Psychiatric Rehabilitation Journal 2014, Vol. 37, No. 2, 79 – 85
© 2014 American Psychological Association 1095-158X/14/$12.00 DOI: 10.1037/prj0000044
The IPS Supported Employment Learning Collaborative Deborah R. Becker, Robert E. Drake, and Gary R. Bond
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Geisel School of Medicine at Dartmouth Objective: Learning collaboratives aim to improve the quality and outcomes of health care. This paper updates the Johnson & Johnson–Dartmouth Community Mental Health Program, a 12-year learning collaborative on supported employment for people with mental illness. Methods: We gathered data from quarterly employment reports, monthly Individual Placement and Support (IPS) meetings, and presentations at the 2013 annual meeting of the learning collaborative. Results: The number of participant states or regions (and sites within these jurisdictions) was expanded to 16 jurisdictions in the United States and 3 in European countries. The quarterly rate of competitive employment has averaged 43% over 11 years in the U.S. sites. The collaborative has spawned numerous interactions, trainings, innovations, and research projects. Conclusions and Implications for Practice: Long-term learning collaboratives can produce high quality services, good outcomes, sustainability, and innovation. Keywords: supported employment, serious mental illness, learning collaborative
Most people who live with serious mental illness view employment as central to their recoveries, yet fewer than 15% have jobs and fewer than 2% receive evidence-based employment services (Bond & Drake, 2013). Since 2001, the Johnson & Johnson Office of Corporate Contributions has partnered with Dartmouth Psychiatric Research Center to increase access to evidence-based supported employment, also known as Individual Placement and Support (IPS supported employment). The Johnson & Johnson–Dartmouth Community Mental Health Program began as a small demonstration in three states and has evolved into an extensive learning collaborative that encompasses 16 jurisdictions in the United States (Alameda County California, Colorado, Connecticut, the District of Columbia, Illinois, Kansas, Kentucky, Maryland, Minnesota, Missouri, North Carolina, Ohio, Oregon, South Carolina, Vermont, and Wisconsin) and major regions of three European countries (Italy, The Netherlands, and Spain). Learning collaboratives emphasize the collection and monitoring of objective data regarding program implementation and outcome, regular communication among stakeholders, sharing of ideas and information, provision of training and technical assistance, and a commitment to research and innovation (Hulscher, Schouten, Grol, & Buchan, 2012; Nadeem, Olin, Hill, Hoagwood, & Horwitz, 2013). The IPS learning collaborative features all of these elements.
The purpose of this paper is to update progress on the IPS learning collaborative. We describe current status, outcomes, innovations, current research, and future directions.
Current Status Since 2001, the Johnson & Johnson–Dartmouth Community Mental Health Program has invited states and regional leaders interested in disseminating IPS to join the collaborative. Before joining the program, the state or regional leaders engage with Dartmouth to demonstrate the working partnership between the mental health authority and state vocational rehabilitation, the funding plan to implement and sustain IPS supported employment, and the interest of providers to participate. States and regions that join the collaborative receive four years of funding matched by their departments of mental health and vocational rehabilitation. The collaborative has two tiers: Dartmouth partners with state and regional mental health and vocational authorities to plan, implement, and monitor IPS supported employment programs. Simultaneously, the regional authorities oversee and foster local IPS programs and mutual learning environments within their regions to expand and sustain high-quality services. Dartmouth supports the learning collaborative in several respects: training and consultation to state leaders and trainers regarding funding mechanisms, policies and procedures to adopt IPS, program implementation and monitoring, and tracking outcomes. Dartmouth convenes an annual meeting of the state and regional leaders to discuss outcomes, implementation challenges and strategies, gaps in services, funding barriers, and innovations. Family and consumer leaders from each state and region partner to advocate for high quality employment services at the national and local levels. All states and regions in the United States that have completed the 4-year funding period have continued to participate actively in the learning collaborative. Of 157 sites joining the collaborative since 2002, 130 (83%) were active at the time of a 2012 survey (Bond et al., 2013). At the 2009 annual program meeting, the state and regional liaisons discussed and formally adopted the learning collaborative
This article was published Online First February 10, 2014. Deborah R. Becker, Department of Community and Family Medicine and Psychiatry, Geisel School of Medicine at Dartmouth, Dartmouth Psychiatric Research Center; Robert E. Drake and Gary R. Bond, Department of Psychiatry, Geisel School of Medicine at Dartmouth, Dartmouth Psychiatric Research Center. Correspondence concerning this article should be addressed to Deborah R. Becker, Dartmouth Psychiatric Research Center, Rivermill Commercial Center, 85 Mechanic St., Suite B4-1, Lebanon, NH 03766. E-mail: [email protected] 79
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
80
BECKER, DRAKE, AND BOND
model in part because they were already functioning as a learning collaborative by sharing outcomes, attending face-to-face annual meetings, identifying research projects together, and collaborating with each other. In 2012, through the encouragement of Johnson & Johnson, Dartmouth invited regions from three European countries (the Emilia-Romagna region of Italy, The Netherlands, and Catalonia, Spain) to join the learning collaborative. All IPS sites submit simple program-level quarterly outcomes that include the number of people receiving IPS, the number of people who obtain a competitive job, the number of new participants on the IPS caseload, the number of new job starts, the number of people who transition off the IPS caseload because they are working successfully and no longer needing IPS supports, the number of people participating in credit-bearing education (such as technical school, college, general educational development [GED] programs to earn high school equivalency credential), and the number of new participants in credit-bearing education. The number of IPS specialists with a caseload plus the IPS supervisor (if he or she has a caseload) defines the staffing pattern. Dartmouth summarizes the quarterly outcomes for the state and regional liaisons to distribute and review with the local sites. Sites benefit by sharing outcome data, participating in research projects, and participating in a large international network that promotes employment for people with mental illness. Additionally, sites receive complimentary educational materials that are produced by Dartmouth and others in the collaborative, such as updated manuals, brochures, posters, policy bulletins, newsletters, videos, and the online-supported employment course. Every state within the collaborative has adhered to standards for monitoring quality of implementation of IPS services: adopting and disseminating a shared set of IPS supported employment fidelity standards, conducting fidelity reviews to each site within the IPS learning collaborative, using independent, trained fidelity assessors who make site visits, providing feedback, and encouraging sites to develop corrective action plans (Becker, Swanson, Bond, & Merrens, 2011). Five of the 16 states within the collaborative have attached financial incentives to achieving high fidelity. The learning collaborative hosts an annual 2-day face-to-face meeting for the state and regional leaders, including the IPS trainer, the mental health authority liaison, the vocational rehabilitation liaison, a peer advocate, and the family advocacy team leader. The location of the meeting rotates each year to a different member state or region. The meeting agenda includes guest speakers, large group discussions, small discussion groups, and an awards ceremony and dinner. During these meetings state and regional leaders form relationships, exchange information, and strengthen networks and collaborations. Dartmouth hosts bimonthly teleconferences for the liaisons to continue exchanging information and learning throughout the year. Learning collaborative participants determine the topics discussed in these meetings. Examples include discussion of the Medicaid 1915i amendment, defining the role for Vocational Rehabilitation in implementing IPS, and strategies for providing benefits counseling. Stakeholder committees connect directly with their peers, usually by teleconference. For example, each jurisdiction has a family advocacy team that educates other families about the role of work in recovery from mental illness and IPS supported employment. In addition, they participate on state and regional IPS steering com-
mittees, legislative hearings, and trainings for IPS providers on how to engage families. The family advocates have a bimonthly teleconference to share their activities and experiences and have guest speakers to address topics of interest. Following the 2013 annual meeting, the IPS peer advocates started to have similar bimonthly teleconferences to discuss what role they want in promoting employment as part of recovery. Other peer groups in the collaborative, including the IPS trainers, IPS fidelity reviewers, the vocational rehabilitation liaisons, and a committee focused on cultural considerations and IPS, participate in regular teleconferences. The trainers, for example, discuss implementation challenges and successful strategies for training, technical assistance and consultation.
