A framework for improving the effectiveness of evidence-based practices in vocational rehabilitation

Tailored vocational rehabilitation for people with a work disability pension in The Netherlands; an in-depth data analysis of the content and outcomes of vocational rehabilitation trajectories of the Social Security Institute

PURPOSE

People with a work disability pension receive vocational rehabilitation (VR) services from the Dutch Social Security Institute (SSI) in order to facilitate return-to-work (RTW). The SSI offers tailored VR existing of two trajectories (aimed at getting fit for work or aimed at returning to work). The purpose of this study is to describe the current practice of VR. This includes a description of client characteristics, RTW barriers and the intensity, duration, content and the outcomes of the offered trajectories.

MATERIALS AND METHODS

We analyzed data from 197 clients that were randomly selected from clients who attended a VR trajectory between 1 January t 2017 and 31 December 2018. Data were obtained from the SSI registration databases and client files.

RESULTS

Both VR trajectories at the SSI have a different aim, but in practice the content of the VR interventions often overlaps. Around half of both trajectories reached their goal. Reasons for unsuccessful trajectories were that the client did not find work or barriers were more complex than initially assessed.

CONCLUSIONS

The SSI delivers tailored VR to the specific needs of the client, however substantiations for why a certain VR intervention is offered are limited. Guidelines are needed to support professionals.

Employment interventions to assist people who experience borderline personality disorder: A scoping review

BACKGROUND

Employment is an important social determinant of health and is associated with positive health outcomes. However, individuals who have been diagnosed with borderline personality disorder (BPD) are significantly underrepresented in the workforce. Whilst there is an array of evidence based therapeutic interventions, there remains a gap in knowledge regarding the most effective ways to enhance employment outcomes for people with a diagnosis of BPD.

AIM

To explore employment interventions for people with BPD, map the available evidence and identify key concepts and knowledge gaps.

METHODS

A scoping review was conducted to identify and map the relevant literature. Findings were summarised using a narrative approach. Consultation was provided by a reference group including peer support workers with lived experience of BPD and mental health clinicians.

RESULTS

Seven articles met the inclusion criteria, including non-randomised and case study/series designs and a randomised controlled trial protocol, with participant numbers generally low. All programmes combined a psychotherapeutic component with work related goals; however, there were notable differences in relation to the conceptual/theoretical approach of the psychotherapeutic component and delivery of the work-related components. Barriers and enablers to programme participation and success are explored.

CONCLUSIONS

This review provides important insights into the characteristics of vocational rehabilitation interventions for people diagnosed with BPD. The findings will inform the co-production of approaches to support people with BPD to engage in employment.

Exploring the Association between Individual-Level Attributes and Fidelity to a Vocational Rehabilitation Intervention within a Randomised Controlled Trial

Understanding what attributes or characteristics of those delivering interventions affect intervention fidelity and patient outcomes is important for contextualising intervention effectiveness. It may also inform implementation of interventions in future research and clinical practice. This study aimed to explore the relationships between attributes of Occupational Therapists (OTs), their faithful delivery of an early stroke specialist vocational rehabilitation intervention (ESSVR), and stroke survivor return-to-work (RTW) outcomes. Thirty-nine OTs were surveyed about their experience and knowledge of stroke and vocational rehabilitation and were trained to deliver ESSVR. ESSVR was delivered across 16 sites in England and Wales between February 2018 and November 2021. OTs received monthly mentoring to support ESSVR delivery. The amount of mentoring each OT received was recorded in OT mentoring records. Fidelity was assessed using an intervention component checklist completed using retrospective case review of one randomly selected participant per OT. Linear and logistic regression analyses explored relationships between OT attributes, fidelity, and stroke survivor RTW outcome. Fidelity scores ranged from 30.8 to 100% (Mean: 78.8%, SD: 19.2%). Only OT engagement in mentoring was significantly associated with fidelity (b = 0.29, 95% CI = 0.05-0.53, p < 0.05). Increased fidelity (OR = 1.06, 95% CI = 1.01-1.1, p = 0.01) and increasing years of stroke rehabilitation experience (OR = 1.17, 95% CI = 1.02-1.35) was significantly associated with positive stroke survivor RTW outcomes. Findings of this study suggest that mentoring OTs may increase fidelity of delivery of ESSVR, which may also be associated with positive stroke survivor return-to-work outcomes. The results also suggest that OTs with more experience of stroke rehabilitation may be able to support stroke survivors to RTW more effectively. Upskilling OTs to deliver complex interventions, such as ESSVR, in clinical trials may require mentoring support in addition to training to ensure fidelity.

