Individual Placement and Support Pathways to Success

Gene Oulvey, Ph.D.Illinois Department of Human Services

Division of Rehabilitation Services

IATP State Conference 2019

Objectives of the session

Participants will be able to:

• Identify the core components and associated practices of evidence-based supported employment (IPS)

•Understand the proof that IPS is effective

• Understand how IPS promotes independence and access

Overview for the sleep deprived

•IPS is an effective evidence-based practice

•The long-term perspective is even better

•Implementation is critical

•What amplifies effectiveness: More people and more hours

Other Disability Populations

•The principles and practices that comprise IPS are familiar to Vocational Rehabilitation

•The research and practical experience that surrounds the IPS Model helps us focus on what is likely to be effective

•Bottom line: IPS is a good idea and may be a best alternative even where the evidence does not exist for an Evidence-Based Practice

IPS International

• Australia• Bulgaria• Canada• China (Hong Kong)• Denmark• Finland• Germany• Ireland• Italy

• Japan

• Netherlands

• New Zealand

• Norway

• Spain

• Sweden

• Switzerland

• United Kingdom

Randomized Controlled Trials (RCTs) of Supported Employment

•Strongest scientific design for evaluating whether a treatment works

•Studies include: • More than 30 conducted for IPS across four continents•At least 25 used full implementation of IPS

Competitive Employment Rates: IPS Studies

Overall Findings for 23 RCTs

All 23 studies showed a significant advantage for IPS

Mean competitive employment rates for the 23 studies:

55% for IPS

23% for controls

(Each study weighted equally in calculating mean rates)

Impact of Competitive Employment on Nonvocational Outcomes

•Domains with positive impact reported in multiple studies:•Self esteem – 100% (3/3 studies)•Symptoms – 57% (4/7 studies)•Life satisfaction – 33% (3/9 studies)

(Luciano, Bond, & Drake, 2014)

Clients also reported:

•Greater self-confidence and hopefulness

•More energy

•Less loneliness and boredom

Studies of Long-Term Outcomes

from Supported Employment

Test: 10 years

McHugo: 3.5 years

Bond: 3.5 years

Salyers: 10 years

Becker: 8-12 years

Drake: 10 years

Mean Tenure of Longest-Held Jobin Two IPS Studies

10-Year Follow-up of Day

Treatment to SE Conversion

92% worked during follow-up

47% currently working

33% worked at least 5 years

Many reported increases in hope, self-esteem,

relationships

(Salyers, 2004)

8-12 Year Follow-up of

SE

71% working at follow-up

Nearly all in competitive jobs– 7% sheltered, 10% volunteer

71% worked more than 50% of FU

But 90% still receiving benefits

(Becker, 2006)

Limitations of SE

One-fourth do not work

Most people do not work full-time

Most people stay on benefits

Explaining the variance

•25% the local economy

•25% the IPS fidelity score

•50% personal characteristics

(Becker, 2006)

Amplifying the Effects

– Existing and emerging technologies

(Smith, Lord, Do)

– Ethnic & racial minorities (DRS)

– Youth (Noel)

– Role of VR (Oulvey, Carpenter-Song)

– Cognitive training (McGurk)

– Medications (MATRICS)

Definition ofSupported Employment

•Mainstream job in community

•Pays at least minimum wage

•Work setting includes people who are not disabled

•Service agency provides ongoing support

•Intended for people with most severe disabilities

Evidence-Based Principles

•Eligibility is based on consumer choice

•Supported employment is integrated with treatment

•Competitive employment is the goal

•Personalized benefits planning is provided

•Job search starts soon after a consumer expresses

interest in working

•Follow-along supports are continuous

•Consumer preferences are important

•Build relationships with employers

IPS Is Effective in a Wide Variety of Target Populations

➢PTSD diagnosis➢Frequently hospitalized➢Mental illness + substance use➢Older adults➢Homeless➢Criminal justice history➢On disablilty benefits➢African American➢Hispanic

VA Study: PTSD

- RCT assigned groups to IPS (N = 42) or to traditional VR services (N = 43)- Tracked employment rate for 12 months- 76% of the IPS group sustained competitive employment vs. 28% of the VR group- The IPS group worked 42% of the eligible work weeks vs. 16% for the VR group- The IPS group was 2.7 times more likely to secure competitive employment vs. the VR group- Current VA study including TBI to be published

(Davis, et al., 2012)

VA Study: Spinal Cord Injury

•RCT: Total N = 201; IPS sites N = 81, VR sites N = 76, No IPS sites N = 44

•Ages 18 – 65

•Benefits: 13% SSI, 59.9% SSDI, 57.4% VA

•The IPS group was 2.5 x more likely to obtain competitive employment than the VR group, 11.4 x more likely than No IPS sites

•Poor implementation at the VA sites

resulted in lower outcomes

(Ottomanelli, et al., 2012)

BIP: New Populations

•Adults and youth with developmental disabilities

• - Intellectual disabilities

• - Autism Spectrum

• - Physical developmental disabilities

•Cross-training in Customized Employment

• - Vocational assessment

• - Employer relationship development

BIP IPS Sites

• 4 Urban, 4 Suburban, 7 Rural

15 agencies

• African American community

• Hispanic and Latino community

• East Asian community

3 sites targeted minority populations

Diagnostic Groups across 15 Sites

Communities

• - Illinois Asian community

• - Illinois Latino community

• - Refugees, victims of torture

• - Rural communities

Transition-age youth

• - Teams focusing on Chicago Public School system

• - Teams focusing on suburban school systems

- Teams focusing on rural school systems

- Teams focusing on youth with mental illness

- Teams focusing on youth with developmental disabilities

-Teams focusing on youth with multiple disabilities (e.g., learning disabilities)

PRJ Article: Neuchterlein et al.