Outcomes The Johnson & Johnson-Dartmouth Program started reporting quarterly program outcomes in October–December, 2002 and has continued to the present. Ninety-two percent of sites have submitted outcome data continuously every quarter after joining the collaborative, confirming the collaborative’s strong commitment to outcome data collection and monitoring. Dartmouth has been producing quarterly reports summarizing the data and sending graphs back to the states during this period as well (Bond et al., 2013). In the initial reporting period in 2002, 792 people received IPS services and 299 people worked competitively. As shown in Figure 1, access to IPS supported employment has steadily expanded over the past 11 years as the number of new sites and new states and regions has increased. Annual competitive employment averages have been 40% or higher for each year after the initial year, which was 38%. In April–June, 2013, a total of 11,153 people were on the IPS caseload in the United States and 4,753 worked in a competitive job. The European partners in the collaborative follow a similar implementation plan of building consensus, providing training and consultation, tracking outcomes, and monitoring implementation using the IPS supported employment fidelity scale. They receive four years of funding, training, and consultation from Dartmouth, and other benefits of the collaborative (i.e., annual meetings, regular teleconferences with peers, complimentary educational materials, etc.). Currently, the European partners are discussing how to share outcomes and how to learn from each other’s cultural and economic contexts and that of the United States.
Recent Developments and Innovations Johnson and Johnson has also supported several special projects in the United States to demonstrate the feasibility of IPS supported employment for people who were homeless (Cleveland, Ohio), people who were in the criminal justice system (Chicago, Illinois), and people in peer-operated programs (New Jersey). In several jurisdictions, traditional clubhouses have elected to implement IPS supported employment. The collaborative has created and tested new methods and tools for training staff, tracking outcomes, and monitoring program fidelity. For example, recognizing the training needs of new IPS sites and of established sites experiencing staff turnover, Dartmouth developed an online training course. Another project in-
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
IPS SUPPORTED EMPLOYMENT LEARNING COLLABORATIVE
Figure 1.
81
Annual averages of people served and working in the IPS learning collaborative.
volved the development of Web-based fidelity software to assist with IPS supported employment fidelity reviews.
Online Training Course States and regions have experienced a need for expanded consultation and training capacity as the number of sites implementing IPS supported employment increases. To augment training by state trainers, Dartmouth designed the IPS supported employment online course in 2010. The course includes nine learning modules and an additional two modules for supervisors. Supervisors are encouraged to take the course with their employment specialists. Participants work at their own speed, but sections of the course close based on a timeline. Each learning module consists of 30 to 40 minutes of videos, reading, and questions and answers. Following the computer work, students practice new skills in their day-to-day work and describe their fieldwork experiences on the course’s discussion board. For example, after learning new techniques for building relationships with employers, students practice those techniques by meeting with employers. Unlike many other online courses, this training course includes contact with instructors who answer questions and comment on all discussion board postings. The course has been offered since 2010, and more than one thousand employment specialists, supervisors, IPS trainers, Vocational Rehabilitation counselors, and peer specialists from 32 states and 12 countries have participated.
tion for quality improvement. Program fidelity consistently correlates with good employment outcomes (Bond, Becker, Drake, & Vogler, 1997; Bond, Peterson, Becker & Drake, 2012). Conducting fidelity reviews includes writing a report with the findings and recommendations for improving program implementation. Fidelity reviewers, however, describe substantial time burden for writing these reports and potential for variation in scoring the fidelity scale items (Becker et al., 2011). In 2012, the Dartmouth IPS team developed a Web-based fidelity tool that automates the IPS fidelity report. Reviewers input information for each fidelity item, choose from a list of common comments/observations, and can insert their own comments as well. Similarly, reviewers choose from a list of recommendations that are often used in fidelity reviews and/or create their own recommendations. The fidelity template tool helps to standardize scoring, feedback, and recommendations.
Research Several recent study areas of the learning collaborative include the following: IPS implementation guidelines, employment benchmarks, validation of the 25-item IPS fidelity scale, role of vocational rehabilitation, employment outcomes in rural areas, employer attitudes on hiring people with criminal backgrounds, building employer relationships for job development, information technology and engagement, and education and IPS.
Web-Based Fidelity Template
Implementation Guidelines
Monitoring program implementation using the IPS supported employment fidelity scale (Becker et al., 2008) provides informa-
Key dissemination strategies have emerged from the Johnson & Johnson–Dartmouth Program (Becker, Swanson, & Lynde, 2008;
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
82
BECKER, DRAKE, AND BOND
Swanson, Burson, Harper, Johnson, & Litvak, 2011). First, state administrators from mental health and vocational rehabilitation address policies and funding barriers to promote IPS supported employment. Second, they partner with the IPS trainers to provide team-based training, field mentoring, and ongoing consultation to guide IPS implementation. Third, states and regions start with at least one full-time IPS trainer to provide in vivo training and mentoring. Two site visits per month are recommended until a program site achieves adequate IPS fidelity. Most of the states and regions in the collaborative used the 4-year funding from the Johnson & Johnson–Dartmouth Program to pay for the trainer position and subsequently continued the position through other funding sources. Fourth, the IPS trainer ensures that the IPS supervisor learns the skills of outcome-based supervision, field mentoring, and partnering with the local vocational rehabilitation counselors. Fifth, IPS trainers receive training, field mentoring, guidance, and support from Dartmouth, and connection to their peer network in the United States and in Europe to share information and learn new implementation strategies. Sixth, trained reviewers conduct IPS supported employment fidelity reviews to assess program implementation and make suggestions for corrective actions. Seventh, state leaders start small by initially supporting implementation in three to five sites, which is manageable for a full-time IPS trainer and allows for incremental learning about implementation in their state or region. Eighth, site selection procedures are used to identify sites that are ready to implement IPS. Liaisons and trainers visit sites interested in implementation to evaluate the leadership’s commitment and consent for organizational changes. Ninth, state leadership teams and local sites use fidelity scores and outcome data to make changes. For example, one state team noticed that fidelity scores for job development items were generally low statewide. The IPS trainers and supervisors increased modeling and coaching in the field and saw a rise in employment outcomes (Swanson et al., 2011). Feedback on performance in the form of user-friendly reports promotes communication between leaders and commitment to the learning collaborative principles (Marty, Rapp, McHugo, & Whitley, 2008).
Employment Benchmarks Employment supervisors and agency leaders want information about employment benchmarks to monitor their program goals. Using quarterly employment outcomes reported by 151 past and present programs in the IPS collaborative, we calculated the mean employment rate for each program during its time in the collaborative and then examined the frequency distribution of these rates to determine benchmarks (Drake, Bond, & Becker, 2012). The 25th percentile was 31%; the 50th percentile (median) was 41%; and the 75th percentile was 50%. These data suggest that a benchmark of 31% is a minimal standard, typically associated with either program start-up or suboptimal functioning. Quarterly employment rate benchmarks of 41% for established programs and 50% for high functioning programs seem realistic.
from national state trainers and consultants. To determine the validity of the updated 25-item scale, researchers analyzed fidelity scores for the 25-item scale, employment outcome data, local unemployment rate and program longevity from 79 sites from eight states in the IPS learning collaborative (Bond et al., 2012). The results showed good psychometric properties, including internal consistency reliability of .88 and predictive validity of .34 as measured by the correlation between IPS-25 and site-level employment rate.
