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Effectiveness of Individual Placement and Support: Research Update. Gary R. Bond Dartmouth Psychiatric Research Center USPRA Conference Boston, Massachusetts June 15, 2011. Presentation Outline. Theory Model description Effectiveness Cost-effectiveness

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effectiveness of individual placement and support research update

Effectiveness of Individual Placement and Support: Research Update

Gary R. Bond

Dartmouth Psychiatric Research Center

USPRA Conference

Boston, Massachusetts

June 15, 2011

presentation outline
Presentation Outline
  • Theory
  • Model description
  • Effectiveness
  • Cost-effectiveness
  • Program fidelity and dissemination
six traditional assumptions
Six 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 assumption 1
IPS:Assumption 1
  • Most people with severe mental illness want to work in regular community jobs
why focus on competitive employment
Why Focus on 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 competitive open employment
The Primary Goal in Work Arena: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
ips assumption 2
IPS:Assumption 2
  • No reason to screening for job readiness, because measures assumed to predict employability are inaccurate
ips assumption 3
IPS:Assumption 3
  • Employment helps people manage symptoms and control substance use, not the other way around
ips assumption 4
IPS:Assumption 4
  • Employment services are most effective when integrated with mental health treatment
ips assumption 5
IPS:Assumption 5
  • Stepwise programs (skills training, sheltered jobs, etc.) create dependency and lead to high dropout rates
ips assumption 6
IPS:Assumption 6
  • Client job preferences are the key to individualized job searches, not job market
ips assumption 7
IPS:Assumption 7
  • Ongoing support after job placement is crucial to successful job tenure
traditional ips supported assumptions employment
Screen for readiness

Stabilize first

Stepwise prep

Separate agencies

Job availability

Time limit support

Zero exclusion

Focus on client goals

Rapid job search

Integrated services

Client choice

Ongoing support

Traditional  IPS Supported Assumptions Employment
model description
Model Description

Individual Placement and Support (IPS) Model of Supported Employment

ips 8 evidence based principles
IPS:8 Evidence-Based Principles
  • Open to anyone who wants to work
  • Focus on competitive employment
  • Rapid job search
  • Systematic job development
ips 8 evidence based principles continued
IPS:8 Evidence-Based Principles (Continued)
  • Client preferences guide decisions
  • Individualized long-term supports
  • Integrated with treatment
  • Benefits counseling provided
ips has
IPS Has…

Strong and Consistent Evidence of Effectiveness in Increasing Competitive Employment Outcomes

recognition of ips as an evidence based practice
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
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)


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

(Bond, Drake & Campbell, in prep.)

ips has1
IPS Has…


“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 in general population
Negative Effects of Unemployment in 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 competitive employment for clients with mental illness
Associated Benefits of Competitive Employment for Clients with Mental Illness
  • Increased income
  • Improved self esteem
  • Increased quality of life
  • Reduced symptoms

Sources: Arns, 1993, 1995; Bond, 2001; Fabian, 1989, 1992; Mueser, 1997; Van Dongen, 1996, 1998

ips has2
IPS Has…

Positive Long-Term Outcomes

ips is

Adaptable to a Wide Variety of Communities and Populations

where and with whom has ips been successfully implemented
Where and with Whom Has IPS 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
is ips cost effective
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
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 social security ssdi and ssi
Impact of Mental Illness on 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 offset for ips
Cost Offset for IPS

Supported 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)

  • 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 fidelity assessment
Dartmouth Approach to Fidelity 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 ebp fidelity scales
Data Collection Procedures for EBP 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 for ebp fidelity items
Format forEBP Fidelity Items
  • Items rated on 5-point behaviorally-anchored continuum:

1 = Not Implemented…

5 = Fully Implemented

ips fidelity scale
IPS 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 is1

Relatively Easy to Implement

ips implementation projects
IPS Implementation Projects
  • National EBP Project
  • Mental Health Treatment Study
  • IPS Learning Collaborative
ips learning collaborative becker drake and dartmouth psychiatric research center
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
factors promoting evolution of the ips model
Factors Promoting Evolution of the 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