Community Ment Health J DOI 10.1007/s10597-014-9694-y
ORIGINAL PAPER
Education and Employment Needs and Receipt of Services in Community and Inpatient Mental Health Settings Vahe Kehyayan • John P. Hirdes • Christopher Michael Perlman
Received: 16 January 2012 / Accepted: 10 January 2014 Springer Science+Business Media New York 2014
Abstract The interRAI Education and Employment Clinical Assessment Protocol (EdEmp CAP) identifies three groups of individuals in community and inpatient mental health settings: those who are at risk of losing their employment or disrupting their education; those who require support in employment or educational participation; or those for whom interventions related to education and employment are not triggered. The EdEmp CAP was effective in identifying subpopulations who were at risk, but who did not receive any vocational rehabilitation or counseling. The EdEmp CAP can be used in clinical practice to identify individuals who might benefit from specific interventions in these areas. Keywords planning
Assessment interRAI Mental health Care
Introduction Unemployment rates for persons with mental illness are very high (Lehman 1995; McCreadie 1992; Mood Disorders Society of Canada 2008). This may be related to a number of factors, including the disabling effects of mental illness or addiction, the stigma and discrimination associated with mental illness, and the lack of employment opportunities available to persons with mental illness V. Kehyayan (&) J. P. Hirdes C. M. Perlman School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1, Canada e-mail: [email protected] V. Kehyayan University of Calgary - Qatar, Doha, Qatar
(Stuart 2004). Unemployment in these individuals may also be associated with the lack of access to vocational rehabilitation, counseling services, supported employment, or other interventions targeted toward social and behavioural factors that may be associated with unemployment. Work, employment, engagement and meaningful roles are recognized as having therapeutic effects on the path to recovery for individuals with mental illness (Bond and Jones 2005; Morris and Lloyd 2004). Meaningful vocational activities, such as employment, participation in individual placement and support programs, or participation in education, have been associated with positive outcomes, including increased self-esteem, alleviated psychiatric symptoms, reduced dependency and avoidance of relapse (Crowther et al. 2001; Lehman 1995; Lehman et al. 2002; Mueser et al. 2004; Murphy et al. 2005). While the impact of vocational activities on positive outcomes is widely recognized, clinicians should employ an evidence-informed approach to identify the vocational needs of their clients, particularly those who are at risk of losing their employment or dropping out of school. There is also a relative lack of evidence-based intervention guidelines to help persons with mental illness find or keep their employment, or pursue their education or other meaningful roles. The objectives of this paper are: •
•
to identify individuals with mental illness in community and inpatient mental health settings who are at risk of losing their employment or disrupting their education, using the interRAI Education and Employment Clinical Assessment Protocol (EdEmp CAP); to identify persons with mental illness who are not employed or pursuing education, but who might benefit from interventions aimed at supporting their involvement in work or education;
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•
•
to describe the demographic, social, and clinical characteristics of these individuals, and the services they receive to address their vocational rehabilitation needs; and to highlight the benefits of using the EdEmp CAP to inform clinical decision making.
interRAI Mental Health Clinical Assessment Protocols interRAI (www.interRAI.org) is a not-for-profit 33-country research network that has developed an integrated suite of assessment instruments for use in several health sectors, including mental health, long-term care, home care, and acute care settings (Bernabei et al. 2009; Gray et al. 2009; Hirdes et al. 2008). This family of instruments includes the interRAI Mental Health (interRAI MH) for use in inpatient mental health settings and the interRAI Community Mental Health (interRAI CMH) for use in community mental health settings. These assessment instruments are intended to serve multiple applications for multiple audiences, including care planning, outcome measurement, case mix classification and quality monitoring (Hirdes et al. 1999). The clinical applications of these instruments are the Clinical Assessment Protocols (CAPs; Hirdes et al. 2011). The CAPs use standardized decision-support algorithms to trigger collaborative care planning in multiple domain areas (see, for example, Mathias et al. 2010). Prior versions of these CAPs have been validated against clinician ratings (Martin et al. 2009). More recently, interRAI’s Network of Excellence in Mental Health completed a multiyear refinement effort to update all CAPs for mental health, including a CAP related to education and employment. Education & Employment Clinical Assessment Protocol The interRAI’s EdEmp CAP was developed specifically to help clinicians identify and respond to the vocational needs of persons with mental illness. The EdEmp CAP focuses on a person’s functioning and quality of life with the aim of supporting their recovery from mental illness and optimal functioning. The EdEmp CAP offers outcome-based approaches that use reassessment over time to target support services and interventions to alleviate the effects of mental health symptoms, promote autonomy and psychosocial and physical wellbeing, enhance community engagement, and support participation in activities that are meaningful to the person. Based on responses to specific items in the interRAI MH and CMH assessment instruments, the EdEmp CAP identifies three groups or subpopulations of persons with mental illness. The first group, referred to as ‘‘Level 2’’ in the context of this paper, is comprised of individuals who are
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at risk of losing their employment or dropping out of school due to the presence of any one of the following indicators of risk: (1) an increase in lateness or absenteeism over the last 6 months; (2) poor productivity or disruptiveness at work/school; (3) an expressed intent to quit work/school; or (4) persistent unemployment or a fluctuating work history over the last 2 years. The goal of the EdEmp CAP for this group is to reduce the risk of unemployment or dropping out of school. The second group (Level 1) includes three subgroups of individuals: (1) persons of any age who are unemployed but seeking employment; (2) unemployed persons aged 16–65 years who are NOT seeking employment but could work given that they have minimal impairments in ADL and cognitive function, few indications of positive symptoms, full insight into their mental health condition, AND minimal indications of behaviour problems; and (3) persons aged 10–30 who have recently dropped out of or failed school. The goal of the EdEmp CAP for this group is to support employment, educational participation, or the assumption of meaningful roles among persons who are currently not employed. The third group of individuals includes (referred to as Level 0): (1) those who are employed or at school with no apparent risk of losing employment or dropping out of school; (2) those who have retired; and (3) those who are unemployed but are not seeking employment due to major mental health or disability issues.
Method Data Sources All data for this study were drawn from assessments completed with the two instruments noted above: (1) the interRAI Community Mental Health (interRAI CMH) for a sample of community based clients, and (2) the interRAI Mental Health (interRAI MH) for a sample of persons in inpatient mental health settings. Both of these instruments include items that can be combined into different summary scales (see Table 1). As well, items from either instrument can address social and behavioral characteristics (e.g., interpersonal conflict) as well as receipt of various interventions (e.g., Alcohol or drug treatment). These interRAI mental health assessment instruments are comprised of items that assess a person’s mental health history, mental state indicators, behaviour, cognition, functional status, health conditions, life events, medication, employment and education, capacity to manage finances, and service utilization, treatments, and interventions. Trained clinicians assess patients using all possible sources of information at time of admission, every 90 days thereafter
Community Ment Health J Table 1 interRAI mental health instruments, EdEmp CAP, and interRAI performance scales Instruments & scales
Purpose/function
interRAI MH
Comprehensive assessment instrument used in in-patient mental health settings
interRAI CMH
Comprehensive assessment instrument used in community mental health settings
EdEmp CAP
Clinical assessment protocol triggered from items on the interRAI MH and CMH to help clinicians develop individualized care plans for persons with mental illness to support their recovery through employment or education
CPS
Describes the person’s cognitive status using items found on both the interRAI MH and CMH; a summary scale
DRS
Describes the person’s mood status based on a summary of 7 items found on the interRAI MH and CMH; a summary scale
Positive symptoms scale
Describes the person’s psychotic symptoms such as hallucinations. Four items found on the interRAI MH and CMH are summed; an outcome measure
Negative symptoms scale
Describes the person’s negative symptoms, such as withdrawal based on items from the interRAI MH or CMH; an outcome measure
and upon discharge (Hirdes et al. 2002; Martin et al. 2009). These instruments provide clinicians with a comprehensive assessment of patients and their level of functioning, and they contain items to trigger care plan development and to support outcome measurement over time. Based on responses to specific items in these instruments, the EdEmp CAP is said to be ‘‘triggered’’ for the purpose of care planning. The trigger level is important to consider as each level is associated with specific care planning considerations (Hirdes et al. 2011). The CAP manual provides guidelines for clinicians to prepare an individualized care plan for the person to help address these areas of risk. Thus, as the EdEmp CAP identifies three distinct groups, the EdEmp CAP is said to be triggered for Levels 1 and 2 groups. It is not triggered for the Level 0 group because they may not be eligible for employment (e.g., due to retirement), they are functioning adequately in their work or school roles, or they have sufficient physical or mental health impairments that employment or formal educational opportunities may be beyond their functional ability. Two main groups are considered for intervention. The first includes those who currently have jobs or are going to school, but whose behavior places those activities in jeopardy. The CAP is triggered at Level 2 when the interRAI assessment indicates that s/he is at risk of losing their employment or dropping out of school due to the