Role of Vocational Rehabilitation IPS supported employment is typically implemented within a mental health agency. But the federal/state vocational rehabilitation program in the United States can enhance IPS services for people who meet eligibility requirements. For example, vocational rehabilitation counselors have considerable information about the local job market, all types of disabilities and health problems, and support for services and equipment. But how do vocational rehabilitation counselors function in relation to IPS supported employment in day-to-day practice? The Illinois state IPS team investigated this question in partnership with Dartmouth researchers. Using qualitative methodology, they conducted 21 focus groups with mental health consumers, vocational rehabilitation counselors, IPS specialists, and mental health practitioners. The interviews identified features of strong collaboration and specific strategies to enhance the effectiveness of the vocational rehabilitation and IPS team partnership for increasing employment outcomes. For example, to promote regular communication create guidelines for vocational rehabilitation counselor liaisons to attend monthly IPS staff team meetings (Oulvey, Carpenter-Song, & Swanson, 2013).
Rural Areas and Outcomes Does rurality affect the employment outcomes of people in IPS? Our team answered this question by analyzing longitudinal outcome data from 87 agencies in the IPS learning collaborative (Haslett, Bond, Drake, Becker, & McHugo, 2011). Sites were categorized by population density. The results indicated that rurality does not adversely affect employment outcomes of people in IPS. A subsequent study further suggested that mean fidelity ratings for rural and urban sites are also similar (Peterson, Bond, Becker, & Drake, in press).
Employer Attitudes on Hiring People With Legal System Involvement Many employment specialists report that employers will not hire people with a felony record. To understand this concern, Dartmouth trainers convened 12 state trainers from the IPS collaborative to design an employer survey about employer hiring practices. The trainers interviewed 128 employers in the United States and found that 63% had knowingly hired a person with a felony conviction. The authors provided recommendations about job interviewing techniques for people with felony convictions (Swanson, Langfitt-Reese, & Bond, 2012).
Validating the Revised IPS Supported Employment Fidelity Scale
Building Employer Relationships for Job Development
The 15-item IPS fidelity scale (Bond et al., 1997) was updated in 2008 to reflect new research findings and recommendations
IPS specialists must connect directly with the employers for job development. But few IPS specialists receive structured training on
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
IPS SUPPORTED EMPLOYMENT LEARNING COLLABORATIVE
how to build employer relationships. Based on years of experience training and mentoring IPS specialists and supervisors, Dartmouth trainers described a framework for IPS specialists to develop relationships with employers to learn about their businesses and hiring practices (Swanson, Becker, & Bond, 2013; Swanson & Becker, 2013). IPS specialists share this information about employers and their businesses with clients to help make good job matches that are consistent with employer needs and client preferences, skills, and experiences. As part of field mentoring, IPS supervisors demonstrate how to interview employers, observe IPS specialists meeting with employers, and provide feedback and recommendations for developing the skills for building employer relationships.
Information Technology and Service Engagement Mental health practitioners have been gatekeepers of employment services. Are clients given the necessary information in an inviting way to make choices about engaging in employment services? Current information technology provides possibilities to engage people in IPS and other psychiatric services. Our group (Haslett, McHugo, Bond, & Drake, in press) developed a mobile computer-based engagement intervention to educate clients about IPS supported employment and provided direct access to services through electronic self-referral. In a pilot study, 45 people were randomly assigned to the computerized intervention or to the comparison group that received a brochure with similar information. Significantly more people from the computerized intervention had at least one contact with an employment specialist within one month of the intervention than the people in the comparison condition.
tional program (10% in programs that had any people in education programs). Of those people, 18% (140/770) had entered the educational program that quarter. We speculate that there are several reasons why the education rate is much lower than the employment rate. First, the goal of education is overshadowed by the primary emphasis of IPS on employment. Second, IPS programs are geared up primarily to provide employment support, rather than education support. Third, funding for supported education is even more difficult than supported employment. Fourth, employment specialists and other practitioners may fail to recognize education as goal for career advancement. Education is increasingly a part of IPS with the recent attention to young adults and early intervention. We need more information to determine whether people who want to advance their careers through further education and training are accessing educational opportunities. Are young adults with mental illness staying in school or returning to school after interruptions caused by illness? Are people completing degrees rather than just completing courses? Recent studies show that the young adult population is showing interest in returning to both school and work (Baksheev, Allott, Jackson, McGorry, & Killackey, 2012; Killackey, Jackson, & McGorry, 2008; Nuechterlein et al., 2008; Rinaldi et al., 2010). Currently no clear guidelines exist for implementing supported education. Overall, the research on supported education is weak with research studies using different measures, different models, weak research designs, and small sample sizes (Rogers, Kash-MacDonald, Bruker, & Maru, 2010; Chandler, 2008). Further research should help define effective educational supports, recommended staffing patterns, and ways to overcome barriers to implementing supported education.
Future Directions
Education and IPS Many people want to advance their careers through education. Traditionally, people were offered educational opportunities through stepwise, group support in segregated settings rather than regular classroom experiences for credit alongside peers from the general population. Kansas colleagues in the IPS collaborative conducted two surveys to identify the staffing patterns for educational services, the educational services provided by the programs, and the elements of supported education that IPS supervisors consider important (Manthey, Rapp, Carlson, Holter, & Davis, 2012). Of the 98 agencies contacted from the 11 states in the collaborative at the time of the study, 68 completed the first survey. Respondents qualified to complete the second survey if their IPS program included supported education services. Fiftyseven percent of the people who responded to the first survey were eligible for the second survey, and from that group 84% completed the second survey. The majority of IPS programs provided supported education services. The most common staffing pattern was IPS specialists providing both supported employment and supported education. Recent data from the IPS learning collaborative indicate that in the quarter April–June, 2013, 67% of the 140 U.S. programs reported people participating in credit-bearing education and training programs, such as technical school, college, or a GED program. Overall, during this period 7% (770/11,153) of all the people in the 140 IPS programs participated in a credit-bearing educa-
83
Sustainability What factors contribute to the sustainability of IPS supported employment programs? How has the IPS learning collaborative contributed to the sustainability of IPS in each of the states/ regions? In 2011, the National Institute of Disability and Rehabilitation Research awarded Dartmouth a 3-year field-initiated research study to investigate the sustainability of programs in the IPS learning collaborative (Bond et al., 2013). The study is based on interviews with state and local program leaders to understand what factors influenced the survival and growth of IPS programs and the factors that led to the discontinuation of IPS programs.
Financing Barrier The growth of evidence-based supported employment largely depends on solving the financing barriers that have restricted the broad expansion of IPS in the United States. Currently, states and local sites face complicated financial schemes. The main sources of funding for IPS supported employment include Medicaid programs, state and local mental health funds, and the state/federal vocational rehabilitation system. The collaborative members share their financing strategies with each other, but largely still lack assurance of steady funding. Until a clear, streamlined, national financing plan is available, states and local agencies will continue
BECKER, DRAKE, AND BOND
84
to have difficulty expanding access to evidence-based supported employment.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Conclusions The IPS learning collaborative exemplifies a corporateuniversity-government partnership. Johnson & Johnson Corporate Contributions has given annual gifts starting in 2000 to increase access to IPS supported employment in the United States and now in three countries in Europe. The generous yearly gift provides the foundation for the learning collaborative activities. Partnering with Dartmouth researchers, state and regional mental health and vocational rehabilitation leaders systematically implement IPS, collect program outcomes, monitor implementation, and participate in studies together to advance the field. The strong commitment by state leaders to the learning collaborative beyond the initial period in which the state receives seed money is testimony to the perceived value of the collaborative. The IPS learning collaborative provides a mechanism to enhance program implementation, dissemination, and sustainability of evidence-based supported employment for people with serious mental illness. The state and regional leaders report many benefits of participating in the collaborative: partnering with IPS researchers, networking with colleagues from other geographic areas, collecting and comparing employment and education data, participating in research studies that advance the field, and having a framework to replicate the collaborative model on a state/ regional level. Many people who live with mental illnesses want to gain competitive employment and enjoy the benefits of work that other people enjoy— earning an income, using one’s talents and skills, having a structured meaningful activity. IPS supported employment assists tens of thousands of people in their recovery from mental illness through work. Solving the financing barriers presents an essential next step.