Modification of the Individual Placement and Support Model of Supported Employment

Individual placement and support (IPS) is a robust evidence-based model of supported employment for people with mental health conditions that has been implemented in high-income countries. The model is now being extended to new populations and settings, often with modifications. Current evidence indicates that minor modifications may increase fit, major alterations of core principles generally reduce effectiveness, and augmentations have mixed success. The authors recommend that those who implement IPS adhere to its core principles whenever possible, use standardized methods to document and assess modifications, and follow basic scientific procedures to develop, measure, and evaluate modifications before recommending policy changes.

Developing an implementation fidelity checklist for a vocational rehabilitation intervention

BACKGROUND

Despite growing numbers of studies reporting the efficacy of complex interventions and their implementation, many studies fail to report information on implementation fidelity or describe how fidelity measures used within the study were developed. This study aimed to develop a fidelity checklist for measuring the implementation fidelity of an early, stroke-specialist vocational rehabilitation intervention (ESSVR) in the RETAKE trial.

METHODS

To develop the fidelity measure, previous checklists were reviewed to inform the assessment structure, and core intervention components were extracted from intervention descriptions into a checklist, which was ratified by eight experts in fidelity measurement and complex interventions. Guidance notes were generated to assist with checklist completion. To test the measure, two researchers independently applied the checklist to fifteen stroke survivor intervention case notes using retrospective observational case review. The scoring was assessed for interrater reliability.

RESULTS

A fidelity checklist containing 21 core components and 6 desirable components across 4 stages of intervention delivery was developed with corresponding guidance notes. Interrater reliability of each checklist item ranged from moderate to perfect (Cohen's kappa 0.69-1).

CONCLUSIONS

The resulting checklist to assess implementation fidelity is fit for assessing the delivery of vocational rehabilitation for stroke survivors using retrospective observational case review. The checklist proved its utility as a measure of fidelity and may be used to inform the design of future implementation strategies.

TRIAL REGISTRATION

ISRCTN, ISRCTN12464275. Registered on 13 March 2018.

Evaluation of an implementation strategy for Individual Placement and Support in the Netherlands: a 30-month observational study

BACKGROUND

Individual Placement and Support (IPS) is an evidence-based, effective approach to help people with severe mental illness (SMI) obtain and maintain competitive employment. The aim of the present study was to examine employment outcomes and associations with an organizational and a financial factor in people with SMI who participated in Individual Placement and Support using a multifaceted implementation strategy (IPS + MIS). The goal of this strategy was to improve IPS implementation by enhancing collaboration among mental health care and vocational rehabilitation stakeholders, and realizing secured IPS funding.

METHODS

An observational cohort study including 103 participants was conducted, with a 30-month follow-up. Descriptive analyses were used to examine employment outcomes. Multivariable logistic and linear regression analyses were performed to study associations with an organizational and a financial factor: the level of experience of mental health agencies with providing IPS + MIS and the type of IPS funding (i.e. municipality funding (reference group) and the Dutch Social Security Institute: the Institute for Employee Benefits Schemes (UWV) funding).