presence of any of the following indicators of risk: (1) an increase in lateness or absenteeism over the last 6 months; (2) poor productivity or disruptiveness at work or school; (3) an expressed intent to quit work or school; or (4) persistent unemployment or fluctuating work history over the last 2 years (Hirdes et al. 2011). The second group targeted for intervention (Level 1) is comprised of persons who are not in the paid labour force or pursuing formal education, but who may have a reasonable chance of being engaged in that way with the right supports. This includes three types of persons: (1) those who do not have employment but describe themselves as looking for employment; (2) those who are unemployed and are NOT looking for employment but who likely possess the necessary physical and mental abilities to work if it were available; and (3) persons who recently failed or dropped out of school, who may be able to reconnect with the educational system given a short passage of time. Although these groups are somewhat heterogeneous in nature, the common focus of care planning is on supporting the person to find new opportunities to become engaged in work or education. The CAP provides informational guidelines for clinicians to consider in developing a collaborative care plan with persons in these different groups. The RAI MH (an earlier version of the interRAI MH) has been mandated in all adult inpatient mental health settings in Ontario, Canada since October 2005. It has also been adopted by the province of Newfoundland and Labrador and is being implemented by the sole standalone psychiatric hospital in Manitoba. Under this mandate, each patient is required to have a full assessment upon admission, every 90 days, and at discharge. Such comprehensive assessments support the identification of health care needs and person-centred care planning, and allow the monitoring of changes in residents’ health status and physical and cognitive functioning over time (Hirdes et al. 2000, 2002). The interRAI CMH (Hirdes et al. 2011) is used in community mental health settings and has about 60 % overlap in assessment items with the interRAI MH. The interRAI CMH also has unique specialized items like: employment arrangements (e.g., competitive or supported employment); volunteering; and enrolment in formal education programs. It has been piloted in several community mental health settings in Canada, Iceland, Finland and Hong Kong. The CMH has been adopted by the province of Newfoundland and Labrador as the provincial standard assessment for that sector, and two US states are in the process of adopting the instrument. The validity and reliability of these instruments have been well established (e.g., Hirdes et al. 2002, 2008; Jones et al. 2010; Neufeld et al. 2012). The interRAI assessment instruments include items needed for various scales and algorithms that may be used for outcomes measurement such as health, functioning, and
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mental health symptoms (Hirdes et al. 2011). For instance, the cognitive performance scale (CPS) measures cognitive performance with scores ranging from 0 to 6 and its items include daily decision-making, short-term memory, expression, and self-performance in eating. The depression rating scale (DRS) measures depressive symptoms with scores ranging from 0 to 14 (e.g., 3? is indicative of possible depression, 6? is indicative of more severe depression). The Positive Symptoms Scale-short (PSSshort) reflects psychotic symptoms with scores ranging from 0 to 12 and its items include hallucinations, command hallucinations, delusions, and abnormal thought processes. The RAI MH also includes items describing social withdrawal, often referred to as negative symptoms. Scored from 0 (indicator not exhibited in the last 3 days) to 3 (indicator observed daily in the last 3 days), these items include anhedonia, loss of interest, lack of motivation, and reduced interaction. When added together, these scales form a negative symptom scale (NSS) that ranges from 0 to 12, with higher scores indicating a greater number and frequency of observed negative symptoms. These scales have been tested for their reliability and validity (e.g., Burrows et al. 2000, 2002; Jones et al. 2010; Morris et al. 1994; Perlman et al. 2013). Table 1 provides a summary of each of the interRAI mental health assessment instruments, the EdEmp CAP, and outcome measurement scales. Sample The sample for this study included 1,015 individuals in community and 44,915 individuals in inpatient mental health settings. Data were provided through a data sharing agreement between the Canadian Institute for Health Information (CIHI) which serves as the repository of all data collected from interRAI instruments by Canadian provinces/territories including the RAI MH and interRAI CMH, and the researchers at the University of Waterloo. The inpatient data for this study were retrieved from the CIHI repository of patient/client assessments in inpatient mental health settings in Canada where the RAI MH instrument was used. The data from community mental health settings were collected as part of a Canadian pilot study of the interRAI CMH. The authors take full responsibility for the conduct of the study, the analysis and interpretation of the data, helping to write the manuscript, and approving its final copy. Analysis A descriptive analysis of the data in this study was conducted using Statistical Analysis Software (SAS) to compare the three groups of individuals. As well, crosstabulation was used to examine any associations with key
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variables of interest (e.g., diagnoses, negative and positive symptoms, depressive symptoms, cognitive performance) and the EdEmp CAP levels 0, 1, and 2). Ethics Clearance Ethics clearance for this research was obtained through the Office of Research at the University of Waterloo.
Results The sample in community mental health settings included 52.1 % males with a mean age of 47.3 (SD = 17.2), while in inpatient settings there were slightly fewer males (49.8 %), average age was slightly lower (mean = 45.6; SD = 16.9) and a higher proportion of patients under the age of 25 (12 %) compared to the community (10 %). In both settings, more males triggered Level 2 than females. The majority of persons in each sample had one or more psychiatric admissions. The EdEmp CAP Level 2 was triggered for about 17 % of individuals in the community and 23 % in inpatient settings. On the other hand, CAP Level 1 was triggered for 18 % of individuals in the community and 13 % of those in inpatient settings. Of those in the community who triggered Level 2, 25 % made trade-offs among necessities of living (such as purchasing adequate food, shelter, clothing, prescribed medications, sufficient home heat or cooling, or necessary health care) compared to 10.8 % of those in inpatient settings. As would be expected, Table 2 shows that the lowest percentage of persons over the age of 65 was evident among those who triggered the EdEmp CAP in both community and inpatient settings. In both settings, those who triggered both Level 1 and Level 2 were most likely to be in the 25–44 age category. In inpatient settings there were higher proportions of males in the triggered Level 2 compared to the non-triggered group (p \ 0.0001); however, this was not significant in the community setting. With respect to the mental health diagnoses, there were only moderate differences in the proportion with mood disorders or personality disorders in either setting. However, there was a substantially higher percentage of persons with a substance use disorder in each of the triggered levels compared with the non-triggered level. In addition, while there were no differences in the percentage with schizophrenia between the non-triggered and Level 1 triggered groups, there was a substantially lower percentage of persons at trigger Level 2 with schizophrenia. In both settings, a larger percentage of individuals in the triggered Level 2 had no prior lifetime psychiatric hospitalizations compared to either of Level 1 or Level 0. In contrast, a smaller percentage of those in Level 2 had 6 or more prior admissions compared to
Community Ment Health J Table 2 Characteristics of individuals with mental illness who trigger at each level of the education & employment CAP in community mental health and inpatient settings Characteristics
Community (N = 1,015) EdEmp CAP Level 2 (n = 174)a % (n)
% Triggered Mean age (SD) Mean age
17.0
Inpatient (N = 83,280) EdEmp CAP Level 1 (n = 218)a % (n) 18.0
EdEmp CAP Level 0 (n = 623)a % (n) 65.0
47.3 (17.2) 36.6
EdEmp CAP Level 2 (n = 18,993)a % (n) 23.0
EdEmp CAP Level 1 (n = 11,100)a % (n)
EdEmp CAP Level 0 (n = 53,187)a % (n)
13.0
64.0
35.2
50.6
45.6 (16.9) 38.7
53.3
37.7
Age Under 25
25.3 (44)
17.0 (37)
3.4 (21)
19.9 (3783)
29.2 (3238)
5.5 (2940)
25–44
47.1 (82)
50.5 (110)
31.8 (198)
49.9 (9483)
44.9 (4978)
34.6 (18424)
45–65
24.1 (42)
31.2 (68)
37.9 (236)
28.6 (5423)
24.5 (2720)
39.0 (20721)
3.5 (6)
1.4 (3)
27.0 (168)
1.6 (304)
1.5 (164)
20.9 (11102)
65? Sex (male)
52.1 %
49.8 %
Sex Male
59.8 (98)
49.8 (105)
50.8 (306)
57.0 (10834)
53.6 (5952)
46.5 (24712)
Female
40.2 (66)
50.2 (106)
49.2 (296)
42.9 (8154)
46.4 (5145)
53.5 (28463)
Made trade-offs Most important diagnosis
25.0
11.2
13.5
10.8
6.9
4.9
Schizophrenia
35.2 (58)
44.6 (94)
43.35 (244)
27.8 (5276)
34.6 (3838)
36.7 (19512)
Mood disorder
38.6 (66)
35.0 (76)
35.8 (202)
38.8 (7368)
40.2 (4467)
40.2 (21373)
3.7 (6)
2.4 (5)
1.5 (8)
1.5 (276)
2.5 (276)
1.2 (614)
11.6 (19)
1.4 (3)
2.8 (15)
22.4 (4261)
13.5 (1497)
8.2 (4334)
Personality disorder Substance-related disorder
Number of psychiatric admissions (lifetime)
a
None
35.7 (60)
19.50 (42)
15.2 (69)
34.1 (6473)
26.8 (2974)
25.0 (13280)
1–3
36.9 (62)
44.2 (95)
33.8 (153)
40.6 (7716)
36.8 (4080)
34.3 (18220)
4–5
10.1 (17)
15.4 (33)
16.1 (73)
12.3 (2326)
16.0 (1777)
15.6 (8308)
6?