References Baksheev, G. N., Allott, K., Jackson, H. J., McGorry, P. D., & Killackey, E. (2012). Predictors of vocational recovery among young people with first-episode psychosis: Findings from a randomized controlled trial. Psychiatric Rehabilitation Journal, 35, 421– 427. doi:10.1037/h0094574 Becker, D. R., Drake, R. E., Bond, G. R., Nawaz, S., Haslett, W. R., & Martinez, R. (2011). A national mental health learning collaborative on supported employment. Psychiatric Services, 62, 704 –706. doi:10.1176/ appi.ps.62.7.704 Becker, D. R., Swanson, S. J., Bond, G. R., Carlson, L., Flint, L., Smith, G., & Lynde, D. (2008). Supported employment fidelity scale. Lebanon, NH: Dartmouth Psychiatric Research Center, http://sites .dartmouth.edu/ips Becker, D. R., Swanson, S., Bond, G. R., & Merrens, M. R. (2011). Evidence-based supported employment fidelity review manual (2nd ed.). Lebanon, NH: Dartmouth Psychiatric Research Center. Becker, D. R., Swanson, S., & Lynde, D. (2008). Strategies for state-wide implementation of supported employment: The Johnson & Johnson– Dartmouth Community Mental Health Program. Psychiatric Rehabilitation Journal, 31, 296 –299. doi:10.2975/31.4.2008.296.299 Bond, G. R., Becker, D. R., Drake, R. E., McHugo, G. J., Peterson, A. E., & Greene, M. A. (2013). Preliminary report on the NIDRR sustainability study: Summary of site leader interviews. Lebanon, NH: Dartmouth Psychiatric Research Center.
Bond, G. R., Becker, D. R., Drake, R. E., & Vogler, K. (1997). A fidelity scale for the Individual Placement and Support model of supported employment. Rehabilitation Counseling Bulletin, 40, 265–284. Bond, G. R., & Drake, R. E. (2013). Making the case for IPS supported employment. Administration and Policy in Mental Health and Mental Health Services Research, 39. doi:10.1007/s10488-10012–10444-10486 Bond, G. R., Peterson, A. E., Becker, D. R., & Drake, R. E. (2012). Validating the revised Individual Placement and Support Fidelity Scale (IPS-25). Psychiatric Services, 63, 758 –763. doi:10.1176/appi.ps .201100476 Chandler, D. (2008, June). Supported education for persons with psychiatric disabilities. California Institute for Mental Health. Drake, R. E., Bond, G. R., & Becker, D. R. (2012). Individual Placement and Support: An evidence-based approach to supported employment. New York, NY: Oxford University Press. doi:10.1093/acprof:oso/ 9780199734016.001.0001 Haslett, W. R., Bond, G. R., Drake, R. E., Becker, D. R., & McHugo, G. J. (2011). Individual Placement and Support: Does rurality matter? American Journal of Psychiatric Rehabilitation, 14, 237–244. doi:10.1080/ 15487768.2011.598106 Haslett, W. R., McHugo, G. J., Bond, G. R., & Drake, R. E. (in press). Computerized engagement for supported employment: A randomized controlled trial. Hulscher, M. E., Schouten, L. M., Grol, R. P., & Buchan, H. (2012). Determinants of success of quality improvement collaboratives: What does the literature show? British Medical Journal Quality and Safety, Online First, published on August 9 2012 as 10.1136/bmjqs-2011– 000651 Killackey, E., Jackson, H. J., & McGorry, P. D. (2008). Vocational intervention in first-episode psychosis: A randomized controlled trial of individual placement and support versus treatment as usual. The British Journal of Psychiatry, 193, 114 –120. doi:10.1192/bjp.bp.107.043109 Manthey, T. J., Rapp, C. A., Carlson, L., Holter, M. C., & Davis, J. K. (2012). The perceived importance of integrated supported employment and employment services. Journal of Rehabilitation, 78, 16 –24. Marty, D., Rapp, C. A., McHugo, G., & Whitley, R. (2008). Factors influencing consumer outcome monitoring in implementation of evidence-based practices: Results from the National EBP Implementation Project. Administration and Policy in Mental Health and Mental Health Services Research, 35, 204 –211. doi:10.1007/s10488-0070157-4 Nadeem, E., Olin, S. S., Hill, L. C., Hoagwood, K. E., & Horwitz, S. M. (2013). Understanding the components of quality improvement collaboratives: A systematic literature review. Milbank Quarterly, 91, 354 – 394. doi:10.1111/milq.12016 Nuechterlein, K. H., Subotnik, K. L., Turner, L. R., Ventura, J., Becker, D. R., & Drake, R. E. (2008). Individual placement and support for individuals with recent-onset schizophrenia: Integrating supported education and supported employment. Psychiatric Rehabilitation Journal, 31, 340 –349. doi:10.2975/31.4.2008.340.349 Oulvey, E., Carpenter-Song, E. A., & Swanson, S. J. (2013). Principles for enhancing the role of state vocational rehabilitation in IPS-supported employment. Psychiatric Rehabilitation Journal, 36, 4 – 6. doi:10.1037/ h0094740 Peterson, A. E., Bond, G. R., Becker, D. R., & Drake, R. E. (in press). Achieving high fidelity to supported employment: Comparing programs in small and large communities. Community Mental Health Journal. Rinaldi, M., Killackey, E., Smith, J., Shepherd, G., Singh, S. P., & Craig, T. (2010). First episode psychosis and employment: A review. International Review of Psychiatry, 22, 148 –162. doi:10.3109/ 09540261003661825 Rogers, E. S., Kash-MacDonald, M., Bruker, D., & Maru, M. (2010). Systematic review of supported education literature 1989 –2009. Boston,
IPS SUPPORTED EMPLOYMENT LEARNING COLLABORATIVE
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
MA: Boston University, Sargent College, Center for Psychiatric Rehabilitation. www.bu.edu/drrk Swanson, S. J., & Becker, D. R. (2013). IPS supported employment: A practical guide. Lebanon, NH: Dartmouth Psychiatric Research Center. Swanson, S. J., Becker, D. R., & Bond, G. R. (2013). Job development guidelines in supported employment. Psychiatric Rehabilitation Journal, 36, 122–123. doi:10.1037/h0094988 Swanson, S. J., Burson, K., Harper, J., Johnson, B., & Litvak, J. (2011). Implementation issues for IPS supported employment: Stakeholders share their strategies. American Journal of Psychiatric Rehabilitation, 14, 165–180. doi:10.1080/15487768.2011.598099
85
Swanson, S. J., Langfitt-Reese, S., & Bond, G. R. (2012). Employer attitudes about criminal justice history. Psychiatric Rehabilitation Journal, 35, 385–390. doi:10.1037/h0094498
Received November 3, 2013 Revision received December 1, 2013 Accepted December 6, 2013 䡲
© 2014 American Psychological Association 1095-158X/14/$12.00 DOI: 10.1037/prj0000044
The IPS Supported Employment Learning Collaborative Deborah R. Becker, Robert E. Drake, and Gary R. Bond
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Geisel School of Medicine at Dartmouth Objective: Learning collaboratives aim to improve the quality and outcomes of health care. This paper updates the Johnson & Johnson–Dartmouth Community Mental Health Program, a 12-year learning collaborative on supported employment for people with mental illness. Methods: We gathered data from quarterly employment reports, monthly Individual Placement and Support (IPS) meetings, and presentations at the 2013 annual meeting of the learning collaborative. Results: The number of participant states or regions (and sites within these jurisdictions) was expanded to 16 jurisdictions in the United States and 3 in European countries. The quarterly rate of competitive employment has averaged 43% over 11 years in the U.S. sites. The collaborative has spawned numerous interactions, trainings, innovations, and research projects. Conclusions and Implications for Practice: Long-term learning collaboratives can produce high quality services, good outcomes, sustainability, and innovation. Keywords: supported employment, serious mental illness, learning collaborative