IPS effective for assisting youth with

severe mental illness to sustain

employment

Also effective for assisting youth to

complete schooling, including advanced

education

Evidence of recovery, long-term

studies

IPS Supported Employment for Clients with First-

episode Schizophrenia

0

20

40

60

80

100

Baseline 6 Months 12 Months 18 Months

% o

f E

mp

loy

me

nt

or

sc

ho

ol

IPS

SAU

Early Psychosis Study (Nuechterlein, 2005)

8 Follow-up Studies of Early Intervention Programs Providing IPS

Diversion from Disability Benefits

•Help Young Adults Avoid a life in Poverty

•Better for Our Country

•A promising area for cost savings is young adults who are experiencing early psychosis. If supported employment were available economist estimate the nation could save $368 million annually in

•Medicaid, Social Security and other state programs

Source: David Salkever Ph.d

What About Supported Education?

•Consumer choice always a primary consideration

•Education and training expand options

•SE program should help consumers enroll in community programs (GED classes, colleges, technical schools)

Technology

• - Virtual reality Job Interviewing Training

• - 9 X better outcomes vs. control group

• - Next: Virtual Reality soft skills development

•- Dartmouth Center for Supported Employment Technology

•- Identifor, WorkingWell, Dartmouth suite for administration of IPS programs

Enhancing IL Human Service System

• - IPS is the only evidenced-based Vocational Rehabilitation model. Predictive fidelity scale.

• - High success rate with diverse populations and high cost effectiveness has lead to great interest from other human service and allied systems.

• - Dept. of Corrections, Juvenile Justice, DCFS, Chicago Public Schools, Healthcare & Family Services, etc.

Do Client Characteristics Predict Success in Supported Employment?

•Co-occurring substance use does not lead to lower employment rates.•Consumers generally do better in supported employment than in alternative programs regardless of background characteristics such as: •gender, education, ethnicity, diagnosis, hospitalization history, cognitive functioning

Job Preferences Are Important

IPS Team:Recommended Structure

•Minimum of 2 full-time staff

•Staff devoted exclusively to SE

•Full-time leader/supervisor who also provides employment services

•Offices physically located in mental health center

IPS Team

•Individual caseloads, but help each other (with job leads, etc.)

•Caseloads of about 20 consumers or less is ideal

•Weekly team meetings + individual supervision

Employment Supervisor Duties

•Manages referrals

•Hires and supervises employment staff

•Ensures employment specialists are learning and using effective skills in:Engagement AssessmentJob development Job support

Collaboration With Vocational Rehabilitation

•VR counselor meets consumers at mental health agency

•VR counselor is part of the treatment team

•VR counselor conveys same message as the rest of team

Vocational Rehabilitation

-- VR has a corporate culture that values work-

first and assumes anyone is capable of

employment.

-- VR staff have job placement/development

skills & networks.

-- VR staff have expertise in multi-disability

work accommodations.

-- VR staff have access to an array of

resources.(Oulvey, Carpenter-Song, Swanson, 2013)

IPS section of VR

Casework Manual

⚫ 10 days from referral to IPS

⚫ Up to 14 days back dating if employed

at referral

⚫ Mandates VR liaison counselor meet

with the rest of the IPS team at least 1x

per month

⚫ Any LPHA can certify diagnosis

Competitive jobs are the goal

Employment specialists build relationships with employers based upon client job interests

Job Search Plan

•Explore jobs by visiting work sites: develop relationships

•Develop employment plan

•Revise assessment and employment plan based on consumer’s experiences

Individualized Job Search

•Base on consumer’s preferences, strengths, abilities, experiences, and deficits (e.g., substance use)

•Seek:•Permanent competitive jobs •Diverse jobs suiting individual consumers•Different settings

Job Endings

•Each job viewed as learning experience

•Job transitions are considered normal

•With a job loss, consumer and entire (IPS and treatment) team strategize for next step

Track Implementation

•Use 25-item SE Fidelity Scale to measure implementation of evidence-based practice

•Staff in supported employment program can see if they are on track

•Basis for giving objective feedback

Hartford Study: Stable and high fidelity over time after short start-up

IPS Fidelity

60

65

70

75

1 2 3 4 5 6 7

Number of Assessment

To

tal S

co

re

Capital Region

Costs: New Hampshire Dual

Diagnosis Study

N = 187, persons with psychotic

disorders & co-occurring substance

abuse disorders

ACT: Case management 3 yrs.,

naturalistic follow-up 13 years

Groups: No/low work group N = 136;

Steady increase group N = 51

Costs: New Hampshire study

Steady worker group declined significantly

in total costs relative to no work group

Average annual cost difference per

participant = $16,619

Average 10-year cost difference per

participant = $166,350

Findings similar for a clustered group of

participants who are alike on baseline

characteristics

Federal Funding Report 2011

⚫ VR with expanded role

⚫ Full implementation will require

changes in VR practices

⚫ Enhanced Medicaid support

⚫ http://aspe.hhs.gov/daltcp/reports/2010

/supempLR.pdf

⚫ http://aspe.hhs.gov/daltcp/reports/2011

/supempFR.pdf

⚫ Dartmouth PRC newsletter, Fall 2011

Leadership Roles•Provide necessary resources

•Seek buy-in from consumers, families, and practitioners

•Give recognition to staff and consumer for successes

•Rapp’s finding – Critical role of supervisor in program success

Make Time Commitment

•Typically, 6 - 12 months needed to develop skills, interest, and confidence for implementing evidence-based supported employment

Summary

•Programs following IPS supported employment principles have better outcomes

•Effective employment supervisors are key to good implementation

•Resource materials complement training and supervision

Information: books,

videos, research articlesIPS Center

http://www.ipsworks.org/