RESULTS

Forty-six percent of the participants were competitively employed at any time during the 30-month follow-up; the median number of days until competitive job obtainment and in competitive jobs was 201 and 265, respectively. The majority of all jobs obtained (81%) were categorized as 'elementary occupations', 'clerical support workers', and 'service and sales workers'. A higher level of experience of the mental health agencies with providing IPS + MIS was found to be positively associated with job obtainment (OR = 3.83, 95% CI 1.42-10.30, p = 0.01) and the number of days worked in competitive jobs (B = 1.21, 95% CI 0.36-2.07, p = 0.01). UWV funding was found to be negatively associated with job obtainment (OR = 0.30, 95% CI 0.11-0.77, p = 0.01). No association was found for the type of IPS funding and the number of days worked in competitive jobs (B = -0.73, 95% CI -1.48-0.02, p = 0.06).

CONCLUSIONS

This study shows that almost half of the people who participate in IPS + MIS obtain a competitive job within 30 months. The results further suggest that both the level of experience of mental health agencies with providing IPS + MIS, and funding may play a role in employment outcomes.

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.

"These are people just like us who can work": Overcoming clinical resistance and shifting views in the implementation of Individual Placement and Support (IPS)

Purpose

Individual Placement and Support (IPS) is a recovery-based approach to support people with mental health difficulties back into employment. Embedding of IPS within the mental health Multi-Disciplinary Team (MDT) is a key component of IPS fidelity; however, few studies have examined how those involved with IPS implementation navigate this process. This article explores how IPS Employment Specialists (ES) and Occupational Therapist (OT) Managers integrated and embedded IPS within traditionally-oriented MDTs as part of a national reform program in the Republic of Ireland.

Methods

The study design was qualitative, descriptive with data collected through three focus groups with 17 IPS ESs and 11 OT Managers. Data were analyzed using thematic synthesis.

Results

Three key themes emerged from analysis. The first characterizes the context into which IPS landed, described as one marked by clinical resistance, doubt, and fear of risk. The second explores the strategies and factors that helped with the introduction of IPS into Irish mental health services. These included strategies, such as providing education and information about IPS and reassuring the MDT about IPS governance and IPS ES’ competencies. The evidenced-based nature of IPS and its attached accountabilities through IPS fidelity measures were perceived to be an important factor in its acceptance. The final theme encapsulates perceptions of how IPS impacted on the MDTs’ views of people with mental health difficulties. Findings suggest a shift in the ways in which MDTs view their clients. Initial fears about work capacity and risk shifted towards seeing people beyond the label of ‘service user’ and their diagnosis.

Conclusions

It is contended that IPS is an approach that allows practitioners to engage with real recovery-practice and may be one key to unlocking how a recovery approach can truly trickle down and embed itself within mental health service provision and support mental health system reform.

How do supported employment programs work? Answers from a systematic literature review

Many studies have found that supported employment (SE) has effectively helped people with severe mental illness obtain and maintain competitive employment. However, most SE studies have asked "What works?" rather than discerning what works for whom, in what circumstances, in what respects and how. It is important to understand the outcomes of SE and identify the impact factors (contexts and mechanisms) that can trigger them. Four literature databases were searched for studies that analyzed counseling settings. Overall, 104 publications met the inclusion criteria. The review showed that most of the research on SE programs were one-dimensional, looking at either the effects of SE programs, the client or the professional, or the relationship between clients and professionals. The model reveals that impact factors are interconnected and can have a cumulative impact on the client, professionals, and the environment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10775-022-09533-3.

Predictive Association of Low- and High-Fidelity Supported Employment Programs with Multiple Outcomes in a Real-World Setting: A Prospective Longitudinal Multi-site Study

PURPOSE

The individual placement and support (IPS) model of supported employment is a leading evidence-based practice in community mental health services. In Japan, individualized supported employment that is highly informed by the philosophy of the IPS model has been implemented. While there is a body of evidence demonstrating the association between program fidelity and the proportion of participants gaining competitive employment, the association between fidelity and a wider set of vocational and individual outcomes has received limited investigation. This study aimed to assess whether high-fidelity individualized supported employment programs were superior to low-fidelity programs in terms of vocational outcomes, preferred job acquisition, and patient-reported outcome measures (PROMs).

