention group: IPS + other mental health services –Control group: Usual services  Two-year follow-up

24. MHTS Sample  14% of nearly 16,000 beneficiaries contacted agreed to participate  Final sample: 2,055 Intervention: 1,004 Control: 1,051

25. Monthly Paid Employment Rates in MHTS Overall Employment Rates: Intervention: 61% Control: 40%

26. What About Long-Term Outcomes?  Many psychosocial interventions produce improvements in short-term outcomes  BUT improvements often disappear over the long term  True for IPS?

27. 2 Long-Term IPS Follow-up Studies (Salyers 2004; Becker, 2007) Clients also reported: Greater self- confidence and hopefulness, more energy, less loneliness and boredom

28. Conclusion: IPS Has… Strong Evidence for Effectiveness Across a Range of Employment Measures, Including Long-Term Outcomes

29. Impact of IPS on Recovery

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

31. Benefits of Steady Competitive Employment  Improved self esteem  Improved social networks  Increased quality of life  Reduced psychiatric symptoms  Reduced substance use  Less use of disability system Arns, 1993, 1995; Barreira, 2011; Bond, 2001; Burns, 2009;Drake, in press: Fabian, 1992; Krupa, 2012; Kukla, 2012; McHugo, 2012; Mueser, 1997; Van Dongen, 1996, 1998; Xie, 2005

32. Conclusion: Steady Employment Contributes to Long-Term Recovery

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

34. Fidelity  Fidelity defined as: the degree to which a service model is implemented as intended  Working hypothesis: Better implemented programs (with higher fidelity) have better outcomes

35. 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)

36. 8 Keys to Implementing IPS  End old ways of doing things (e.g., day programs)  Use fidelity reviews as guide  Exercise leadership: –Agency directors provide resources –Supervisors set firm behavioral expectations

37. 8 Keys to Implementing IPS (continued)  Hire and retain staff suited for IPS  Provide field mentoring  Collaborate closely with treatment teams  Track indicators you want to improve (Bond et al., 2008)

38. IPS Learning Collaborative (Becker et al., 2011)  Launched in 2002  Grown to 130 programs in 14 states  83% of programs joining since 2002 have been sustained

39. .

40. Features of IPS Learning Collaborative  Provide time-limited seed money  Create position of IPS state leader  State agency buy-in (MH and VR)  Start small, grow gradually  Commit to fidelity and outcome reporting  Nurture mechanisms for sharing of experiences

41. IPS Fidelity and Outcomes in 88 Sites in Learning Collaborative (Bond et al., 2012)

42. Conclusions  Employment is a key to recovery  IPS is an effective program to achieve this goal  Learning collaborative best way to implement IPS widely