Most people who live with serious mental illness view employment as central to their recoveries, yet fewer than 15% have jobs and fewer than 2% receive evidence-based employment services (Bond & Drake, 2013). Since 2001, the Johnson & Johnson Office of Corporate Contributions has partnered with Dartmouth Psychiatric Research Center to increase access to evidence-based supported employment, also known as Individual Placement and Support (IPS supported employment). The Johnson & Johnson–Dartmouth Community Mental Health Program began as a small demonstration in three states and has evolved into an extensive learning collaborative that encompasses 16 jurisdictions in the United States (Alameda County California, Colorado, Connecticut, the District of Columbia, Illinois, Kansas, Kentucky, Maryland, Minnesota, Missouri, North Carolina, Ohio, Oregon, South Carolina, Vermont, and Wisconsin) and major regions of three European countries (Italy, The Netherlands, and Spain). Learning collaboratives emphasize the collection and monitoring of objective data regarding program implementation and outcome, regular communication among stakeholders, sharing of ideas and information, provision of training and technical assistance, and a commitment to research and innovation (Hulscher, Schouten, Grol, & Buchan, 2012; Nadeem, Olin, Hill, Hoagwood, & Horwitz, 2013). The IPS learning collaborative features all of these elements.
The purpose of this paper is to update progress on the IPS learning collaborative. We describe current status, outcomes, innovations, current research, and future directions.
Current Status Since 2001, the Johnson & Johnson–Dartmouth Community Mental Health Program has invited states and regional leaders interested in disseminating IPS to join the collaborative. Before joining the program, the state or regional leaders engage with Dartmouth to demonstrate the working partnership between the mental health authority and state vocational rehabilitation, the funding plan to implement and sustain IPS supported employment, and the interest of providers to participate. States and regions that join the collaborative receive four years of funding matched by their departments of mental health and vocational rehabilitation. The collaborative has two tiers: Dartmouth partners with state and regional mental health and vocational authorities to plan, implement, and monitor IPS supported employment programs. Simultaneously, the regional authorities oversee and foster local IPS programs and mutual learning environments within their regions to expand and sustain high-quality services. Dartmouth supports the learning collaborative in several respects: training and consultation to state leaders and trainers regarding funding mechanisms, policies and procedures to adopt IPS, program implementation and monitoring, and tracking outcomes. Dartmouth convenes an annual meeting of the state and regional leaders to discuss outcomes, implementation challenges and strategies, gaps in services, funding barriers, and innovations. Family and consumer leaders from each state and region partner to advocate for high quality employment services at the national and local levels. All states and regions in the United States that have completed the 4-year funding period have continued to participate actively in the learning collaborative. Of 157 sites joining the collaborative since 2002, 130 (83%) were active at the time of a 2012 survey (Bond et al., 2013). At the 2009 annual program meeting, the state and regional liaisons discussed and formally adopted the learning collaborative
This article was published Online First February 10, 2014. Deborah R. Becker, Department of Community and Family Medicine and Psychiatry, Geisel School of Medicine at Dartmouth, Dartmouth Psychiatric Research Center; Robert E. Drake and Gary R. Bond, Department of Psychiatry, Geisel School of Medicine at Dartmouth, Dartmouth Psychiatric Research Center. Correspondence concerning this article should be addressed to Deborah R. Becker, Dartmouth Psychiatric Research Center, Rivermill Commercial Center, 85 Mechanic St., Suite B4-1, Lebanon, NH 03766. E-mail: [email protected] 79
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
80
BECKER, DRAKE, AND BOND
model in part because they were already functioning as a learning collaborative by sharing outcomes, attending face-to-face annual meetings, identifying research projects together, and collaborating with each other. In 2012, through the encouragement of Johnson & Johnson, Dartmouth invited regions from three European countries (the Emilia-Romagna region of Italy, The Netherlands, and Catalonia, Spain) to join the learning collaborative. All IPS sites submit simple program-level quarterly outcomes that include the number of people receiving IPS, the number of people who obtain a competitive job, the number of new participants on the IPS caseload, the number of new job starts, the number of people who transition off the IPS caseload because they are working successfully and no longer needing IPS supports, the number of people participating in credit-bearing education (such as technical school, college, general educational development [GED] programs to earn high school equivalency credential), and the number of new participants in credit-bearing education. The number of IPS specialists with a caseload plus the IPS supervisor (if he or she has a caseload) defines the staffing pattern. Dartmouth summarizes the quarterly outcomes for the state and regional liaisons to distribute and review with the local sites. Sites benefit by sharing outcome data, participating in research projects, and participating in a large international network that promotes employment for people with mental illness. Additionally, sites receive complimentary educational materials that are produced by Dartmouth and others in the collaborative, such as updated manuals, brochures, posters, policy bulletins, newsletters, videos, and the online-supported employment course. Every state within the collaborative has adhered to standards for monitoring quality of implementation of IPS services: adopting and disseminating a shared set of IPS supported employment fidelity standards, conducting fidelity reviews to each site within the IPS learning collaborative, using independent, trained fidelity assessors who make site visits, providing feedback, and encouraging sites to develop corrective action plans (Becker, Swanson, Bond, & Merrens, 2011). Five of the 16 states within the collaborative have attached financial incentives to achieving high fidelity. The learning collaborative hosts an annual 2-day face-to-face meeting for the state and regional leaders, including the IPS trainer, the mental health authority liaison, the vocational rehabilitation liaison, a peer advocate, and the family advocacy team leader. The location of the meeting rotates each year to a different member state or region. The meeting agenda includes guest speakers, large group discussions, small discussion groups, and an awards ceremony and dinner. During these meetings state and regional leaders form relationships, exchange information, and strengthen networks and collaborations. Dartmouth hosts bimonthly teleconferences for the liaisons to continue exchanging information and learning throughout the year. Learning collaborative participants determine the topics discussed in these meetings. Examples include discussion of the Medicaid 1915i amendment, defining the role for Vocational Rehabilitation in implementing IPS, and strategies for providing benefits counseling. Stakeholder committees connect directly with their peers, usually by teleconference. For example, each jurisdiction has a family advocacy team that educates other families about the role of work in recovery from mental illness and IPS supported employment. In addition, they participate on state and regional IPS steering com-
mittees, legislative hearings, and trainings for IPS providers on how to engage families. The family advocates have a bimonthly teleconference to share their activities and experiences and have guest speakers to address topics of interest. Following the 2013 annual meeting, the IPS peer advocates started to have similar bimonthly teleconferences to discuss what role they want in promoting employment as part of recovery. Other peer groups in the collaborative, including the IPS trainers, IPS fidelity reviewers, the vocational rehabilitation liaisons, and a committee focused on cultural considerations and IPS, participate in regular teleconferences. The trainers, for example, discuss implementation challenges and successful strategies for training, technical assistance and consultation.