17.3 (29)
20.9 (45)
34.8 (158)
13.1 (2478)
20.4 (2269)
25.2 (13379)
Not all of total frequencies in cells add up to column totals due to missing data
those in Levels 1 and 0. As shown in Table 3, having potential problems with addiction was more likely to be evident among those who trigger Level 2 in both community and inpatient settings. The majority of persons in both settings had no or only mild impairment in cognitive performance, but those in community settings were less likely to be cognitively intact compared with inpatient settings. For both settings, those who triggered the EdEmp CAP at either level are more likely to be cognitively ‘‘intact’’. On the other hand, the triggered Level 2 group is more likely to have DRS scores of 3 or more (suggesting potential depression) than the nontriggered group in the community. Conversely, they are less likely to have high scores in positive symptoms. Table 4 shows the association between individuals’ social and behavioural characteristics in relation to the EdEmp CAP. Interpersonal conflicts were more evident among those at Level 2, particularly in the community setting. In addition, evidence of disturbed or dysfunctional
family relationships was more likely to be present when the CAP was triggered in either Level 2 or Level 1 groups. Table 5 shows the receipt of services and mental health interventions by EdEmp CAP levels in community and inpatient settings. Although those in community settings are more likely to receive vocational rehabilitation than those in inpatient settings, the overwhelming majority of persons in both contexts do not receive such services even among those who trigger the CAP. The rates of psychosocial rehabilitation services are higher, but these are still only received by the minority of persons in either setting. Persons who trigger the EdEmp CAP in community settings are more likely to receive services and interventions aimed at managing symptoms (e.g., anger and behaviour management) compared with their inpatient counterparts. Those in the community who triggered this CAP were less likely to have received interventions aimed at social-family functioning than those in inpatient settings.
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Community Ment Health J Table 3 Summary of Scale Scores by Education & Employment CAP Trigger Level in Community and Inpatient Mental Health Settings interRAI scalesb
Community (N = 1,015)
Inpatient (N = 83,280)
EdEmp CAP Level 2 (n = 174)a % (n)
EdEmp CAP Level 1 (n = 218)a % (n)
EdEmp CAP Level 0 (n = 623)a % (n)
EdEmp CAP Level 2 (n = 18,993)a % (n)
EdEmp CAP Level 1 (n = 11,100)a % (n)
EdEmp CAP Level 0 (n = 53,187)a % (n)
77.0 (134) 23.0 (40)
85.3 (186) 14.7 (32)
89.9 (560) 10.1 (63)
67.3 (12551) 32.7 (6093)
77.4 (8461) 22.6 (2467)
84.5 (35512) 15.5 (6530)
CAGEc 0–1 2–4 CPS 0 (intact)
52.9 (92)
54.6 (119)
42.2 (263)
69.7 (13244)
70.8 (7863)
53.0 (28182)
1–2
44.8 (78)
43.1 (94)
49.4 (308)
24.6 (4669)
23.7 (2648)
32.7 (17411)
3?
2.3 (4)
2.3 (5)
8.46 (52)
5.7 (1080)
5.3 (589)
14.3 (7594)
0–2
52.3 (91)
67.4 (147)
69.3 (432)
49.0 (9305)
53.4 (5946)
47.1 (25034)
3–5
28.7 (50)
20.6 (45)
16.29 (101)
31.9 (6060)
29.5 (3269)
31.4 (16688)
6?
19.08 (33)
11.9 (26)
14.5 (90)
19.1 (3628)
17.0 (1885)
21.6 (11465) 62.0 (30603)
DRSd
Positive symptoms scalee 0–2
94.8 (165)
92.73 (202)
91.8 (572)
71.0 (12700)
74.14 (7776)
3–5
2.9 (5)
5.5 (12)
5.9 (37)
15.5 (2775)
14.1 (1489)
21.6 (10681)
6?
2.3 (4)
1.8 (4)
2.3 (14)
13.5 (2414)
11.8 (1236)
16.4 (8078)
a
Not all of total frequencies in cells add up to column totals due to missing data
b
Higher scale scores indicate more severity
c
CAGE is a substance use screener. A score of 2 or more is indicative of a potential problem with substance addiction
d
DRS: a score of 3? is indicative of possible depression and a score of 6? is indicative of more severe depression
e
Positive symptoms scale: higher scores indicate higher levels of psychotic symptoms
Table 4 Social and behavioral characteristics of individuals with mental illness who trigger at each level of the education & employment CAP in community mental health and inpatient settings Characteristics
Community (N = 1,015) EdEmp CAP Level 2 (n = 174) % (n)
Inpatient (N = 83,280) EdEmp CAP Level 1 (n = 218) % (n)
EdEmp CAP Level 0 (n = 623) % (n)
EdEmp CAP Level 2 (n = 18,993) % (n)
EdEmp CAP Level 1 (n = 11,100) % (n)
EdEmp CAP Level 0 (n = 53,187) % (n)
Has a criminal record
17.9 (29)
18.9 (39)
18.8 (78)
NA
NA
NA
Social relations: belief that relationships with immediate family disturbed or dysfunctional
25.0 (42)
20.0 (43)
18.5 (84)
26.4 (4926)
20.0 (2186)
17.0 (7152)
Interpersonal conflict (e.g., with family)
43.5 (73)
33.5 (72)
30.7 (139)
16.9 (3142)
15.2 (1659)
14.3 (6009)
Personal strengths: Not having a positive outlook
63.7 (107)
43.7 (94)
57.0 (258)
NA
NA
NA
4.8 (8)
4.2 (9)
7.5 (34)
NA
NA
NA
Activity Level: no days out in last 3 days NA not applicable
Discussion Unemployment, a disrupted education, or the lack of meaningful roles in the community is a major concern for the well being of persons with mental illness. This study
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indicates that many persons with mental illness are at a substantial risk of losing their employment or, if of school age, dropping out of school. Education and employment risk is a result of increased lateness or absenteeism, poor productivity or disruptiveness at work/school, an expressed
Community Ment Health J Table 5 Interventions for individuals with mental illness who trigger at each level of the education & employment CAP in community mental health and inpatient settings Interventions
Community (N = 1,015)
Inpatient (N = 83,280)
EdEmp CAP Level 2 (n = 174)a % (n)
EdEmp CAP Level 1 (n = 218) % (n)
EdEmp CAP Level 0 (n = 623) % (n)
Did not receive any
83.3 (140)
80.0 (172)
86.3 (391)
Offered but refused
3.0 (5)
5.1 (11)
3.5 (16)
0.3 (60)
0.3 (37)
0.3 (125)
Scheduled in 30 days
5.4 (9)
6.1 (13)
1.6 (7)
3.3 (621)
1.6 (176)
1.2 (495)
Received 8–30 days ago OR in last 7 days
8.3 (14)
8.8 (19)
8.6 (39)
2.6 (487)
2.0 (214)
1.0 (414)
Did not receive any
59.8 (104)
61.0 (133)
62.5 (388)
47.4 (9000)
58.6 (6500)
56.6 (30094)
Offered but refused
4.6 (8)
1.4 (3)
3.7 (23)
1.3 (254)
1.2 (132)
1.4 (730)
EdEmp CAP Level 2 (n = 18,993) % (n)
EdEmp CAP Level 1 (n = 11,100) % (n)
EdEmp CAP Level 0 (n = 53,187) % (n)
96.1 (10501)
97.5 (41008)
Vocational rehabilitation/counseling 93.7 (17476)
Psychosocial rehabilitation
Scheduled in 30 days
2.3 (4)
3.2 (7)
1.3 (8)
41.0 (7778)
33.0 (3662)
35.1 (18641)
33.3 (58)
34.4 (75)
32.5 (202)
10.3 (1961)
7.3 (806)
7.0 (3722)
58.3 (98)
65.6 (141)
61.6 (279)
48.5 (9033)
60.4 (6600)
58.2 (24463)
7.7 (13) 3.0 (5)
1.43 (3) 4.7 (10)
4.0 (18) 2.4 (11)
1.7 (324) 39.8 (7413)
1.5 (165) 30.0 (3278)
1.6 (680) 32.0 (13455)
31.0 (52)
28.4 (61)
32.0 (145)
10.1 (1874)
8.1 (885)
8.2 (3444)
Did not receive any
87.5 (147)
92.1 (198)
92.7 (420)
71.1 (13257)
79.8 (8720)
83.2 (34986)
Offered but refused
7.7 (13)
2.8 (6)
2.9 (13)
1.7 (347)
2.4 (262)
2.0 (834)
Scheduled in 30 days
0.0 (0)
0.9 (2)
0.9 (16)
23.7 (4416)
14.7 (1607)
12.8 (834)
4.80 (86)
4.2 (9)
3.5 (16)
3.4 (624)
3.1 (339)
2.0 (837)
Did not receive any
85.2 (143)
92.6 (199)
89.6 (406)
81.5 (15196)
89.0 (9729)
88.1 (37029)
Offered but refused
4.2 (7)
0.9 (2)
3.1 (14)
0.7 (133)
0.8 (85)
0.9 (364)
Scheduled in 30 days
3.6 (3)
0.0 (0)
0.9 (4)
12.99 (2422)
7.8 (855)
8.8 (3709)
Received 8–30 days ago OR in last 7 days
7.1 (12)
6.5 (14)
6.4 (29)
4.8 (2422)
2.4 (259)
2.2 (940)
81.2 (137)
88.8 (191)
81.0 (367)
66.9 (12470)
77.6 (8475)
74.2 (31211)
3.0 (5) 1.8 (5)
0.5 (1) 0.9 (2)
1.1 (5) 0.9 (4)
0.8 (155) 30.3 (5655)
0.7 (76) 20.1 (2195)
1.0 (413) 23.1 (9691)
13.7 (23)
9.8 (21)
17.0 (77)
2.0 (364)
1.7 (182)
1.7 (727)
Received 8–30 days ago OR in last 7 days Social-family functioning Did not receive any Offered but refused Scheduled in 30 days Received 8–30 days ago OR in last 7 days Alcohol–drug treatment
Received 8–30 days ago OR in last 7 days Anger management
Behavioural management Did not receive any Offered but refused Scheduled in 30 days Received 8–30 days ago OR in last 7 days a
Not all of total frequencies in cells add up to column totals due to missing data
intent to quit work/school, or persistent unemployment or a fluctuating work history. The results of this study indicate that males are more at risk of losing their employment or dropping out of school than females. As the purpose of this study was to provide an overview of the EdEmp CAP and its potential use in care planning, the limited analyses of the data were not intended to yield a full explanation for this observed difference in risk. It may be that it is more difficult for males to remain in the workforce or in school due to the nature of employment conditions (e.g., full-time
