The effects of supported employment interventions in populations of people with conditions other than severe mental health: a systematic review

The societal impact of individual placement and support implementation on employment outcomes for young adults receiving temporary health-related welfare benefits: a difference-in-differences study

BACKGROUND

Individual placement and support (IPS) is an evidence-based practice that helps individuals with mental illness gain and retain employment. IPS was implemented for young adults at a municipality level through a cross-sectoral collaboration between specialist mental healthcare, primary mental healthcare, and the government funded employment service (NAV). We investigated whether IPS implementation had a causal effect on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation (work assessment allowance, WAA) welfare benefit, measured at the societal level compared to municipalities that did not implement IPS.

METHOD

We used a difference in differences design to estimate the effects of IPS implementation on the outcome of workdays per year using longitudinal registry data. We estimate the average effect of being exposed to IPS implementation during four-years of implementation compared to ten control municipalities without IPS for all WAA recipients.

RESULTS

We found a significant, positive, causal effect on societal level employment outcomes of 5.6 (p = 0.001, 95% CI 2.7-8.4) increased workdays per year per individual, equivalent to 12.7 years of increased work in the municipality where IPS was implemented compared to municipalities without IPS. Three years after initial exposure to IPS implementation individuals worked, on average, 10.5 more days per year equating to 23.8 years of increased work.

CONCLUSIONS

Implementing IPS as a cross sectoral collaboration at a municipality level has a significant, positive, causal, societal impact on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation welfare benefit.

Addressing Social Needs in Clinical Settings: Implementation and Impact on Health Care Utilization, Costs, and Integration of Care

In recent years, health care policy makers have focused increasingly on addressing social drivers of health as a strategy for improving health and health equity. Impacts of social, economic, and environmental conditions on health are well established. However, less is known about the implementation and impact of approaches used by health care providers and payers to address social drivers of health in clinical settings. This article reviews current efforts by US health care organizations and public payers such as Medicaid and Medicare to address social drivers of health at the individual and community levels. We summarize the limited available evidence regarding intervention impacts on health care utilization, costs, and integration of care and identify key lessons learned from current implementation efforts.

The effects of an interdisciplinary employment program on paid employment and mental health among persons with severe mental disorders

PURPOSE

This study evaluates the effects of the interdisciplinary employment program 'Work As Best Care (WABC)' on employment participation and mental health of persons with severe mental disorders.

METHODS

WABC is a 'work first' employment program for unemployed persons with severe mental disorders in which employment professionals work closely together with mental health professionals. In a longitudinal non-randomized controlled study, participants of WABC (n = 35) are compared with participants of the control group (n = 37), who received regular employment support. Participants were followed for 1 year and filled out questionnaires on individual characteristics and health at baseline, after 6 and 12 months. This information was enriched with monthly register data on employment status from 2015 until 2020. Difference-in-differences analyses were performed to investigate changes in employment participation among participants of WABC and the control group. A generalized linear mixed-effects model was used to compare changes in mental health (measured on 0-100 scale) between the two groups.

RESULTS

Before WABC, employment participation was 22.0%points lower among participants of WABC compared to the control group. After starting WABC, employment participation increased with 15.3%points per year among participants of WABC, compared to 5.6%points in the control group. Among all participants of WABC, no change in mental health was found (β 1.0, 95% CI - 3.4; 5.5). Only female participants of WABC showed a significant change in mental health (β 8.0, 95% CI 2.6; 13.4).

CONCLUSION

To enhance employment participation of persons with severe mental disorders, an interdisciplinary 'work-first' approach in which professionals of employment services and mental health services work in close collaboration, is of paramount importance.

Understanding interventions and outcomes in supported employment and individual placement support: A qualitative evidence synthesis

BACKGROUND

Economically developed economies continue to display large and long-standing disability employment gaps. Train-then-place activation models have traditionally dominated efforts to support non-working disabled people to gain employment but recently there has been increasing interest in place-then-train Supported Employment (SE) activation models.