METHODS

A prospective longitudinal study with 24-month follow-up analyzed 16 individualized supported employment programs. The Japanese version of the individualized Supported Employment Fidelity scale (JiSEF) was used to assess the structural quality of supported employment programs (scores: low-fidelity program, ≤ 90; high-fidelity program, ≥ 91). Job acquisition, work tenure, work earnings, job preference matching (e.g., occupation type, salary, and illness disclosure), and PROMs such as the INSPIRE and WHO-Five Well-being index were compared between groups.

RESULTS

There were 75 and 127 participants in the low-fidelity group (k = 6) and high-fidelity group (k = 10), respectively. The high-fidelity group demonstrated better vocational outcomes than the low-fidelity group, i.e., higher competitive job acquisition (71.7% versus 38.7%, respectively, adjusted odds ratio (aOR) = 3.6, p = 0.002), longer work tenure (adjusted mean difference = 140.8, p < 0.001), and better match for illness disclosure preference (92.6% versus 68.0%, respectively, aOR = 5.9, p = 0.003). However, we found no differences between groups in other preference matches or PROM outcomes.

CONCLUSION

High-fidelity individualized supported employment programs resulted in good vocational outcomes in a real-world setting. However, enhancing service quality to increase desired job acquisition and improve PROMs will be important in the future.

CLINICAL TRIAL REGISTRATION

UMIN000025648.

Developing a vocational social rehabilitation model to increase the independence of the instrumental activity of daily living (ADL) among people with severe mental illness

Background: One of the efforts made to return people with severe mental illness to the community is to prepare with sufficient skills so then they can return to a productive life. The purpose of this study was to develop a vocational social rehabilitation model to increase the independence of the instrumental activity of daily living (ADL) among people with severe mental illness.

Design and Methods: The study was conducted in 2 stages. Phase 1 used an observational design with a cross sectional approach. It was conducted at the Menur Mental Hospital from March to July 2020. The population of this study were all people with severe mental illness with a psychotic degree scoring ≥30. The total sample was 100. The data was analyzed using the Partial Least Square. The second phase was carried out by compiling modules from strategic issues and conducting expert consultations.

Results: The results of phase 1 showed that the instrumental ADL independence was directly influenced by perceived behavior, memory phase, motivation phase, skills and intention. Additionally, it is indirectly influenced by socio-demography, mental illness severity, attitude towards behavior, subjective norm, perceived behavioral control, attention, retention, motor reproduction, motivation and skill. The results of the phase 2 carried out were used to compile modules based on the stages of vocational rehabilitation consisting of determining eligibility, preparatory counseling, implementing rehabilitation, evaluation and ongoing support.

Conclusion: The vocational social rehabilitation model is related to the independence of the Instrumental ADL among people with severe mental illness.

Consumer, health professional and employment specialist experiences of an individual placement and support programme

BACKGROUND

Individuals with severe mental illness (SMI) are under-represented in the workforce. The Individual Placement and Support (IPS) programme is an evidence-based intervention that co-locates an Employment Specialist in a community mental health team to support individuals with a SMI with their goal of finding work. Previous research predominantly explored IPS programme outcomes rather than stakeholder experiences.

AIM

To explore programme stakeholder perspectives and experiences during the early stages of IPS programme implementation.

METHODS

Qualitative descriptive methodology explored consumers (n = 11), health professionals and employment specialist (n = 11) perceptions and experiences of the IPS programme. Semi-structured interviews were conducted and thematically analysed.

RESULTS

Three main themes emerged: enacting core care philosophies, IPS programme process and catalyst for supportive environments and relationships. The combination of IPS programme relationships, enactment of core care philosophies, and programme process promoted development of supportive environments and relationships for consumers participating in the programme.

CONCLUSION

Findings suggest IPS processes promoted the enactment of person-centred and recovery-oriented care approaches and positively influenced care planning practices and service culture.

SIGNIFICANCE

IPS directly tackles the compounding disadvantage resulting from unemployment for people with a SMI. At a service level, IPS can foster positive changes to care practices and service culture.