versus part-time) or that the specific symptoms related to their mental illness differs in a manner that affects sustained employment. The finding that the majority of persons over the age of 65 did not trigger the EdEmp CAP in either setting may be a measure of the validity of the CAP. That is, as this group of individuals is least likely to be in the job market looking for employment or being enrolled in school, vocational intervention is not necessary. As well, those in the age category 25–45 who would be expected to be pursuing
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employment or education, were shown to be triggering Levels 1 and 2. It is interesting to note that despite the risks of losing employment or dropping out of school most persons in the study sample did not receive any services that may be helpful such as vocational rehabilitation or counseling to maintain their employment or stay in school, psychosocial rehabilitation to address their social and interpersonal relations, or other treatments or interventions for anger management and addictions. A small percentage of persons were offered such interventions, but they refused. Some others were scheduled to receive such services in 30 days. More individuals in the community than in-patients received psychosocial rehabilitation, social-family functioning and behavioural management in the preceding 8–30 or in the last 7 days. Unemployment leads to financial hardship and individuals with mental illness are forced to make trade-offs among purchases of adequate food, shelter, clothing, prescribed medications, sufficient home heat or cooling, and necessary health care. Meaningful employment or participation in education has been shown to increase self-esteem, alleviate psychiatric symptoms, and reduce dependency and relapse (Bond and Jones 2005; Lehman 1995). However, based on the findings of this study, individuals who are most at risk are not receiving the necessary therapeutic interventions to help them pursue education or employment that may contribute to their journey to recovery. To help these individuals with their personal journey to recovery, clinicians need to expand their treatment or intervention strategies beyond traditional approaches—such as managing adherence to psychotropic medication treatment—and include psychosocial and vocational rehabilitation. The interRAI assessment instruments and the associate EdEmp CAP may serve as effective tools to help identify persons with mental illness in community and inpatient mental health settings who are at risk of losing their employment or who could be supported to obtain employment. Aside from triggering algorithms described here, the EdEmp CAP includes evidence-based guidelines that may assist clinicians to help their clients with mental illness achieve their education or employment goals, including obtaining or keeping a job, pursuing schooling, or being engaged in meaningful social roles, such as volunteering. These intervention guidelines may be targeted to those individuals who have been unemployed for a while and wish to re-enter the workforce, and to those who have been separated from their jobs because of short- or longterm disability and wish to return to their job. The EdEmp CAP guidelines provide a full range of therapeutic interventions, including: assessing risk factors for unemployment or loss of employment; setting vocational goals and assessing readiness for employment; assessing and
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addressing the literacy skills necessary for performance on the job; assessing the readiness of and creating a supportive work environment; and general intervention measures to improve employment outcomes, including preventing the loss of employment. Specific intervention measures for education and volunteering are also included. Several limitations must be considered with regard to the findings of this study. First, for the purposes set out for this paper, only descriptive statistical analyses were carried out. Multivariate methods could be used in future analyses to identify specific risk factors associated with trigger levels. In addition, longitudinal analyses would be helpful to demonstrate trajectories of change in the experience of these individuals. Another limitation is that the community sample population was substantially smaller than the inpatient sample. A larger sample might contribute to better explanations of the observed relationships. While only a small proportion of individuals in both settings refused vocational rehabilitation or counseling services that offered, reasons for refusal should be explored.
Conclusions Based on the findings of this study, there is a substantial gap between the vocational rehabilitation needs of persons with mental illness in community and inpatient mental health settings and the services or therapeutic interventions that they receive to address those needs. These individuals also do not receive other supportive services targeted to their risk factors, such as addictions, anger, or interpersonal relationships. To help these individuals in their personal journey to recovery, clinicians need to expand their treatment or intervention strategies beyond traditional approaches—such as managing adherence to psychotropic medication treatment—and include psychosocial rehabilitation and vocational rehabilitation. Conflict of interest There are no known conflicts of interest related to this study.
References Bernabei, R., Gray, L., Hirdes, J., Pei, X., Henrard, J. C., Jonsson, P. V., et al. (2009). International gerontology. In J. B. Halter, J. G. Ouslander, M. E. Tinetti, S. Studenski, K. P. High, & S. Asthana (Eds.), Hazzard’s geriatric medicine & gerontology (6th ed., pp. 69–96). New York: McGraw Hill Medical. Bond, G. R., & Jones, A. (2005). Supported employment. In R. E. Drake, M. R. Merrens, & D. W. Lynde (Eds.), Evidence-based mental health practice: a textbook (pp. 367–394). New York, NY: W W Norton & Co. Burrows, A. B., Morris, J. N., Simon, S. E., Hirdes, J. P., & Phillips, C. (2000). Development of a minimum data set-based depression
Community Ment Health J rating scale for use in nursing homes. Age and Ageing, 29(2), 165–172. Crowther, R., Marshall, M., Bond, G. R., et al. (2001). Helping people with severe mental illness to obtain work: Systemiatic review. British Medical Journal, 322, 204–208. Gray, L. C., Berg, K., Fries, B. E., Henrard, J., Hirdes, J. P., Steel, K., et al. (2009). Sharing clinical information across care settings: The birth of an integrated assessment system. BMC Health Services Research, 9, 71. Hirdes, J. P., Curtin-Telegdi, N., Mathias, K., Perlman, C. M., Saarela, T., Kolbeinsson, H., et al. (2011). interRAI mental health clinical assessment protocols (CAPS) for use with community and hospital-based mental health assessment instruments. V. 9.1, Canadian Edition. Washington, DC: interRAI. Hirdes, J. P., Fries, B. E., Morris, J. N., Steel, K., Mor, V., Frijters, D., et al. (1999). Integrated health information systems based on the RAI/MDS series of instruments. Healthcare Management Forum/Canadian College of Health Service Executives=Forum Gestion Des Soins De Sante/College Canadien Des Directeurs De Services De Sante, 12(4), 30–40. Hirdes, J. P., Ljunggren, G., Morris, J. N., Frijters, D. H. M., Finne Soveri, H., Gray, L., et al. (2008). Reliability of the interRAI suite of assessment instruments: A 12-country study of an integrated health information system. BMC Health Services Research, 8, 1–11. Hirdes, J. P., Marhaba, M., Smith, T. F., Clyburn, L., Mitchell, L., Lemick, R. A., et al. (2000). Development of the resident assessment instrument-mental health (RAI-MH). Hospital Quarterly, 4(2), 44–51. Hirdes, J. P., Smith, T. F., Rabinowitz, T., Yamauchi, K., Pe´rez, E., Telegdi, N. C., et al. (2002). The resident assessment instrumentmental health (RAI-MH): Inter-rater reliability and convergent validity. Journal of Behavioral Health Services & Research, 29(4), 419–432. Jones, K., Perlman, C. M., Hirdes, J. P., & Scott, T. (2010). Screening cognitive performance with the resident assessment instrument for mental health (RAI-MH) cognitive performance scale. Canadian Journal of Psychiatry, 55, 736–740. Lehman, A. F. (1995). Vocational rehabilitation in schizophrenia. Schizophrenia Bulletin, 21(4), 645–656. Lehman, A. F., Goldberg, R., Dixon, L. B., et al. (2002). Improving employment outcomes for persons with severe mental illnesses. Archives General Psychiatry, 59, 165–172.