OBJECTIVE

Evidence regarding the effectiveness of SE approaches is growing. However, authors have called for greater understanding of the mechanisms underpinning these interventions. We therefore carried out a systematic review of qualitative research to understand the processes operating.

METHODS

We carried out a systematic review of qualitative research around SE interventions carried out in developed countries since 2000 in any population excepting those with severe mental illness. We used thematic synthesis and logic modelling methods and assessed the quality of the body of literature.

RESULTS

We identified and included 13 relevant source studies containing qualitative data. Key aspects of the programmes reported were the nature of the support, the employment advisor, and the type of employment. Influencing factors were client-related, employer and employment-related, programme-related, and system-related. Effects beyond the gaining of employment included a changed attitude to work, different outlook, increased skills and/or confidence. Suggested longer-term impacts were on health and wellbeing, financial security, independence, contribution to society and sense of belonging.

CONCLUSIONS

This review adds to the growing evidence regarding the value of SE interventions for disabled people. It adds insights regarding the key elements of the programmes, and suggests outcomes beyond the measures typically considered within quantitative studies.

Factors influencing sustainable employment of persons with acquired brain injury (ABI) or spinal cord injury (SCI): A qualitative study evaluating the perspective of health and work professionals

Background

The number of persons with acquired brain injury (ABI) or spinal cord injury (SCI) who leave the labor market early despite successfully return to work post-injury, demonstrates the challenge for them to remain employed. Evidence on how enabling and hindering factors influence daily work across the lifespan and how they affect employment-related services is scarce. Professionals directly involved in work integration can add to this evidence through their experiential knowledge.

Purpose

To identify and explore the factors that enable or hinder sustainable employment for persons with ABI or SCI from the perspective of health and work professionals.

Methods

We conducted 23 semi-structured interviews with professionals in Switzerland, directly involved in work reintegration and retention of persons with ABI or SCI. Interviews were transcribed verbatim and thematically analyzed.

Results

Participants identified three main themes related to the concept of "sustainable employment". First, the value and impact of initial work integration; an early, multidisciplinary, person-centered work integration, with the early involvement of employers is ideal. A good match between the worker and the workplace is sought. Second, critical factors for long-term sustainable work: the main risks for persons with ABI are changing supervisors, workplace restructuring and the introduction of new technologies, while deteriorating health and the occurrence of secondary health problems are the greatest risk for persons with SCI. Third, the relevance of knowledge, experience and attitudes of professionals; Knowledge of the consequences of an ABI or SCI, the legal basis and the social security process, and the attitude of professionals towards the injured worker were considered important.

Conclusions

From the professional's perspective, enabling and hindering factors for sustainable employment in the long-term are fundamentally very similar for persons with ABI and SCI. But different physical, mental and neuropsychological effects call for individually adapted measures. While persons with SCI primarily require ongoing medical care, conscious management of changes in the workplace is critical for persons with ABI. For both groups, an easily accessible counseling and support service should be established for work-threatening problems in the long-term. Furthermore, diagnosis-specific training programs for professionals of employment-related services and disability management should be developed.

A pilot trial investigating the feasibility of a future randomised controlled trial of Individualised Placement and Support for people unemployed with chronic pain recruiting in primary care

BACKGROUND

We investigated the feasibility of recruiting patients unemployed for more than 3 months with chronic pain using a range of methods in primary care in order to conduct a pilot trial of Individual Placement and Support (IPS) to improve quality of life outcomes for people with chronic pain.

METHODS

This research was informed by people with chronic pain. We assessed the feasibility of identification and recruitment of unemployed patients; the training and support needs of employment support workers to integrate with pain services; acceptability of randomisation, retention through follow-up and appropriate outcome measures for a definitive trial. Participants randomised to IPS received integrated support from an employment support worker and a pain occupational therapist to prepare for, and take up, a work placement. Those randomised to Treatment as Usual (TAU) received a bespoke workbook, delivered at an appointment with a research nurse not trained in vocational rehabilitation.