Outcomes The Johnson & Johnson-Dartmouth Program started reporting quarterly program outcomes in October–December, 2002 and has continued to the present. Ninety-two percent of sites have submitted outcome data continuously every quarter after joining the collaborative, confirming the collaborative’s strong commitment to outcome data collection and monitoring. Dartmouth has been producing quarterly reports summarizing the data and sending graphs back to the states during this period as well (Bond et al., 2013). In the initial reporting period in 2002, 792 people received IPS services and 299 people worked competitively. As shown in Figure 1, access to IPS supported employment has steadily expanded over the past 11 years as the number of new sites and new states and regions has increased. Annual competitive employment averages have been 40% or higher for each year after the initial year, which was 38%. In April–June, 2013, a total of 11,153 people were on the IPS caseload in the United States and 4,753 worked in a competitive job. The European partners in the collaborative follow a similar implementation plan of building consensus, providing training and consultation, tracking outcomes, and monitoring implementation using the IPS supported employment fidelity scale. They receive four years of funding, training, and consultation from Dartmouth, and other benefits of the collaborative (i.e., annual meetings, regular teleconferences with peers, complimentary educational materials, etc.). Currently, the European partners are discussing how to share outcomes and how to learn from each other’s cultural and economic contexts and that of the United States.
Recent Developments and Innovations Johnson and Johnson has also supported several special projects in the United States to demonstrate the feasibility of IPS supported employment for people who were homeless (Cleveland, Ohio), people who were in the criminal justice system (Chicago, Illinois), and people in peer-operated programs (New Jersey). In several jurisdictions, traditional clubhouses have elected to implement IPS supported employment. The collaborative has created and tested new methods and tools for training staff, tracking outcomes, and monitoring program fidelity. For example, recognizing the training needs of new IPS sites and of established sites experiencing staff turnover, Dartmouth developed an online training course. Another project in-
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
IPS SUPPORTED EMPLOYMENT LEARNING COLLABORATIVE
Figure 1.
81
Annual averages of people served and working in the IPS learning collaborative.
volved the development of Web-based fidelity software to assist with IPS supported employment fidelity reviews.
Online Training Course States and regions have experienced a need for expanded consultation and training capacity as the number of sites implementing IPS supported employment increases. To augment training by state trainers, Dartmouth designed the IPS supported employment online course in 2010. The course includes nine learning modules and an additional two modules for supervisors. Supervisors are encouraged to take the course with their employment specialists. Participants work at their own speed, but sections of the course close based on a timeline. Each learning module consists of 30 to 40 minutes of videos, reading, and questions and answers. Following the computer work, students practice new skills in their day-to-day work and describe their fieldwork experiences on the course’s discussion board. For example, after learning new techniques for building relationships with employers, students practice those techniques by meeting with employers. Unlike many other online courses, this training course includes contact with instructors who answer questions and comment on all discussion board postings. The course has been offered since 2010, and more than one thousand employment specialists, supervisors, IPS trainers, Vocational Rehabilitation counselors, and peer specialists from 32 states and 12 countries have participated.
tion for quality improvement. Program fidelity consistently correlates with good employment outcomes (Bond, Becker, Drake, & Vogler, 1997; Bond, Peterson, Becker & Drake, 2012). Conducting fidelity reviews includes writing a report with the findings and recommendations for improving program implementation. Fidelity reviewers, however, describe substantial time burden for writing these reports and potential for variation in scoring the fidelity scale items (Becker et al., 2011). In 2012, the Dartmouth IPS team developed a Web-based fidelity tool that automates the IPS fidelity report. Reviewers input information for each fidelity item, choose from a list of common comments/observations, and can insert their own comments as well. Similarly, reviewers choose from a list of recommendations that are often used in fidelity reviews and/or create their own recommendations. The fidelity template tool helps to standardize scoring, feedback, and recommendations.
Research Several recent study areas of the learning collaborative include the following: IPS implementation guidelines, employment benchmarks, validation of the 25-item IPS fidelity scale, role of vocational rehabilitation, employment outcomes in rural areas, employer attitudes on hiring people with criminal backgrounds, building employer relationships for job development, information technology and engagement, and education and IPS.
Web-Based Fidelity Template
Implementation Guidelines
Monitoring program implementation using the IPS supported employment fidelity scale (Becker et al., 2008) provides informa-
Key dissemination strategies have emerged from the Johnson & Johnson–Dartmouth Program (Becker, Swanson, & Lynde, 2008;
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
82
BECKER, DRAKE, AND BOND
Swanson, Burson, Harper, Johnson, & Litvak, 2011). First, state administrators from mental health and vocational rehabilitation address policies and funding barriers to promote IPS supported employment. Second, they partner with the IPS trainers to provide team-based training, field mentoring, and ongoing consultation to guide IPS implementation. Third, states and regions start with at least one full-time IPS trainer to provide in vivo training and mentoring. Two site visits per month are recommended until a program site achieves adequate IPS fidelity. Most of the states and regions in the collaborative used the 4-year funding from the Johnson & Johnson–Dartmouth Program to pay for the trainer position and subsequently continued the position through other funding sources. Fourth, the IPS trainer ensures that the IPS supervisor learns the skills of outcome-based supervision, field mentoring, and partnering with the local vocational rehabilitation counselors. Fifth, IPS trainers receive training, field mentoring, guidance, and support from Dartmouth, and connection to their peer network in the United States and in Europe to share information and learn new implementation strategies. Sixth, trained reviewers conduct IPS supported employment fidelity reviews to assess program implementation and make suggestions for corrective actions. Seventh, state leaders start small by initially supporting implementation in three to five sites, which is manageable for a full-time IPS trainer and allows for incremental learning about implementation in their state or region. Eighth, site selection procedures are used to identify sites that are ready to implement IPS. Liaisons and trainers visit sites interested in implementation to evaluate the leadership’s commitment and consent for organizational changes. Ninth, state leadership teams and local sites use fidelity scores and outcome data to make changes. For example, one state team noticed that fidelity scores for job development items were generally low statewide. The IPS trainers and supervisors increased modeling and coaching in the field and saw a rise in employment outcomes (Swanson et al., 2011). Feedback on performance in the form of user-friendly reports promotes communication between leaders and commitment to the learning collaborative principles (Marty, Rapp, McHugo, & Whitley, 2008).
Employment Benchmarks Employment supervisors and agency leaders want information about employment benchmarks to monitor their program goals. Using quarterly employment outcomes reported by 151 past and present programs in the IPS collaborative, we calculated the mean employment rate for each program during its time in the collaborative and then examined the frequency distribution of these rates to determine benchmarks (Drake, Bond, & Becker, 2012). The 25th percentile was 31%; the 50th percentile (median) was 41%; and the 75th percentile was 50%. These data suggest that a benchmark of 31% is a minimal standard, typically associated with either program start-up or suboptimal functioning. Quarterly employment rate benchmarks of 41% for established programs and 50% for high functioning programs seem realistic.
from national state trainers and consultants. To determine the validity of the updated 25-item scale, researchers analyzed fidelity scores for the 25-item scale, employment outcome data, local unemployment rate and program longevity from 79 sites from eight states in the IPS learning collaborative (Bond et al., 2012). The results showed good psychometric properties, including internal consistency reliability of .88 and predictive validity of .34 as measured by the correlation between IPS-25 and site-level employment rate.