Martin, L., Hirdes, J. P., Morris, J. N., Montague, P., Rabinowitz, T., & Fries, B. E. (2009). Validating the mental health assessment protocols (MHAPs) in the resident assessment instrument mental health (RAI-MH). Journal of Psychiatric and Mental Health Nursing, 16(7), 643–653. Mathias, K., Hirdes, J. P., & Pittman, D. (2010). A care planning strategy for traumatic life events in community mental health and inpatient psychiatry based on the interRAI assessment instruments. Community Mental Health Journal. doi:10.1007/ s10597-010-9308-2. McCreadie, R. G. (1992). The Nithsdale schizophrenia surveys: An overview. Social Psychiatry and Psychiatric Epidemiology, 27(1), 40–45. Mood Disorders Society of Canada (2008). Stigma and discrimination. Retrieved April 12, 2008, from http://www.mooddisorders canada.ca/stigma/projectbackground.htm. Morris, J. N., Fries, B. E., Mehr, D. R., & Hawes, C. (1994). MDS cognitive performance scale. Journals of Gerontology, 49(4), M174–M182. Morris, P., & Lloyd, C. (2004). Vocational rehabilitation in psychiatry: A re-evaluation. Australian and New Zealand Journal of Psychiatry, 38(7), 490–494. Mueser, K. T., Clark, R. E., Haines, M., Bond, G. R., Essock, S. M., Becker, D. R., et al. (2004). The Hartford study of supported employment in persons with severe mental illness. Journal of Consulting and Clinical Psychology, 72(3), 479–490. Murphy, A. A., Mullen, M. G., & Spagnolo, A. B. (2005). Enhancing individual placement and support: Promoting job tenure by integrating natural supports and supported education. American Journal of Psychiatric Rehabilitation, 8, 37–61. doi:10.1080/ 15487760590953948. Neufeld, E., Perlman, C. M., & Hirdes, J. P. (2012). Predicting inpatient aggression using the interRAI risk of harm to others clinical assessment protocol. The Journal of Behavioral Health Services & Research, 39(4), 472–480. Perlman, C. M., Hirdes, J. P., Barbaree, H., Fries, B. E., McKillop, I., Morris, J. N., et al. (2013). Development of mental health quality indicators (MHQIs) for inpatient psychiatry based on the interRAI mental health assessment. BMC Health Services Research, 13, 15. doi:10.1186/1472-6963-13-15. Stuart, H. (2004). Stigma and work. Healthcare Papers, 5(2), 100–111.
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ORIGINAL PAPER
Education and Employment Needs and Receipt of Services in Community and Inpatient Mental Health Settings Vahe Kehyayan • John P. Hirdes • Christopher Michael Perlman
Received: 16 January 2012 / Accepted: 10 January 2014 Springer Science+Business Media New York 2014
Abstract The interRAI Education and Employment Clinical Assessment Protocol (EdEmp CAP) identifies three groups of individuals in community and inpatient mental health settings: those who are at risk of losing their employment or disrupting their education; those who require support in employment or educational participation; or those for whom interventions related to education and employment are not triggered. The EdEmp CAP was effective in identifying subpopulations who were at risk, but who did not receive any vocational rehabilitation or counseling. The EdEmp CAP can be used in clinical practice to identify individuals who might benefit from specific interventions in these areas. Keywords planning
Assessment interRAI Mental health Care
Introduction Unemployment rates for persons with mental illness are very high (Lehman 1995; McCreadie 1992; Mood Disorders Society of Canada 2008). This may be related to a number of factors, including the disabling effects of mental illness or addiction, the stigma and discrimination associated with mental illness, and the lack of employment opportunities available to persons with mental illness V. Kehyayan (&) J. P. Hirdes C. M. Perlman School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1, Canada e-mail: [email protected] V. Kehyayan University of Calgary - Qatar, Doha, Qatar
(Stuart 2004). Unemployment in these individuals may also be associated with the lack of access to vocational rehabilitation, counseling services, supported employment, or other interventions targeted toward social and behavioural factors that may be associated with unemployment. Work, employment, engagement and meaningful roles are recognized as having therapeutic effects on the path to recovery for individuals with mental illness (Bond and Jones 2005; Morris and Lloyd 2004). Meaningful vocational activities, such as employment, participation in individual placement and support programs, or participation in education, have been associated with positive outcomes, including increased self-esteem, alleviated psychiatric symptoms, reduced dependency and avoidance of relapse (Crowther et al. 2001; Lehman 1995; Lehman et al. 2002; Mueser et al. 2004; Murphy et al. 2005). While the impact of vocational activities on positive outcomes is widely recognized, clinicians should employ an evidence-informed approach to identify the vocational needs of their clients, particularly those who are at risk of losing their employment or dropping out of school. There is also a relative lack of evidence-based intervention guidelines to help persons with mental illness find or keep their employment, or pursue their education or other meaningful roles. The objectives of this paper are: •
•
to identify individuals with mental illness in community and inpatient mental health settings who are at risk of losing their employment or disrupting their education, using the interRAI Education and Employment Clinical Assessment Protocol (EdEmp CAP); to identify persons with mental illness who are not employed or pursuing education, but who might benefit from interventions aimed at supporting their involvement in work or education;
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•
•
to describe the demographic, social, and clinical characteristics of these individuals, and the services they receive to address their vocational rehabilitation needs; and to highlight the benefits of using the EdEmp CAP to inform clinical decision making.
interRAI Mental Health Clinical Assessment Protocols interRAI (www.interRAI.org) is a not-for-profit 33-country research network that has developed an integrated suite of assessment instruments for use in several health sectors, including mental health, long-term care, home care, and acute care settings (Bernabei et al. 2009; Gray et al. 2009; Hirdes et al. 2008). This family of instruments includes the interRAI Mental Health (interRAI MH) for use in inpatient mental health settings and the interRAI Community Mental Health (interRAI CMH) for use in community mental health settings. These assessment instruments are intended to serve multiple applications for multiple audiences, including care planning, outcome measurement, case mix classification and quality monitoring (Hirdes et al. 1999). The clinical applications of these instruments are the Clinical Assessment Protocols (CAPs; Hirdes et al. 2011). The CAPs use standardized decision-support algorithms to trigger collaborative care planning in multiple domain areas (see, for example, Mathias et al. 2010). Prior versions of these CAPs have been validated against clinician ratings (Martin et al. 2009). More recently, interRAI’s Network of Excellence in Mental Health completed a multiyear refinement effort to update all CAPs for mental health, including a CAP related to education and employment. Education & Employment Clinical Assessment Protocol The interRAI’s EdEmp CAP was developed specifically to help clinicians identify and respond to the vocational needs of persons with mental illness. The EdEmp CAP focuses on a person’s functioning and quality of life with the aim of supporting their recovery from mental illness and optimal functioning. The EdEmp CAP offers outcome-based approaches that use reassessment over time to target support services and interventions to alleviate the effects of mental health symptoms, promote autonomy and psychosocial and physical wellbeing, enhance community engagement, and support participation in activities that are meaningful to the person. Based on responses to specific items in the interRAI MH and CMH assessment instruments, the EdEmp CAP identifies three groups or subpopulations of persons with mental illness. The first group, referred to as ‘‘Level 2’’ in the context of this paper, is comprised of individuals who are
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at risk of losing their employment or dropping out of school due to the presence of any one of the following indicators of risk: (1) an increase in lateness or absenteeism over the last 6 months; (2) poor productivity or disruptiveness at work/school; (3) an expressed intent to quit work/school; or (4) persistent unemployment or a fluctuating work history over the last 2 years. The goal of the EdEmp CAP for this group is to reduce the risk of unemployment or dropping out of school. The second group (Level 1) includes three subgroups of individuals: (1) persons of any age who are unemployed but seeking employment; (2) unemployed persons aged 16–65 years who are NOT seeking employment but could work given that they have minimal impairments in ADL and cognitive function, few indications of positive symptoms, full insight into their mental health condition, AND minimal indications of behaviour problems; and (3) persons aged 10–30 who have recently dropped out of or failed school. The goal of the EdEmp CAP for this group is to support employment, educational participation, or the assumption of meaningful roles among persons who are currently not employed. The third group of individuals includes (referred to as Level 0): (1) those who are employed or at school with no apparent risk of losing employment or dropping out of school; (2) those who have retired; and (3) those who are unemployed but are not seeking employment due to major mental health or disability issues.