RESULTS

Using a range of approaches, recruitment through primary care was difficult and resource-intensive (1028 approached to recruit 37 eligible participants). Supplementing recruitment through pain services, another 13 people were recruited (total n = 50). Randomisation to both arms was acceptable: 22 were allocated to IPS and 28 to TAU. Recruited participants were generally not 'work ready', particularly if recruited through pain services.

CONCLUSION

A definitive randomised controlled trial is not currently feasible for recruiting through primary care in the UK. Although a trial recruiting through pain services might be possible, participants could be unrepresentative in levels of disability and associated health complexities. Retention of participants over 12 months proved challenging, and methods for reducing attrition are required. The intervention has been manualised.

Who benefits from individual placement and support? A meta-analysis

AIMS

Individual placement and support (IPS) is an evidence-based service model to support people with mental disorders in obtaining and sustaining competitive employment. IPS is increasingly offered to a broad variety of service users. In this meta-analysis we analysed the relative effectiveness of IPS for different subgroups of service users both based on the diagnosis and defined by a range of clinical, functional and personal characteristics.

METHODS

We included randomised controlled trials that evaluated IPS for service users diagnosed with any mental disorder. We examined effect sizes for the between-group differences at follow-up for three outcome measures (employment rate, job duration and wages), controlling for methodological confounders (type of control group, follow-up duration and geographic region). Using sensitivity analyses of subgroup differences, we analysed moderating effects of the following diagnostic, clinical, functional and personal characteristics: severe mental illness (SMI), common mental disorders (CMD), schizophrenia spectrum disorders, mood disorders, duration of illness, the severity of symptoms, level of functioning, age, comorbid alcohol and substance use, education level and employment history.

RESULTS

IPS is effective in improving employment outcomes compared to the control group in all subgroups, regardless of any methodological confounder. However, IPS was relatively more effective for service users with SMIs, schizophrenia spectrum disorders and a low symptom severity. Although IPS was still effective for people with CMD and with major depressive disorder, it was relatively less effective for these subgroups. IPS was equally effective after both a short and a long follow-up period. However, we found small, but clinically not meaningful, differences in effectiveness of IPS between active and passive control groups. Finally, IPS was relatively less effective in European studies compared to non-European studies, which could be explained by a potential benefits trap in high welfare countries.

CONCLUSIONS

IPS is effective for all different subgroups, regardless of diagnostic, clinical, functional and personal characteristics. However, there might be a risk of false-positive subgroup outcomes and results should be handled with caution. Future research should focus on whether, and if so, how the IPS model should be adapted to better meet the vocational needs of people with CMD and higher symptom severity.

Facilitators and Barriers to Sustainable Employment After Spinal Cord Injury or Acquired Brain Injury: The Person's Perspective

Background

Sustaining employment after initial return to work represents a major challenge for people with a disability. While individuals with spinal cord injury (SCI) and acquired brain injury (ABI) make a prime example for this challenge, their view on factors supporting and hindering sustainable employment have rarely been investigated in depth so far.

Purpose

To examine facilitators and barriers to sustainable employment, as perceived by persons with SCI or ABI.

Methods

Fourteen focus groups and four individual interviews were conducted and thematically analyzed.

Results

Perceived facilitators and barriers to sustainable employment reflected the three biopsychosocial areas of personal, impairment-related and environmental factors. For both condition groups, key facilitators included environmental factors (i.e., aspects of the work organization, the workplace, supportive private and work environment) and personal factors (i.e., the ability to self-advocate, to communicate and to learn how to live with one's own disability). Major barriers comprised injury-related impairments, including decreased mobility and pain for people with SCI and fatigue and limited cognitive resources for persons with ABI, as well as environmental factors related to insurance procedures and the social security system for both conditions.

Conclusions

The biopsychosocial factors identified in our study as well as their interplay should receive particular attention to optimally support sustainable employment in vocational integration and work retention practice. Interventions should particularly focus on the empowerment of those affected as well as on the creation of supportive work environments that match their abilities and needs.