Role of Vocational Rehabilitation IPS supported employment is typically implemented within a mental health agency. But the federal/state vocational rehabilitation program in the United States can enhance IPS services for people who meet eligibility requirements. For example, vocational rehabilitation counselors have considerable information about the local job market, all types of disabilities and health problems, and support for services and equipment. But how do vocational rehabilitation counselors function in relation to IPS supported employment in day-to-day practice? The Illinois state IPS team investigated this question in partnership with Dartmouth researchers. Using qualitative methodology, they conducted 21 focus groups with mental health consumers, vocational rehabilitation counselors, IPS specialists, and mental health practitioners. The interviews identified features of strong collaboration and specific strategies to enhance the effectiveness of the vocational rehabilitation and IPS team partnership for increasing employment outcomes. For example, to promote regular communication create guidelines for vocational rehabilitation counselor liaisons to attend monthly IPS staff team meetings (Oulvey, Carpenter-Song, & Swanson, 2013).
Rural Areas and Outcomes Does rurality affect the employment outcomes of people in IPS? Our team answered this question by analyzing longitudinal outcome data from 87 agencies in the IPS learning collaborative (Haslett, Bond, Drake, Becker, & McHugo, 2011). Sites were categorized by population density. The results indicated that rurality does not adversely affect employment outcomes of people in IPS. A subsequent study further suggested that mean fidelity ratings for rural and urban sites are also similar (Peterson, Bond, Becker, & Drake, in press).
Employer Attitudes on Hiring People With Legal System Involvement Many employment specialists report that employers will not hire people with a felony record. To understand this concern, Dartmouth trainers convened 12 state trainers from the IPS collaborative to design an employer survey about employer hiring practices. The trainers interviewed 128 employers in the United States and found that 63% had knowingly hired a person with a felony conviction. The authors provided recommendations about job interviewing techniques for people with felony convictions (Swanson, Langfitt-Reese, & Bond, 2012).
Validating the Revised IPS Supported Employment Fidelity Scale
Building Employer Relationships for Job Development
The 15-item IPS fidelity scale (Bond et al., 1997) was updated in 2008 to reflect new research findings and recommendations
IPS specialists must connect directly with the employers for job development. But few IPS specialists receive structured training on
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
IPS SUPPORTED EMPLOYMENT LEARNING COLLABORATIVE
how to build employer relationships. Based on years of experience training and mentoring IPS specialists and supervisors, Dartmouth trainers described a framework for IPS specialists to develop relationships with employers to learn about their businesses and hiring practices (Swanson, Becker, & Bond, 2013; Swanson & Becker, 2013). IPS specialists share this information about employers and their businesses with clients to help make good job matches that are consistent with employer needs and client preferences, skills, and experiences. As part of field mentoring, IPS supervisors demonstrate how to interview employers, observe IPS specialists meeting with employers, and provide feedback and recommendations for developing the skills for building employer relationships.
Information Technology and Service Engagement Mental health practitioners have been gatekeepers of employment services. Are clients given the necessary information in an inviting way to make choices about engaging in employment services? Current information technology provides possibilities to engage people in IPS and other psychiatric services. Our group (Haslett, McHugo, Bond, & Drake, in press) developed a mobile computer-based engagement intervention to educate clients about IPS supported employment and provided direct access to services through electronic self-referral. In a pilot study, 45 people were randomly assigned to the computerized intervention or to the comparison group that received a brochure with similar information. Significantly more people from the computerized intervention had at least one contact with an employment specialist within one month of the intervention than the people in the comparison condition.
tional program (10% in programs that had any people in education programs). Of those people, 18% (140/770) had entered the educational program that quarter. We speculate that there are several reasons why the education rate is much lower than the employment rate. First, the goal of education is overshadowed by the primary emphasis of IPS on employment. Second, IPS programs are geared up primarily to provide employment support, rather than education support. Third, funding for supported education is even more difficult than supported employment. Fourth, employment specialists and other practitioners may fail to recognize education as goal for career advancement. Education is increasingly a part of IPS with the recent attention to young adults and early intervention. We need more information to determine whether people who want to advance their careers through further education and training are accessing educational opportunities. Are young adults with mental illness staying in school or returning to school after interruptions caused by illness? Are people completing degrees rather than just completing courses? Recent studies show that the young adult population is showing interest in returning to both school and work (Baksheev, Allott, Jackson, McGorry, & Killackey, 2012; Killackey, Jackson, & McGorry, 2008; Nuechterlein et al., 2008; Rinaldi et al., 2010). Currently no clear guidelines exist for implementing supported education. Overall, the research on supported education is weak with research studies using different measures, different models, weak research designs, and small sample sizes (Rogers, Kash-MacDonald, Bruker, & Maru, 2010; Chandler, 2008). Further research should help define effective educational supports, recommended staffing patterns, and ways to overcome barriers to implementing supported education.
Future Directions
Education and IPS Many people want to advance their careers through education. Traditionally, people were offered educational opportunities through stepwise, group support in segregated settings rather than regular classroom experiences for credit alongside peers from the general population. Kansas colleagues in the IPS collaborative conducted two surveys to identify the staffing patterns for educational services, the educational services provided by the programs, and the elements of supported education that IPS supervisors consider important (Manthey, Rapp, Carlson, Holter, & Davis, 2012). Of the 98 agencies contacted from the 11 states in the collaborative at the time of the study, 68 completed the first survey. Respondents qualified to complete the second survey if their IPS program included supported education services. Fiftyseven percent of the people who responded to the first survey were eligible for the second survey, and from that group 84% completed the second survey. The majority of IPS programs provided supported education services. The most common staffing pattern was IPS specialists providing both supported employment and supported education. Recent data from the IPS learning collaborative indicate that in the quarter April–June, 2013, 67% of the 140 U.S. programs reported people participating in credit-bearing education and training programs, such as technical school, college, or a GED program. Overall, during this period 7% (770/11,153) of all the people in the 140 IPS programs participated in a credit-bearing educa-
83
Sustainability What factors contribute to the sustainability of IPS supported employment programs? How has the IPS learning collaborative contributed to the sustainability of IPS in each of the states/ regions? In 2011, the National Institute of Disability and Rehabilitation Research awarded Dartmouth a 3-year field-initiated research study to investigate the sustainability of programs in the IPS learning collaborative (Bond et al., 2013). The study is based on interviews with state and local program leaders to understand what factors influenced the survival and growth of IPS programs and the factors that led to the discontinuation of IPS programs.
Financing Barrier The growth of evidence-based supported employment largely depends on solving the financing barriers that have restricted the broad expansion of IPS in the United States. Currently, states and local sites face complicated financial schemes. The main sources of funding for IPS supported employment include Medicaid programs, state and local mental health funds, and the state/federal vocational rehabilitation system. The collaborative members share their financing strategies with each other, but largely still lack assurance of steady funding. Until a clear, streamlined, national financing plan is available, states and local agencies will continue
BECKER, DRAKE, AND BOND
84
to have difficulty expanding access to evidence-based supported employment.