Method Data Sources All data for this study were drawn from assessments completed with the two instruments noted above: (1) the interRAI Community Mental Health (interRAI CMH) for a sample of community based clients, and (2) the interRAI Mental Health (interRAI MH) for a sample of persons in inpatient mental health settings. Both of these instruments include items that can be combined into different summary scales (see Table 1). As well, items from either instrument can address social and behavioral characteristics (e.g., interpersonal conflict) as well as receipt of various interventions (e.g., Alcohol or drug treatment). These interRAI mental health assessment instruments are comprised of items that assess a person’s mental health history, mental state indicators, behaviour, cognition, functional status, health conditions, life events, medication, employment and education, capacity to manage finances, and service utilization, treatments, and interventions. Trained clinicians assess patients using all possible sources of information at time of admission, every 90 days thereafter
Community Ment Health J Table 1 interRAI mental health instruments, EdEmp CAP, and interRAI performance scales Instruments & scales
Purpose/function
interRAI MH
Comprehensive assessment instrument used in in-patient mental health settings
interRAI CMH
Comprehensive assessment instrument used in community mental health settings
EdEmp CAP
Clinical assessment protocol triggered from items on the interRAI MH and CMH to help clinicians develop individualized care plans for persons with mental illness to support their recovery through employment or education
CPS
Describes the person’s cognitive status using items found on both the interRAI MH and CMH; a summary scale
DRS
Describes the person’s mood status based on a summary of 7 items found on the interRAI MH and CMH; a summary scale
Positive symptoms scale
Describes the person’s psychotic symptoms such as hallucinations. Four items found on the interRAI MH and CMH are summed; an outcome measure
Negative symptoms scale
Describes the person’s negative symptoms, such as withdrawal based on items from the interRAI MH or CMH; an outcome measure
and upon discharge (Hirdes et al. 2002; Martin et al. 2009). These instruments provide clinicians with a comprehensive assessment of patients and their level of functioning, and they contain items to trigger care plan development and to support outcome measurement over time. Based on responses to specific items in these instruments, the EdEmp CAP is said to be ‘‘triggered’’ for the purpose of care planning. The trigger level is important to consider as each level is associated with specific care planning considerations (Hirdes et al. 2011). The CAP manual provides guidelines for clinicians to prepare an individualized care plan for the person to help address these areas of risk. Thus, as the EdEmp CAP identifies three distinct groups, the EdEmp CAP is said to be triggered for Levels 1 and 2 groups. It is not triggered for the Level 0 group because they may not be eligible for employment (e.g., due to retirement), they are functioning adequately in their work or school roles, or they have sufficient physical or mental health impairments that employment or formal educational opportunities may be beyond their functional ability. Two main groups are considered for intervention. The first includes those who currently have jobs or are going to school, but whose behavior places those activities in jeopardy. The CAP is triggered at Level 2 when the interRAI assessment indicates that s/he is at risk of losing their employment or dropping out of school due to the
presence of any of the following indicators of risk: (1) an increase in lateness or absenteeism over the last 6 months; (2) poor productivity or disruptiveness at work or school; (3) an expressed intent to quit work or school; or (4) persistent unemployment or fluctuating work history over the last 2 years (Hirdes et al. 2011). The second group targeted for intervention (Level 1) is comprised of persons who are not in the paid labour force or pursuing formal education, but who may have a reasonable chance of being engaged in that way with the right supports. This includes three types of persons: (1) those who do not have employment but describe themselves as looking for employment; (2) those who are unemployed and are NOT looking for employment but who likely possess the necessary physical and mental abilities to work if it were available; and (3) persons who recently failed or dropped out of school, who may be able to reconnect with the educational system given a short passage of time. Although these groups are somewhat heterogeneous in nature, the common focus of care planning is on supporting the person to find new opportunities to become engaged in work or education. The CAP provides informational guidelines for clinicians to consider in developing a collaborative care plan with persons in these different groups. The RAI MH (an earlier version of the interRAI MH) has been mandated in all adult inpatient mental health settings in Ontario, Canada since October 2005. It has also been adopted by the province of Newfoundland and Labrador and is being implemented by the sole standalone psychiatric hospital in Manitoba. Under this mandate, each patient is required to have a full assessment upon admission, every 90 days, and at discharge. Such comprehensive assessments support the identification of health care needs and person-centred care planning, and allow the monitoring of changes in residents’ health status and physical and cognitive functioning over time (Hirdes et al. 2000, 2002). The interRAI CMH (Hirdes et al. 2011) is used in community mental health settings and has about 60 % overlap in assessment items with the interRAI MH. The interRAI CMH also has unique specialized items like: employment arrangements (e.g., competitive or supported employment); volunteering; and enrolment in formal education programs. It has been piloted in several community mental health settings in Canada, Iceland, Finland and Hong Kong. The CMH has been adopted by the province of Newfoundland and Labrador as the provincial standard assessment for that sector, and two US states are in the process of adopting the instrument. The validity and reliability of these instruments have been well established (e.g., Hirdes et al. 2002, 2008; Jones et al. 2010; Neufeld et al. 2012). The interRAI assessment instruments include items needed for various scales and algorithms that may be used for outcomes measurement such as health, functioning, and
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mental health symptoms (Hirdes et al. 2011). For instance, the cognitive performance scale (CPS) measures cognitive performance with scores ranging from 0 to 6 and its items include daily decision-making, short-term memory, expression, and self-performance in eating. The depression rating scale (DRS) measures depressive symptoms with scores ranging from 0 to 14 (e.g., 3? is indicative of possible depression, 6? is indicative of more severe depression). The Positive Symptoms Scale-short (PSSshort) reflects psychotic symptoms with scores ranging from 0 to 12 and its items include hallucinations, command hallucinations, delusions, and abnormal thought processes. The RAI MH also includes items describing social withdrawal, often referred to as negative symptoms. Scored from 0 (indicator not exhibited in the last 3 days) to 3 (indicator observed daily in the last 3 days), these items include anhedonia, loss of interest, lack of motivation, and reduced interaction. When added together, these scales form a negative symptom scale (NSS) that ranges from 0 to 12, with higher scores indicating a greater number and frequency of observed negative symptoms. These scales have been tested for their reliability and validity (e.g., Burrows et al. 2000, 2002; Jones et al. 2010; Morris et al. 1994; Perlman et al. 2013). Table 1 provides a summary of each of the interRAI mental health assessment instruments, the EdEmp CAP, and outcome measurement scales. Sample The sample for this study included 1,015 individuals in community and 44,915 individuals in inpatient mental health settings. Data were provided through a data sharing agreement between the Canadian Institute for Health Information (CIHI) which serves as the repository of all data collected from interRAI instruments by Canadian provinces/territories including the RAI MH and interRAI CMH, and the researchers at the University of Waterloo. The inpatient data for this study were retrieved from the CIHI repository of patient/client assessments in inpatient mental health settings in Canada where the RAI MH instrument was used. The data from community mental health settings were collected as part of a Canadian pilot study of the interRAI CMH. The authors take full responsibility for the conduct of the study, the analysis and interpretation of the data, helping to write the manuscript, and approving its final copy. Analysis A descriptive analysis of the data in this study was conducted using Statistical Analysis Software (SAS) to compare the three groups of individuals. As well, crosstabulation was used to examine any associations with key
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variables of interest (e.g., diagnoses, negative and positive symptoms, depressive symptoms, cognitive performance) and the EdEmp CAP levels 0, 1, and 2). Ethics Clearance Ethics clearance for this research was obtained through the Office of Research at the University of Waterloo.
