Absence of conflict of interest.
Citation
Davis, L.L., Mumba, M.N., Toscano, R., Pilkinton, P., Blansett, C.M., McCall, K., MacVicar, D., & Bartolucci, A. (2022). A randomized controlled trial evaluating the effectiveness of supported employment integrated in primary care. Psychiatric Services, 73(6), 620-627.
Highlights
- The study's objective was to examine the impact of Individual Placement and Support (IPS) integrated within a primary care patient-aligned care team (PACT) on employment and earnings among Veterans with mental health issues.
- The study was a randomized controlled trial that examined the impacts of IPS integrated within a primary care PACT on employment and earnings for veterans with nonpsychotic psychiatric disorders. Using data collected from self-reported employment calendar diaries, pay and tax documents, and medical records, the authors compared outcomes of veterans offered IPS services to a control group offered standard non-IPS vocational rehabilitation services.
- The study suggested that IPS participants had higher employment and earnings than the control group.
- The quality of causal evidence presented in this report is low because this is a randomized control trial with high sample attrition and the authors did not ensure that the groups being compared were similar before the intervention. This means we are not confident that the estimated effects are attributable to IPS integrated within a primary care PACT; other factors are likely to have contributed.
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Intervention Examined
Individual Placement and Support (IPS)
Features of the Intervention
Individual placement and support (IPS) is a personalized supported employment model that assists individuals with disabilities in gaining and keeping competitive employment. IPS is typically used for people with serious mental illnesses and has been shown to improve employment outcomes. The Veterans Health Administration (VHA) offers vocational rehabilitation (VR) services to veterans and began implementing IPS for veterans with serious mental illness in 2004. However, many veterans avoid IPS services due to fears of losing disability benefits, experiencing worsening symptoms, or hurting their job prospects. This study sought to study the effectiveness of IPS offered in a less stigmatizing setting by examining IPS integrated within a primary care patient-aligned care team (PACT) and provided to veterans with nonpsychotic mental disorders.
The intervention used rapid job searches to help veterans secure diverse and competitive jobs, embraced “zero exclusion,” provided personalized information on government benefits, and used a network of employers based on veterans’ interests. IPS specialists participated in PACT huddles, gave monthly staff meeting updates, and met individually with providers.
The intervention served veterans with mental health issues aged 19 or older receiving primary care in a PACT clinic who were eligible for VR services. Eligibility criteria included having a current diagnosis of a nonpsychotic mental disorder and not being actively suicidal or homicidal, being unemployed or underemployed and seeking competitive employment, not participating in any other VR study, and agreeing to a twelve month follow up.
Features of the Study
The study was a randomized controlled trial that examined the impacts of Individual Placement and Support (IPS) in a primary care patient-aligned care team (PACT) on employment and earnings for veterans with nonpsychotic psychiatric disorders. The study included veterans with mental health disorders who were receiving primary care in a primary care PACT clinic through the Tuscaloosa VA Medical Center in Tuscaloosa, Alabama.
The study randomly assigned 58 veterans to the treatment group and 61 veterans to the control group. Treatment group members were offered the intervention. Control group members were offered standard non-IPS vocational rehabilitation services as existing services within the medical center on a consultation basis and not embedded in a PACT. These included compensated work therapy (CWT); sheltered transitional work (TW) assignments in set-aside, minimum wage, time-limited jobs; and CWT–community-based employment services (CBES), which involved limited community job search and placement.
The authors collected data from self-reported employment calendar diaries, pay and tax documents, and medical records. The authors used a statistical model to compare the outcomes of the treatment group to the control group, using logistic regression models to calculate odds ratios.
Findings
Earnings
- The study suggested that IPS group participants had higher income earned from competitive sources, as well as from all sources, than the control group.
Employment
- The study suggested that IPS participants worked more weeks, days, and hours in a competitive job than control group participants.
- The study suggested that IPS participants acquired their first competitive job in fewer weeks, and that a higher share obtained a competitive job within 3 months, than among the control group.
- The study did not suggest a relationship between IPS and the number of weeks worked in full-time competitive employment.
Considerations for Interpreting the Findings
The study had high sample attrition and therefore is not eligible for a high causal evidence rating, the highest rating available for randomized controlled trial designs.
The authors reported that there were no significant differences between the groups on baseline demographic characteristics, including pre-intervention characteristics such as age, sex, and race. However, the authors did not demonstrate this baseline equivalence or include controls for pre-intervention measures of employment and earnings. Since the authors did not account for preexisting differences between the groups before program participation or include sufficient control variables, these preexisting differences—and not IPS—could explain the observed differences in outcomes. Therefore, the study received a low causal evidence rating.
Causal Evidence Rating
The quality of causal evidence presented in this report is low because the study was a randomized control trial with high attrition, and the authors did not ensure that the sample members included in the analysis were similar before the intervention. This means we are not confident that the estimated effects are attributable to IPS integrated within a PACT; other factors are likely to have contributed.