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Impact of public support payments, intensive psychiatric community care, and program fidelity on employment outcomes for people with severe mental illness (Resnick et al. 2003)

Absence of conflict of interest.

Citation

Resnick, S., Neale, M., & Rosenheck, R. (2003). Impact of public support payments, intensive psychiatric community care, and program fidelity on employment outcomes for people with severe mental illness. The Journal of Nervous and Mental Disease, 191(3), 139-144.

Highlights

  • The study evaluated the one-year impacts of a U.S. Department of Veterans Affairs (VA) model of assertive community treatment for veterans with serious mental illnesses known as Intensive Psychiatric Community Care (IPCC) on employment.
  • The study conducted a randomized controlled trial (RCT); those randomly assigned to the treatment group were eligible to receive the IPCC services, whereas those randomly assigned to the control group could not access IPCC services but could use other available health- and workforce-related services from the VA. The authors analyzed outcomes based on self-reported employment data collected from participants one year after random assignment.
  • The study found that 7 percent of veterans in the IPCC group were employed one year after random assignment compared to 11 percent of veterans in the control group. The authors did not report the statistical significance of this difference.
  • The quality of the causal evidence presented in this report is high because it was based on a well-conducted RCT. This means we have confidence that the estimated effects are attributable to the IPCC program and not other factors.

Intervention Examined

Intensive Psychiatric Community Care (IPCC)

Features of the Intervention

The IPCC program, later known as Mental Health Intensive Case Management, was an assertive community treatment model of care for veterans with psychiatric disabilities. The program included a range of rehabilitative services and was primarily staffed by masters-level social workers, nurses, and psychiatrists. The key features of the program were frequent patient–clinician contact, flexibility and community orientation, training in practical problem solving and adaptive skill building, and continuity of care. The IPCC teams assertively maintained contact with patients, including those reluctant to engage.

Features of the Study

The IPCC evaluation involved an RCT that originally included programs in 10 VA hospitals, including 6 acute general medical and surgical hospitals and 4 long-term neuropsychiatric facilities, from 1987 to 1990. This report reanalyzed the one-year impacts of the program on employment for participants in the 6 general medical and surgical hospitals (the study excluded participants from the 4 neuropsychiatric facilities). To be eligible for the evaluation, veterans had to be hospitalized in a psychiatric inpatient unit at the time of recruitment, had to remain hospitalized at least 40 days or at least twice in the prior year, and have had a psychiatric diagnosis other than substance abuse.

At the six sites, the study randomly assigned 528 eligible veterans to either a treatment group offered the IPCC intervention or a control group that did not receive the IPCC but could access standard VA services, including inpatient psychiatric and psychopharmacologic treatment, outpatient psychiatric treatment, and rehabilitation services such as work therapy.

The authors estimated the impact of the IPCC on employment one year after random assignment. The authors obtained background and mental health status information on study participants via self-report at baseline (at the time of random assignment) and one year later. This review focuses on findings from the percentage of individuals in each group who were employed 12 months after random assignment. The authors defined employment as either working at least five days or earning at least $100 in competitive employment in the prior month.

Findings

Employment

  • The study found that 7 percent of veterans in the IPCC group were employed one year after random assignment compared to 11 percent of veterans in the control group. The authors did not report the statistical significance of this difference.

Considerations for Interpreting the Findings

The authors also presented findings from a regression analysis, which found that those in the IPCC group were three times more likely to be employed at the 12-month follow-up, compared to the comparison group. This review does not focus on those findings because the authors controlled for quality of implementation in the regression model, which makes interpreting the results of the intervention overall more difficult. Therefore, the review focuses on the unadjusted percentage of each group employed at follow-up.

Based on the information presented in this article, the authors collected follow-up data from all but eight of the randomly assigned individuals included in the sample. Information reported in Rosenheck and Neale (1998), which drew on data from the same RCT, indicates there might have been lower response rates on the 12-month follow-up. This review assumes the information presented in the reviewed study is accurate; therefore, this was a well-conducted RCT with similar high response rates in both groups (in other words, low attrition).

Causal Evidence Rating

The quality of the causal evidence presented in this report is high because it was based on a well-conducted RCT. This means we have confidence that the estimated effects are attributable to the IPCC program and not other factors.

Additional Sources

Rosenheck, R., & Neale, M. (1998). Cost-effectiveness of intensive psychiatric community care for high users of inpatient services. Archives of General Psychiatry, 55(5), 459-466.

Reviewed by CLEAR

May 2020

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