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