Gary R. Bond

Individual Placement and Support: An Evidence-Based Approach to Supported Employment

Employment is the highest priority for many people with severe mental illness and it is a central aspect of recovery. Over the past two decades, the Individual Placement and Support (IPS) model of supported employment has emerged as the prominent evidence-based approach to vocational rehabilitation. This comprehensive monograph synthesizes the research and experience on IPS supported employment: historical context, core principles, effectiveness, long-term outcomes, non-vocational outcomes, cost-effectiveness, generalizability, fidelity, implementation, policy, and future research. In tracing the evolution of IPS, readers are equipped with an elegant example of the transition from needs assessment, to model development, to testing, and to dissemination.

Predicting Employment in the Mental Health Treatment Study: Do Client Factors Matter?

For people with psychiatric disabilities, demographic characteristics and measures of clinical status are often used to allocate scarce employment services. This study examined a battery of potential client predictors of competitive employment, testing the hypothesis that evidence-based supported employment would mitigate the negative effects of poor work history, uncontrolled symptoms, substance abuse, and other client factors. In a secondary analysis of 2055 unemployed Social Security Disability Insurance beneficiaries with schizophrenia or affective disorders, we examined 20 baseline client factors as predictors of competitive employment. The analysis used logistic regression to identify significant client predictors and then examined interactions between significant predictors and receipt of evidence-based supported employment. Work history was a strong predictor of employment, and other client measures (fewer years on disability rolls, Hispanic ethnicity, and fewer physical health problems) were modestly predictive. Evidence-based supported employment mitigated negative client factors, including poor work history. Participants with a poor work history benefitted from supported employment even more than those with a recent work experience. Evidence-based supported employment helps people with serious mental illness, especially those with poor job histories, to obtain competitive employment. Factors commonly considered barriers to employment, such as diagnosis, substance use, hospitalization history, and misconceptions about disability benefits, often have little or no impact on competitive employment outcomes.

Economic, Labor, and Regulatory Moderators of the Effect of Individual Placement and Support Among People With Severe Mental Illness: A Systematic Review and Meta-analysis

As Individual Placement and Support (IPS) has become the international standard for vocational rehabilitation of adults with serious mental illness, researchers must consider the relationship between IPS and local environments. This meta-analysis used mixed-effects meta-regressions to assess the impact of site-level moderators on the likelihood that IPS recipients, compared with recipients of alternative vocational services, achieved competitive employment. Potential moderators included change in gross domestic product (GDP), local unemployment and unionization rates, and indices describing employment protection regulations, level of disability benefits compensation, and efforts to integrate people with disabilities into the workforce. Regulatory moderators represent facilitators and barriers to employment that may reinforce or detract from the effectiveness of IPS. Across 30 sites drawn from 21 randomized controlled trials in 12 countries (33% in the United States), IPS recipients were 2.31 (95% CI 1.99-2.69) times more likely to find competitive employment than recipients of alternative vocational rehabilitation services. The significant competitive-employment rate advantage of IPS over control services increased in the presence of weaker employment protection legislation and integration efforts, and less generous disability benefits. Policy makers should recognize and account for the fact that labor and disability regulations can create an arrangement of incentives that reduces the relative efficacy of supported employment.

Barriers to Employment for Transition-age Youth with Developmental and Psychiatric Disabilities

Youth with developmental and psychiatric disabilities encounter significant vocational challenges, even when they receive supported employment services. We examined the barriers to employment for 280 transition-age youth with disabilities enrolled in supported employment in eight community rehabilitation centers. Employment team members identified each youth’s top three barriers to employment using a 21-item checklist. Lack of work experience, transportation problems, and program engagement issues represented common barriers for both youth with developmental disabilities (53, 36, and 25%) and youth with psychiatric disabilities (20, 33, and 26%). Additional common barriers among youth with developmental disabilities included cognitive problems (32%) and lack of social skills (23%) and among youth with psychiatric disabilities included poor control of psychiatric symptoms (23%). Despite receiving evidence-based employment services, youth with disabilities encounter many barriers to employment. Awareness of typical barriers for transition-age youth, including those specific to different disability groups, may help employment programs anticipate challenges and develop strategies that avoid these barriers and their effects on employment opportunities.

Prevalence and Quality of Individual Placement and Support (IPS) Supported Employment in the United States

The individual placement and support (IPS) model of supported employment for people with serious mental illness is an evidence-based practice. Factors including a national learning community promoting IPS and enforcement of the Supreme Court’s Olmstead decision have spurred the growth of IPS nationwide. In this study we first evaluated the national prevalence and quality of IPS programs. We then evaluated the impact of learning community membership and Olmstead settlements on IPS program penetration and quality across the United States. We interviewed representatives from 48 state behavioral health agencies and 51 state vocational rehabilitation agencies. Survey questions examined the number of IPS programs in each state, the presence of an Olmstead settlement mandating employment services for people with serious mental illness, and the presence of three indicators of quality in IPS programs: collaboration between statexa0behavioral health and vocational rehabilitation agencies, regular, independent fidelity monitoring, and technical assistance and training for IPS programs. Respondents from 38 (75%) states, including 19 states in the IPS Learning Community and 19 outside the learning community, reported a total of 523 IPS programs nationwide (Mu2009=u200914, SDu2009=u200916). The state IPS program penetration rate (number of IPS programs per 1,000,000 people) ranged from 0.05 to 16.62 (Mu2009=u20093.61, SDu2009=u20093.62) among states with IPS. The penetration rate was similar for learning community and non-learning community states with IPS, but learning community states were much more likely than non-learning community states with IPS to report the presence of each of three quality indicators. Eleven states reported Olmstead or other settlements that positively impacted employment services for people with serious mental illness, but among the 38xa0states with IPS programs, Olmstead states did not differ from non-Olmstead states in IPS program penetration or on the quality indicators. Nationally, most states provide IPS programs, but the within-state penetration rate and quality of implementation vary widely. While learning community and non-learning community states with IPS do not differ in the prevalence of IPS programs, learning community states are much more likely to report key quality indicators, which may enhance these states’ potential for sustaining and expanding IPS. Olmstead settlements have not yet shown a direct impact on the penetration and quality of IPS, but as the Department of Justice continues to enforce the Supreme Court’s Olmstead decision, their significance may increase.