Results The sample in community mental health settings included 52.1 % males with a mean age of 47.3 (SD = 17.2), while in inpatient settings there were slightly fewer males (49.8 %), average age was slightly lower (mean = 45.6; SD = 16.9) and a higher proportion of patients under the age of 25 (12 %) compared to the community (10 %). In both settings, more males triggered Level 2 than females. The majority of persons in each sample had one or more psychiatric admissions. The EdEmp CAP Level 2 was triggered for about 17 % of individuals in the community and 23 % in inpatient settings. On the other hand, CAP Level 1 was triggered for 18 % of individuals in the community and 13 % of those in inpatient settings. Of those in the community who triggered Level 2, 25 % made trade-offs among necessities of living (such as purchasing adequate food, shelter, clothing, prescribed medications, sufficient home heat or cooling, or necessary health care) compared to 10.8 % of those in inpatient settings. As would be expected, Table 2 shows that the lowest percentage of persons over the age of 65 was evident among those who triggered the EdEmp CAP in both community and inpatient settings. In both settings, those who triggered both Level 1 and Level 2 were most likely to be in the 25–44 age category. In inpatient settings there were higher proportions of males in the triggered Level 2 compared to the non-triggered group (p \ 0.0001); however, this was not significant in the community setting. With respect to the mental health diagnoses, there were only moderate differences in the proportion with mood disorders or personality disorders in either setting. However, there was a substantially higher percentage of persons with a substance use disorder in each of the triggered levels compared with the non-triggered level. In addition, while there were no differences in the percentage with schizophrenia between the non-triggered and Level 1 triggered groups, there was a substantially lower percentage of persons at trigger Level 2 with schizophrenia. In both settings, a larger percentage of individuals in the triggered Level 2 had no prior lifetime psychiatric hospitalizations compared to either of Level 1 or Level 0. In contrast, a smaller percentage of those in Level 2 had 6 or more prior admissions compared to
Community Ment Health J Table 2 Characteristics of individuals with mental illness who trigger at each level of the education & employment CAP in community mental health and inpatient settings Characteristics
Community (N = 1,015) EdEmp CAP Level 2 (n = 174)a % (n)
% Triggered Mean age (SD) Mean age
17.0
Inpatient (N = 83,280) EdEmp CAP Level 1 (n = 218)a % (n) 18.0
EdEmp CAP Level 0 (n = 623)a % (n) 65.0
47.3 (17.2) 36.6
EdEmp CAP Level 2 (n = 18,993)a % (n) 23.0
EdEmp CAP Level 1 (n = 11,100)a % (n)
EdEmp CAP Level 0 (n = 53,187)a % (n)
13.0
64.0
35.2
50.6
45.6 (16.9) 38.7
53.3
37.7
Age Under 25
25.3 (44)
17.0 (37)
3.4 (21)
19.9 (3783)
29.2 (3238)
5.5 (2940)
25–44
47.1 (82)
50.5 (110)
31.8 (198)
49.9 (9483)
44.9 (4978)
34.6 (18424)
45–65
24.1 (42)
31.2 (68)
37.9 (236)
28.6 (5423)
24.5 (2720)
39.0 (20721)
3.5 (6)
1.4 (3)
27.0 (168)
1.6 (304)
1.5 (164)
20.9 (11102)
65? Sex (male)
52.1 %
49.8 %
Sex Male
59.8 (98)
49.8 (105)
50.8 (306)
57.0 (10834)
53.6 (5952)
46.5 (24712)
Female
40.2 (66)
50.2 (106)
49.2 (296)
42.9 (8154)
46.4 (5145)
53.5 (28463)
Made trade-offs Most important diagnosis
25.0
11.2
13.5
10.8
6.9
4.9
Schizophrenia
35.2 (58)
44.6 (94)
43.35 (244)
27.8 (5276)
34.6 (3838)
36.7 (19512)
Mood disorder
38.6 (66)
35.0 (76)
35.8 (202)
38.8 (7368)
40.2 (4467)
40.2 (21373)
3.7 (6)
2.4 (5)
1.5 (8)
1.5 (276)
2.5 (276)
1.2 (614)
11.6 (19)
1.4 (3)
2.8 (15)
22.4 (4261)
13.5 (1497)
8.2 (4334)
Personality disorder Substance-related disorder
Number of psychiatric admissions (lifetime)
a
None
35.7 (60)
19.50 (42)
15.2 (69)
34.1 (6473)
26.8 (2974)
25.0 (13280)
1–3
36.9 (62)
44.2 (95)
33.8 (153)
40.6 (7716)
36.8 (4080)
34.3 (18220)
4–5
10.1 (17)
15.4 (33)
16.1 (73)
12.3 (2326)
16.0 (1777)
15.6 (8308)
6?
17.3 (29)
20.9 (45)
34.8 (158)
13.1 (2478)
20.4 (2269)
25.2 (13379)
Not all of total frequencies in cells add up to column totals due to missing data
those in Levels 1 and 0. As shown in Table 3, having potential problems with addiction was more likely to be evident among those who trigger Level 2 in both community and inpatient settings. The majority of persons in both settings had no or only mild impairment in cognitive performance, but those in community settings were less likely to be cognitively intact compared with inpatient settings. For both settings, those who triggered the EdEmp CAP at either level are more likely to be cognitively ‘‘intact’’. On the other hand, the triggered Level 2 group is more likely to have DRS scores of 3 or more (suggesting potential depression) than the nontriggered group in the community. Conversely, they are less likely to have high scores in positive symptoms. Table 4 shows the association between individuals’ social and behavioural characteristics in relation to the EdEmp CAP. Interpersonal conflicts were more evident among those at Level 2, particularly in the community setting. In addition, evidence of disturbed or dysfunctional
family relationships was more likely to be present when the CAP was triggered in either Level 2 or Level 1 groups. Table 5 shows the receipt of services and mental health interventions by EdEmp CAP levels in community and inpatient settings. Although those in community settings are more likely to receive vocational rehabilitation than those in inpatient settings, the overwhelming majority of persons in both contexts do not receive such services even among those who trigger the CAP. The rates of psychosocial rehabilitation services are higher, but these are still only received by the minority of persons in either setting. Persons who trigger the EdEmp CAP in community settings are more likely to receive services and interventions aimed at managing symptoms (e.g., anger and behaviour management) compared with their inpatient counterparts. Those in the community who triggered this CAP were less likely to have received interventions aimed at social-family functioning than those in inpatient settings.
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Community Ment Health J Table 3 Summary of Scale Scores by Education & Employment CAP Trigger Level in Community and Inpatient Mental Health Settings interRAI scalesb
Community (N = 1,015)
Inpatient (N = 83,280)
EdEmp CAP Level 2 (n = 174)a % (n)
EdEmp CAP Level 1 (n = 218)a % (n)
EdEmp CAP Level 0 (n = 623)a % (n)
EdEmp CAP Level 2 (n = 18,993)a % (n)
EdEmp CAP Level 1 (n = 11,100)a % (n)
EdEmp CAP Level 0 (n = 53,187)a % (n)
77.0 (134) 23.0 (40)
85.3 (186) 14.7 (32)
89.9 (560) 10.1 (63)
67.3 (12551) 32.7 (6093)
77.4 (8461) 22.6 (2467)
84.5 (35512) 15.5 (6530)
CAGEc 0–1 2–4 CPS 0 (intact)
52.9 (92)
54.6 (119)
42.2 (263)
69.7 (13244)
70.8 (7863)
53.0 (28182)
1–2
44.8 (78)
43.1 (94)
49.4 (308)
24.6 (4669)
23.7 (2648)
32.7 (17411)
3?
2.3 (4)
2.3 (5)
8.46 (52)
5.7 (1080)
5.3 (589)
14.3 (7594)
0–2
52.3 (91)
67.4 (147)
69.3 (432)
49.0 (9305)
53.4 (5946)
47.1 (25034)
3–5
28.7 (50)
20.6 (45)
16.29 (101)
31.9 (6060)
29.5 (3269)
31.4 (16688)
6?
19.08 (33)
11.9 (26)
14.5 (90)
19.1 (3628)
17.0 (1885)
21.6 (11465) 62.0 (30603)
DRSd
Positive symptoms scalee 0–2
94.8 (165)
92.73 (202)
91.8 (572)
71.0 (12700)
74.14 (7776)
3–5
2.9 (5)
5.5 (12)
5.9 (37)
15.5 (2775)
14.1 (1489)
21.6 (10681)
6?
