Defining EvidenceBased Supported Employment

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Defining Evidence-Based Supported Employment

• Crystal R. Blyler, Ph.D.
• SAMHSA Center for Mental Health Services

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Mental illness is the leading cause of disability
worldwide

• WHO Global Burden of Disease study (1990)
• Depression is number 1
• Other disorders in the top 10
• Bipolar disorder
• Schizophrenia
• Obsessive-compulsive disorder

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Mental illness is the leading cause of disability
within the U.S.

• (McAlpine Warner, 2002)
• 34 of working aged adults receiving SSI
• 27 of all SSDI recipients
• People with mental disorders remain on the SSI
  and SSDI rolls considerably longer than those
  with other disabilities (Kochhar Scott, 1995
  Rupp Scott, 1996)

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Supported Employment services are needed

• Only 15 of people with the most serious and
  persistent mental illnesses are employed
  (Milazzo-Sayre, Henderson, Manderscheid, 1997)
• Mental health consumers want to work
• Fewer than 25 receive any form of vocational
  services (Hollingsworth Sweeney, 1997 Leff
  Wise, 1995)

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Competitive Employment is the Goal

• Pays minimum wage or higher
• Located in mainstream, integrated settings
• A job anyone can hold (not set-aside for mental
  health consumers)
• The job is consumer-owned

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The evidence base

• Randomized controlled trials
• Bond, Drake, Mueser et al. (1997) review
• Cook Razzano (2000) review
• CMHS Employment Intervention Demonstration
  Program (EIDP)

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Employment Intervention Demonstration Program
(EIDP)

• 8 States
• 1648 newly enrolled service recipients
• Not working at baseline
• 90 diagnosed w/schizophrenia, bipolar disorder,
  or major depression
• 64 with concurrent substance abuse diagnoses
• Randomly assigned (enhanced vs. comparison)
• Followed for 2 years
• Bi-annual in-person interviews
• Job status assessed every week
• Service utilization data for entire tenure

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Participant Features Controlled For in the EIDP
Statistical Analyses

• Gender
• Ethnicity
• Age
• Education
• Prior Work History
• Symptoms
• Functioning
• Marital Status

• Co-resident Children lt 18 years old
• Diagnosis of Schizophrenia
• Co-occurring Health Problem or Disability
• Receiving Disability Income

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6 Principles of Evidence-Based Supported
Employment

• Competitive employment is the goal.
• Eligibility is based on consumer choice.
• Employment services are integrated with mental
  health treatment.
• Job search process starts soon after a consumer
  expresses interest in working.
• Follow-along supports are continuous for
  employed consumers.
• Consumer preferences are important.

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What evidence-based Supported Employment is NOT

• Work crews
• Sheltered workshops
• Referral out
• Extensive pre-assessment and testing
• Work preparation/skills development
• Transitional employment positions

• One-time placement
• On-site job coaching
• Rehabilitative day treatment
• Generic psychosocial rehabilitation
• Clinical services alone

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Evidence-based Supported Employment services are
integrated with mental health treatment

• Provided by the same agency
• At the same location
• Psychiatric and vocational staff interact on a
  face-to-face basis at least three times per week
  or more
• Share a single case record

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EIDP Results Supported Employment Works

• Enhanced conditions were more effective than
  comparison conditions in achieving employment
  outcomes
• Competitive employment 55 vs. 34
• Worked at least 40 hours within a given month
  51 vs. 39
• Earnings 122 per month vs. 99 per month

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EIDP Results More is better

• Controlling for all other factors, those who
  received more total hours of vocational services
  had better employment outcomes.
• More clinical services were NOT associated with
  better employment outcomes.

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Average Hours Per Client of Vocational
Clinical Services by Study Condition
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Average Hours per Client of Vocational
Clinical Services by Quality of Employment
Outcome (Worked 40 Hours/Month)
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EIDP Results Integration of vocational and
clinical services is essential

• Participants served by integrated models were
• 2 times as likely to be competitively employed
• 1½ times as likely to work at least 40 hours in a
  month

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Average Number of Days Between Jobs Among EIDP
Participants with More than One Job
Average Number of Days
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Average Length of Jobs by Number Held
Average Length in Days
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Bottom line Costs to implement Supported
Employment

• 2000 - 6000 total costs per client
• 500 - 2000 direct vocational costs per client
  per year
• Personnel costs significantly larger than other
  costs

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CMHS Supported Employment Implementation Resource
Kit

• Research Summaries
• Information sheets for 5 stakeholder groups
  (incl. Spanish)
• Tip sheets for administrators and program
  directors

• Introductory and Training videos
• How-to workbook for practitioners Cultural
  Competence
• Fidelity assessment tools
• Outcome measures

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To obtain a free copy of the Supported Employment
toolkit

• www.samhsa.gov
• 1-800-789-CMHS
• Order Form