Barriers and Facilitators to Sustainment of an Evidence-Based Supported Employment Program

Large-scale initiatives to expand evidence-based practices are often poorly implemented and rarely endure. The purpose of this study was to identify the perceived barriers and facilitators to sustainment of an evidence-based supported employment program, Individual Placement and Support (IPS). Within a 2-year prospective study of sustainment among 129 IPS programs in 13 states participating in a national learning community, we interviewed IPS team leaders and coded their responses to semi-structured interviews using a conceptual framework adapted from another large-scale implementation study. Leaders in 122 agencies (95%) that sustained their IPS programs identified funding, prioritization, and workforce characteristics as both key facilitators and barriers. Additional key factors were lack of local community supports as a barrier and leadership and structured workflow as facilitators. Within the IPS learning community, team leaders attributed the sustainment of their program to funding, prioritization, workforce, agency leadership, and structured workflow. The actions of the learning community’s leadership, state governments, and local programs together may have contributed to the high sustainment rate.

Individual Placement and Support: Penetration and New Populations

Despite what appears to be enormous progress, administrative and financing barriers have impeded widespread adoption of IPS. The latest data from the Substance Abuse and Mental Health Services Administration in fact show that only 2% of adults with serious mental disorders in mental health centers in the U.S. receive IPS (Bruns et al. 2016). Compared with research showing that about 70% of the same group want competitive jobs, the 2% figure indicates minimal penetration (Drake et al. 2016). IPS has also spread in many high-income countries around the world, but to our knowledge penetration data are not available. The first four papers in this special section address dissemination, implementation, and sustainment of IPS services for adults with serious mental disorders. Annalee Johnson-Kwochka and colleagues report on a national survey of IPS prevalence and quality, showing widespread adoption (over 500 programs) and great variance across states. Using qualitative methods, Valerie Noel and colleagues describe the barriers and facilitators to sustaining IPS for local programs within the IPS learning community, confirming that leadership and financing are key factors. Gary Bond and colleagues report on the different strategies used by state mental health and vocational rehabilitation authorities, in the important context of participating in a national learning community. Mustafa Karakas and colleagues update efforts at the federal level to develop funding mechanisms to facilitate the spread of IPS services, with an emphasis on Medicaid waivers and options. Individual Placement and Support (IPS) began in rural New Hampshire in the early 1990s as an attempt to help people with serious mental disorders find and succeed in competitive employment by combining approaches from assertive community treatment and supported employment (Becker and Drake 1993). An initial quasi-experimental study (Drake et al. 1994), followed by a randomized controlled trial (Drake et al. 1996), validated the model. Over two decades since those initial studies, mental health and employment leaders have refined, studied, and disseminated IPS around the world (Bond et al. 2012; Drake et al. 2012; Mueser et al. 2016). Two dozen randomized controlled studies as well as many other qualitative and quantitative studies have helped not only to validate IPS as an evidence-based practice but also to define target populations, mechanisms, implementation procedures, outcomes, and costs. An international IPS Employment Center now provides education, training, outcome data management, technical assistance, and collaborative research through an extensive learning community, which was started at Dartmouth College by Johnson & Johnson philanthropy and now resides at the Rockville Institute of the Westat Corporation (http://www.ipsworks.org). This special section addresses two topics: the spread of IPS for adults with serious mental disorders in the U.S. and the movement to adopt IPS services for new populations.

Sustaining and Expanding Evidence-Based Supported Employment: The Role of State Leaders Participating in a Learning Community.

State leaders often promote implementation ofxa0evidence-based practices but have difficulty sustaining and expanding them over time. This paper examines the activities of leaders in 13 states that have successfully implemented, sustained, and expanded evidence-based supported employment, known as Individual Placement and Support (IPS), for 4 to 12 years. We interviewed state leaders from 13 states participating in a learning community regarding the composition of their leadership team, participation in the learning community, interagency collaboration, state policy alignment, financing, training, and monitoring of fidelity and outcome. To assess state-level performance in implementing, sustaining, and expanding IPS services, we obtained measures of sustainment, expansion, program fidelity, and employment in the subsequent year and compared them to a priori benchmarks. The majority of states (between 69u2009% and 77u2009%)xa0met benchmarks for sustainment, expansion, fidelity, and employment. States varied widely in specific actions to advance IPS, but all had established leadership teams, participated in the national learning community, and built an infrastructure supporting IPS. Leaders in 13 states participating in a learning community have adopted and maintained multiple strategies to sustain and expand evidence-based supported employment at a high level of fidelity with good employment outcomes.

Comparing predictors of employment in Individual Placement and Support: A longitudinal analysis

Individual Placement and Support (IPS) is an evidence-based model of supported employment for people with serious mental illness. We assessed the effects and relative contributions of predictors of employment among IPS recipients using measures of baseline client characteristics, local economic context, and IPS fidelity. A recent work history, less time on the Social Security rolls, greater cognitive functioning, and a lower local unemployment rate were associated with greater probability of employment. The ability of the model to discriminate between outcomes was limited, and substantial improvements in our understanding of IPS employment outcomes will require the study of novel client, environmental, and IPS implementation factors.