2.3 (4)
1.8 (4)
2.3 (14)
13.5 (2414)
11.8 (1236)
16.4 (8078)
a
Not all of total frequencies in cells add up to column totals due to missing data
b
Higher scale scores indicate more severity
c
CAGE is a substance use screener. A score of 2 or more is indicative of a potential problem with substance addiction
d
DRS: a score of 3? is indicative of possible depression and a score of 6? is indicative of more severe depression
e
Positive symptoms scale: higher scores indicate higher levels of psychotic symptoms
Table 4 Social and behavioral characteristics of individuals with mental illness who trigger at each level of the education & employment CAP in community mental health and inpatient settings Characteristics
Community (N = 1,015) EdEmp CAP Level 2 (n = 174) % (n)
Inpatient (N = 83,280) EdEmp CAP Level 1 (n = 218) % (n)
EdEmp CAP Level 0 (n = 623) % (n)
EdEmp CAP Level 2 (n = 18,993) % (n)
EdEmp CAP Level 1 (n = 11,100) % (n)
EdEmp CAP Level 0 (n = 53,187) % (n)
Has a criminal record
17.9 (29)
18.9 (39)
18.8 (78)
NA
NA
NA
Social relations: belief that relationships with immediate family disturbed or dysfunctional
25.0 (42)
20.0 (43)
18.5 (84)
26.4 (4926)
20.0 (2186)
17.0 (7152)
Interpersonal conflict (e.g., with family)
43.5 (73)
33.5 (72)
30.7 (139)
16.9 (3142)
15.2 (1659)
14.3 (6009)
Personal strengths: Not having a positive outlook
63.7 (107)
43.7 (94)
57.0 (258)
NA
NA
NA
4.8 (8)
4.2 (9)
7.5 (34)
NA
NA
NA
Activity Level: no days out in last 3 days NA not applicable
Discussion Unemployment, a disrupted education, or the lack of meaningful roles in the community is a major concern for the well being of persons with mental illness. This study
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indicates that many persons with mental illness are at a substantial risk of losing their employment or, if of school age, dropping out of school. Education and employment risk is a result of increased lateness or absenteeism, poor productivity or disruptiveness at work/school, an expressed
Community Ment Health J Table 5 Interventions for individuals with mental illness who trigger at each level of the education & employment CAP in community mental health and inpatient settings Interventions
Community (N = 1,015)
Inpatient (N = 83,280)
EdEmp CAP Level 2 (n = 174)a % (n)
EdEmp CAP Level 1 (n = 218) % (n)
EdEmp CAP Level 0 (n = 623) % (n)
Did not receive any
83.3 (140)
80.0 (172)
86.3 (391)
Offered but refused
3.0 (5)
5.1 (11)
3.5 (16)
0.3 (60)
0.3 (37)
0.3 (125)
Scheduled in 30 days
5.4 (9)
6.1 (13)
1.6 (7)
3.3 (621)
1.6 (176)
1.2 (495)
Received 8–30 days ago OR in last 7 days
8.3 (14)
8.8 (19)
8.6 (39)
2.6 (487)
2.0 (214)
1.0 (414)
Did not receive any
59.8 (104)
61.0 (133)
62.5 (388)
47.4 (9000)
58.6 (6500)
56.6 (30094)
Offered but refused
4.6 (8)
1.4 (3)
3.7 (23)
1.3 (254)
1.2 (132)
1.4 (730)
EdEmp CAP Level 2 (n = 18,993) % (n)
EdEmp CAP Level 1 (n = 11,100) % (n)
EdEmp CAP Level 0 (n = 53,187) % (n)
96.1 (10501)
97.5 (41008)
Vocational rehabilitation/counseling 93.7 (17476)
Psychosocial rehabilitation
Scheduled in 30 days
2.3 (4)
3.2 (7)
1.3 (8)
41.0 (7778)
33.0 (3662)
35.1 (18641)
33.3 (58)
34.4 (75)
32.5 (202)
10.3 (1961)
7.3 (806)
7.0 (3722)
58.3 (98)
65.6 (141)
61.6 (279)
48.5 (9033)
60.4 (6600)
58.2 (24463)
7.7 (13) 3.0 (5)
1.43 (3) 4.7 (10)
4.0 (18) 2.4 (11)
1.7 (324) 39.8 (7413)
1.5 (165) 30.0 (3278)
1.6 (680) 32.0 (13455)
31.0 (52)
28.4 (61)
32.0 (145)
10.1 (1874)
8.1 (885)
8.2 (3444)
Did not receive any
87.5 (147)
92.1 (198)
92.7 (420)
71.1 (13257)
79.8 (8720)
83.2 (34986)
Offered but refused
7.7 (13)
2.8 (6)
2.9 (13)
1.7 (347)
2.4 (262)
2.0 (834)
Scheduled in 30 days
0.0 (0)
0.9 (2)
0.9 (16)
23.7 (4416)
14.7 (1607)
12.8 (834)
4.80 (86)
4.2 (9)
3.5 (16)
3.4 (624)
3.1 (339)
2.0 (837)
Did not receive any
85.2 (143)
92.6 (199)
89.6 (406)
81.5 (15196)
89.0 (9729)
88.1 (37029)
Offered but refused
4.2 (7)
0.9 (2)
3.1 (14)
0.7 (133)
0.8 (85)
0.9 (364)
Scheduled in 30 days
3.6 (3)
0.0 (0)
0.9 (4)
12.99 (2422)
7.8 (855)
8.8 (3709)
Received 8–30 days ago OR in last 7 days
7.1 (12)
6.5 (14)
6.4 (29)
4.8 (2422)
2.4 (259)
2.2 (940)
81.2 (137)
88.8 (191)
81.0 (367)
66.9 (12470)
77.6 (8475)
74.2 (31211)
3.0 (5) 1.8 (5)
0.5 (1) 0.9 (2)
1.1 (5) 0.9 (4)
0.8 (155) 30.3 (5655)
0.7 (76) 20.1 (2195)
1.0 (413) 23.1 (9691)
13.7 (23)
9.8 (21)
17.0 (77)
2.0 (364)
1.7 (182)
1.7 (727)
Received 8–30 days ago OR in last 7 days Social-family functioning Did not receive any Offered but refused Scheduled in 30 days Received 8–30 days ago OR in last 7 days Alcohol–drug treatment
Received 8–30 days ago OR in last 7 days Anger management
Behavioural management Did not receive any Offered but refused Scheduled in 30 days Received 8–30 days ago OR in last 7 days a
Not all of total frequencies in cells add up to column totals due to missing data
intent to quit work/school, or persistent unemployment or a fluctuating work history. The results of this study indicate that males are more at risk of losing their employment or dropping out of school than females. As the purpose of this study was to provide an overview of the EdEmp CAP and its potential use in care planning, the limited analyses of the data were not intended to yield a full explanation for this observed difference in risk. It may be that it is more difficult for males to remain in the workforce or in school due to the nature of employment conditions (e.g., full-time
versus part-time) or that the specific symptoms related to their mental illness differs in a manner that affects sustained employment. The finding that the majority of persons over the age of 65 did not trigger the EdEmp CAP in either setting may be a measure of the validity of the CAP. That is, as this group of individuals is least likely to be in the job market looking for employment or being enrolled in school, vocational intervention is not necessary. As well, those in the age category 25–45 who would be expected to be pursuing
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Community Ment Health J
employment or education, were shown to be triggering Levels 1 and 2. It is interesting to note that despite the risks of losing employment or dropping out of school most persons in the study sample did not receive any services that may be helpful such as vocational rehabilitation or counseling to maintain their employment or stay in school, psychosocial rehabilitation to address their social and interpersonal relations, or other treatments or interventions for anger management and addictions. A small percentage of persons were offered such interventions, but they refused. Some others were scheduled to receive such services in 30 days. More individuals in the community than in-patients received psychosocial rehabilitation, social-family functioning and behavioural management in the preceding 8–30 or in the last 7 days. Unemployment leads to financial hardship and individuals with mental illness are forced to make trade-offs among purchases of adequate food, shelter, clothing, prescribed medications, sufficient home heat or cooling, and necessary health care. Meaningful employment or participation in education has been shown to increase self-esteem, alleviate psychiatric symptoms, and reduce dependency and relapse (Bond and Jones 2005; Lehman 1995). However, based on the findings of this study, individuals who are most at risk are not receiving the necessary therapeutic interventions to help them pursue education or employment that may contribute to their journey to recovery. To help these individuals with their personal journey to recovery, clinicians need to expand their treatment or intervention strategies beyond traditional approaches—such as managing adherence to psychotropic medication treatment—and include psychosocial and vocational rehabilitation. The interRAI assessment instruments and the associate EdEmp CAP may serve as effective tools to help identify persons with mental illness in community and inpatient mental health settings who are at risk of losing their employment or who could be supported to obtain employment. Aside from triggering algorithms described here, the EdEmp CAP includes evidence-based guidelines that may assist clinicians to help their clients with mental illness achieve their education or employment goals, including obtaining or keeping a job, pursuing schooling, or being engaged in meaningful social roles, such as volunteering. These intervention guidelines may be targeted to those individuals who have been unemployed for a while and wish to re-enter the workforce, and to those who have been separated from their jobs because of short- or longterm disability and wish to return to their job. The EdEmp CAP guidelines provide a full range of therapeutic interventions, including: assessing risk factors for unemployment or loss of employment; setting vocational goals and assessing readiness for employment; assessing and
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addressing the literacy skills necessary for performance on the job; assessing the readiness of and creating a supportive work environment; and general intervention measures to improve employment outcomes, including preventing the loss of employment. Specific intervention measures for education and volunteering are also included. Several limitations must be considered with regard to the findings of this study. First, for the purposes set out for this paper, only descriptive statistical analyses were carried out. Multivariate methods could be used in future analyses to identify specific risk factors associated with trigger levels. In addition, longitudinal analyses would be helpful to demonstrate trajectories of change in the experience of these individuals. Another limitation is that the community sample population was substantially smaller than the inpatient sample. A larger sample might contribute to better explanations of the observed relationships. While only a small proportion of individuals in both settings refused vocational rehabilitation or counseling services that offered, reasons for refusal should be explored.
Conclusions Based on the findings of this study, there is a substantial gap between the vocational rehabilitation needs of persons with mental illness in community and inpatient mental health settings and the services or therapeutic interventions that they receive to address those needs. These individuals also do not receive other supportive services targeted to their risk factors, such as addictions, anger, or interpersonal relationships. To help these individuals in their personal journey to recovery, clinicians need to expand their treatment or intervention strategies beyond traditional approaches—such as managing adherence to psychotropic medication treatment—and include psychosocial rehabilitation and vocational rehabilitation. Conflict of interest There are no known conflicts of interest related to this study.
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