Implementation of supported employment for homeless veterans with psychiatric or addiction disorders: Two-Year outcomes
Experimental studies have robustly demonstrated the effectiveness of the Individualized Placement and Support (IPS) model of supported employment services for people with severe mental illness, and several studies of real-world implementation have shown significant cross-sectional correlations between employment success and fidelity to the IPS model. Experiences with IPS programs have stimulated broad efforts to disseminate evidence-based practices. Although multiple dissemination efforts are underway, analyses on the benefits of efforts to disseminate IPS have been on cross-sectional and site-level data, rather than on longitudinal information on individual clients. To implement IPS in health care systems with limited previous experience, sustained and individualized training programs may be needed to realize potential client benefits. Few studies have demonstrated that IPS, or other evidence-based practices for that matter, can both be implemented in a system that lacks prior experience with the model and yield outcomes for comparable cohorts that are superior, over several years, to those of a comparison group for which this intervention was not available.
This study examined a low-intensity training approach for implementing the individual placement and support (IPS) model at nine Department of Veterans Affairs (VA) programs and compared client outcomes before (phase 1) and after (phase 2) the program was implemented (phase 1).
The setting included 9 Veterans Administration Programs for Homeless Veterans.
A total of 308 veterans were recruited during phase 1, starting in January 2001, when IPS was still unavailable anywhere in the VA. An additional 321 veterans were recruited in phase 2, starting in July 2001, after the IPS employment specialist had been hired and trained, and were invited to participate in IPS for at least two years. Follow-up data collection continued through March 2005.
Participants in phase 1 were compared with participants in phase 2 on baseline characteristics by using chi square tests and t tests. All available participants were included in all analyses whether or not they were currently participating in IPS. Mixed models were then used to compare outcomes between the phases over the two-year follow-up period, controlling for baseline differences, using the MIXED procedure of SAS, with the alpha set at <.05.
Training began with a one-day, on-site, face-to-face orientation for both employment specialists and other VA mental health staff that was led by a social worker with experience training IPS specialists and conducting IPS fidelity ratings. For the duration of the project regular teleconferences continued providing weekly individual case reviews for the first three months, monthly individual case review conferences, and monthly conference calls with all nine employment specialists jointly. A review of ratings of model fidelity at six, 12, and 18 months after program implementation was also performed with a modified version of the IPS fidelity scale. Training was provided by a social worker with extensive experience disseminating the IPS model in other research projects. He was assisted by a VA occupational therapist with experience in supported employment. Monthly conference calls were also held with administrators responsible for program implementation at each site.
Phase 1 control group did not receive IPS services. Comparison was made with Phase 2 group who did receive IPS services.
Measures of both client-level service delivery and site-level fidelity to IPS suggest that implementation was successful at most, but not all, sites. Overall, compared with veterans in the phase 1 group, those in the phase 2 group had a better long-term work history at the time of program entry. When the analyses controlled for baseline differences, the mean number of competitive employment days per month over the two-year follow-up period was 15% higher for veterans in phase 2 (8.4 days compared with 7.3 days; p<.001) and the mean number of days housed during follow-up was also higher in phase 2 (34.1 days compared with 29.8 days; p=.04), but there were no differences for other outcome measures. (Psychiatric Services 58:325—333, 2007)
A sustained training program can be used to implement IPS in systems that have had little past experience with this approach. This effort was associated with improved employment outcomes and more rapid housing placement.