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Conclusions The IPS learning collaborative exemplifies a corporateuniversity-government partnership. Johnson & Johnson Corporate Contributions has given annual gifts starting in 2000 to increase access to IPS supported employment in the United States and now in three countries in Europe. The generous yearly gift provides the foundation for the learning collaborative activities. Partnering with Dartmouth researchers, state and regional mental health and vocational rehabilitation leaders systematically implement IPS, collect program outcomes, monitor implementation, and participate in studies together to advance the field. The strong commitment by state leaders to the learning collaborative beyond the initial period in which the state receives seed money is testimony to the perceived value of the collaborative. The IPS learning collaborative provides a mechanism to enhance program implementation, dissemination, and sustainability of evidence-based supported employment for people with serious mental illness. The state and regional leaders report many benefits of participating in the collaborative: partnering with IPS researchers, networking with colleagues from other geographic areas, collecting and comparing employment and education data, participating in research studies that advance the field, and having a framework to replicate the collaborative model on a state/ regional level. Many people who live with mental illnesses want to gain competitive employment and enjoy the benefits of work that other people enjoy— earning an income, using one’s talents and skills, having a structured meaningful activity. IPS supported employment assists tens of thousands of people in their recovery from mental illness through work. Solving the financing barriers presents an essential next step.
References Baksheev, G. N., Allott, K., Jackson, H. J., McGorry, P. D., & Killackey, E. (2012). Predictors of vocational recovery among young people with first-episode psychosis: Findings from a randomized controlled trial. Psychiatric Rehabilitation Journal, 35, 421– 427. doi:10.1037/h0094574 Becker, D. R., Drake, R. E., Bond, G. R., Nawaz, S., Haslett, W. R., & Martinez, R. (2011). A national mental health learning collaborative on supported employment. Psychiatric Services, 62, 704 –706. doi:10.1176/ appi.ps.62.7.704 Becker, D. R., Swanson, S. J., Bond, G. R., Carlson, L., Flint, L., Smith, G., & Lynde, D. (2008). Supported employment fidelity scale. Lebanon, NH: Dartmouth Psychiatric Research Center, http://sites .dartmouth.edu/ips Becker, D. R., Swanson, S., Bond, G. R., & Merrens, M. R. (2011). Evidence-based supported employment fidelity review manual (2nd ed.). Lebanon, NH: Dartmouth Psychiatric Research Center. Becker, D. R., Swanson, S., & Lynde, D. (2008). Strategies for state-wide implementation of supported employment: The Johnson & Johnson– Dartmouth Community Mental Health Program. Psychiatric Rehabilitation Journal, 31, 296 –299. doi:10.2975/31.4.2008.296.299 Bond, G. R., Becker, D. R., Drake, R. E., McHugo, G. J., Peterson, A. E., & Greene, M. A. (2013). Preliminary report on the NIDRR sustainability study: Summary of site leader interviews. Lebanon, NH: Dartmouth Psychiatric Research Center.
Bond, G. R., Becker, D. R., Drake, R. E., & Vogler, K. (1997). A fidelity scale for the Individual Placement and Support model of supported employment. Rehabilitation Counseling Bulletin, 40, 265–284. Bond, G. R., & Drake, R. E. (2013). Making the case for IPS supported employment. Administration and Policy in Mental Health and Mental Health Services Research, 39. doi:10.1007/s10488-10012–10444-10486 Bond, G. R., Peterson, A. E., Becker, D. R., & Drake, R. E. (2012). Validating the revised Individual Placement and Support Fidelity Scale (IPS-25). Psychiatric Services, 63, 758 –763. doi:10.1176/appi.ps .201100476 Chandler, D. (2008, June). Supported education for persons with psychiatric disabilities. California Institute for Mental Health. Drake, R. E., Bond, G. R., & Becker, D. R. (2012). Individual Placement and Support: An evidence-based approach to supported employment. New York, NY: Oxford University Press. doi:10.1093/acprof:oso/ 9780199734016.001.0001 Haslett, W. R., Bond, G. R., Drake, R. E., Becker, D. R., & McHugo, G. J. (2011). Individual Placement and Support: Does rurality matter? American Journal of Psychiatric Rehabilitation, 14, 237–244. doi:10.1080/ 15487768.2011.598106 Haslett, W. R., McHugo, G. J., Bond, G. R., & Drake, R. E. (in press). Computerized engagement for supported employment: A randomized controlled trial. Hulscher, M. E., Schouten, L. M., Grol, R. P., & Buchan, H. (2012). Determinants of success of quality improvement collaboratives: What does the literature show? British Medical Journal Quality and Safety, Online First, published on August 9 2012 as 10.1136/bmjqs-2011– 000651 Killackey, E., Jackson, H. J., & McGorry, P. D. (2008). Vocational intervention in first-episode psychosis: A randomized controlled trial of individual placement and support versus treatment as usual. The British Journal of Psychiatry, 193, 114 –120. doi:10.1192/bjp.bp.107.043109 Manthey, T. J., Rapp, C. A., Carlson, L., Holter, M. C., & Davis, J. K. (2012). The perceived importance of integrated supported employment and employment services. Journal of Rehabilitation, 78, 16 –24. Marty, D., Rapp, C. A., McHugo, G., & Whitley, R. (2008). Factors influencing consumer outcome monitoring in implementation of evidence-based practices: Results from the National EBP Implementation Project. Administration and Policy in Mental Health and Mental Health Services Research, 35, 204 –211. doi:10.1007/s10488-0070157-4 Nadeem, E., Olin, S. S., Hill, L. C., Hoagwood, K. E., & Horwitz, S. M. (2013). Understanding the components of quality improvement collaboratives: A systematic literature review. Milbank Quarterly, 91, 354 – 394. doi:10.1111/milq.12016 Nuechterlein, K. H., Subotnik, K. L., Turner, L. R., Ventura, J., Becker, D. R., & Drake, R. E. (2008). Individual placement and support for individuals with recent-onset schizophrenia: Integrating supported education and supported employment. Psychiatric Rehabilitation Journal, 31, 340 –349. doi:10.2975/31.4.2008.340.349 Oulvey, E., Carpenter-Song, E. A., & Swanson, S. J. (2013). Principles for enhancing the role of state vocational rehabilitation in IPS-supported employment. Psychiatric Rehabilitation Journal, 36, 4 – 6. doi:10.1037/ h0094740 Peterson, A. E., Bond, G. R., Becker, D. R., & Drake, R. E. (in press). Achieving high fidelity to supported employment: Comparing programs in small and large communities. Community Mental Health Journal. Rinaldi, M., Killackey, E., Smith, J., Shepherd, G., Singh, S. P., & Craig, T. (2010). First episode psychosis and employment: A review. International Review of Psychiatry, 22, 148 –162. doi:10.3109/ 09540261003661825 Rogers, E. S., Kash-MacDonald, M., Bruker, D., & Maru, M. (2010). Systematic review of supported education literature 1989 –2009. Boston,
IPS SUPPORTED EMPLOYMENT LEARNING COLLABORATIVE
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
MA: Boston University, Sargent College, Center for Psychiatric Rehabilitation. www.bu.edu/drrk Swanson, S. J., & Becker, D. R. (2013). IPS supported employment: A practical guide. Lebanon, NH: Dartmouth Psychiatric Research Center. Swanson, S. J., Becker, D. R., & Bond, G. R. (2013). Job development guidelines in supported employment. Psychiatric Rehabilitation Journal, 36, 122–123. doi:10.1037/h0094988 Swanson, S. J., Burson, K., Harper, J., Johnson, B., & Litvak, J. (2011). Implementation issues for IPS supported employment: Stakeholders share their strategies. American Journal of Psychiatric Rehabilitation, 14, 165–180. doi:10.1080/15487768.2011.598099
85
Swanson, S. J., Langfitt-Reese, S., & Bond, G. R. (2012). Employer attitudes about criminal justice history. Psychiatric Rehabilitation Journal, 35, 385–390. doi:10.1037/h0094498
Received November 3, 2013 Revision received December 1, 2013 Accepted December 6, 2013 䡲
