Updated 2/12/14 by Gary Bond

Evidence for the Effectiveness of

Individual Placement and Support Model of

Supported Employment

Presentation Outline

Role of work in recovery Core principles of Individual

Placement and Support (IPS)Evidence for effectivenessImplementation strategies

Why Focus on Work?Most clients want to work!Most clients see work as an essential

part of recovery Being productive = Basic human needIn most societies, typical adult roleMost clients live in povertyWorking may prevent entry into

disability system

Most Clients Want Jobs in Competitive (Open) Employment

Regular community job Pays at least minimum wageNondisabled coworkersNot temporary or “make work”Job belongs to the client, not to

the mental health or rehabilitation agency

Expressed Interest in Employment

Reported in 8 Surveys

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)

Core Principles of the Individual Placement

and Support (IPS) Model

Traditional IPS Assumptions Assumptions

IPS Principles1. Open to anyone who wants to work2. Focus on competitive employment3. Rapid job search4. Systematic job development 5. Client preferences guide decisions6. Individualized long-term supports 7. Integrated with treatment8. Benefits counseling included

Research Evidencefor Effectiveness

6 Day Treatment Conversions to Supported Employment:

Common Study DesignDiscontinued day treatmentReassigned day treatment staff to new

positions Implemented new supported

employment programCompared to 3 sites not converting

Sources: Drake and Becker

Cumulative Employment Rates for 6 Sites Converting to IPS

vs. 4 Control Sites

Similar Results in All Day Treatment Conversions

Large increase in employment ratesNo negative outcomes (e.g., relapses)Clients, families, staff liked changeOverall, all former day treatment

clients got out into community more Resulted in cost savings

20 Randomized Controlled Trials (RCTs) of Individual Placement and Support (IPS)Best evidence available on

effectivenessRCTs are gold standard in medical

research:Random assignment = Participants

assigned by a flip of a coin

Competitive Employment Rates in 20 Randomized Controlled Trials of

Individual Placement and Support

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)

Four Measurement Domains of Employment OutcomesJob acquisition (% employed)Job duration (weeks worked)Hours worked per weekTotal hours worked/earnings

(Bond,Campbell, & Drake, 2012)

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

(Bond, Campbell, & Drake, 2012)

Competitive Employment Duration 2-Year Follow-up After IPS Job Start

(Bond & Kukla, 2011)

IPS for SSDI Beneficiaries

Mental Health Treatment Study (MHTS) (Drake et al. submitted)

Large multi-site controlled trialRecruited SSDI beneficiaries with mental illness

–Most were not receiving community mental health services

–Unemployed at baseline

MHTS DesignStudy 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 servicesTwo-year follow-up

MHTS Sample

14% of nearly 16,000 beneficiaries contacted agreed to participate

Final sample: 2,055 Intervention: 1,004Control: 1,051

Monthly Paid Employment Rates in MHTS

Overall Employment Rates: Intervention: 61% Control: 40%

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?

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

Conclusion: IPS Has…

Strong Evidence for Effectiveness Across a Range

of Employment Measures, Including Long-Term

Outcomes

Impact of IPS on Recovery

Is Work Too Stressful?

As compared to what?Joe Marrone: If you

think work is stressful, try unemployment

Benefits of Steady Competitive Employment

Improved self esteemImproved social networksIncreased quality of lifeReduced psychiatric symptomsReduced substance useLess 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

Conclusion:Steady Employment

Contributes to Long-Term Recovery

IPS ImplementationNational EBP Project

(McHugo, 2007)

IPS Learning Collaborative(Becker. 2011)

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

Implementation Factors in National EBP Project

After 2 years, 29 (55%) of 53 sites implemented at high fidelity–Training, staff attitudes, and

barriers not predictiveStrongly predictive:

–Leadership at all levels–Integration of new practices into

work flow(Torrey, Bond, et al., 2011)

8 Keys to Implementing IPSEnd old ways of doing things

(e.g., day programs)Use fidelity reviews as guideExercise leadership:

–Agency directors provide resources

–Supervisors set firm behavioral expectations

8 Keys to Implementing IPS(continued)

Hire and retain staff suited for IPSProvide field mentoringCollaborate closely with treatment

teamsTrack indicators you want to

improve(Bond et al., 2008)

IPS Learning Collaborative

(Becker et al., 2011)

Launched in 2002 Grown to 130 programs in 14 states83% of programs joining since 2002

have been sustained

..

Features of IPS Learning Collaborative

Provide time-limited seed moneyCreate position of IPS state leaderState agency buy-in (MH and VR)Start small, grow graduallyCommit to fidelity and outcome

reportingNurture mechanisms for sharing of

experiences

IPS Fidelity and Outcomes in 88 Sites in Learning Collaborative

(Bond et al., 2012)

Conclusions

Employment is a key to recovery

IPS is an effective program to achieve this goal

Learning collaborative best way to implement IPS widely