Enhancing recovery and social inclusionthrough competitive employment:

The Queensland Employment Specialist Initiative (ESI-12)

Geoff Waghorn PhDGeoff Waghorn PhDThe Queensland Centre for Mental Health Research (QCMHR) The Queensland Centre for Mental Health Research (QCMHR)

and The University of Queenslandand The University of Queensland

Supported by Queensland Health Supported by Queensland Health (The Directorate of Mental Health) and QCMHR(The Directorate of Mental Health) and QCMHR

Outline

Target groupTarget group SPMI (Serious and Persistent Mental Illness) and SPMI (Serious and Persistent Mental Illness) and

labour force exclusion labour force exclusion Desire to workDesire to work Principles of EBP in SEPrinciples of EBP in SE Preliminary resultsPreliminary results Challenges and opportunitiesChallenges and opportunities ConclusionsConclusions

Target groupTarget group The focus of this presentation is on people with SPMI who want a The focus of this presentation is on people with SPMI who want a

working life as part of their recoveryworking life as part of their recovery So this means ‘volunteers’ most likely to have substantial So this means ‘volunteers’ most likely to have substantial

psychiatric disabilities due to: psychiatric disabilities due to: Schizophrenia Schizophrenia Schizoaffective disorder Schizoaffective disorder Bipolar affective disorder (with psychotic features)Bipolar affective disorder (with psychotic features) First episode psychosisFirst episode psychosis Other severe psychiatric disorders (that cause major impairment of social or Other severe psychiatric disorders (that cause major impairment of social or

occupational functioning)occupational functioning) Major depression and anxiety disordersMajor depression and anxiety disorders Other psychiatric disorders (e.g. eating disorders, personality disorders) Other psychiatric disorders (e.g. eating disorders, personality disorders) Complex co-morbid disorders and multi-morbiditiesComplex co-morbid disorders and multi-morbidities

These are the people most in need of intensive disability These are the people most in need of intensive disability employment services who do not currently get sufficient access to employment services who do not currently get sufficient access to those services those services

Where are Australians with SPMI?Where are Australians with SPMI?

People with psychiatric/psychological disabilities People with psychiatric/psychological disabilities make up of 28% of all DSP recipients in Australia;make up of 28% of all DSP recipients in Australia;

If seeking employment, they are found in DES, JSA If seeking employment, they are found in DES, JSA and Business Service systems, or may not seek help and Business Service systems, or may not seek help at all. at all.

Most clients of Community Mental Health Teams Most clients of Community Mental Health Teams have SPMI;have SPMI;

A large proportion of homeless people have A large proportion of homeless people have untreated or undiagnosed SPMI;untreated or undiagnosed SPMI;

Estimate that over 100,000 Australians of working Estimate that over 100,000 Australians of working age have SPMI. age have SPMI.

Labour force exclusion by diagnostic category

Persons aged 15-64 Persons aged 15-64 years years

Not in the labour Not in the labour Force (%)Force (%)

Looking for Looking for work (%)work (%)

Employed part-Employed part-time or full-time time or full-time

(%)(%)

SourceSource1,21,2

Healthy Australians Healthy Australians 19.1 19.1 4.0 4.0 76.9 76.9 Waghorn et al., 2009. Waghorn et al., 2009.

Anxiety disorders Anxiety disorders 46.1 46.1 4.2 4.2 49.7 49.7 Waghorn et al., 2009. Waghorn et al., 2009.

Mood disorders Mood disorders (excluding post-(excluding post-natal) natal)

51.6 51.6 6.6 6.6 41.8 41.8 Waghorn et al., 2009. Waghorn et al., 2009.

Bipolar affective Bipolar affective disorder (with disorder (with psychosis) [1998]psychosis) [1998]

61.861.8 4.54.5 28.028.0 Jablensky et al., 1999; Jablensky et al., 1999; Waghorn et al., 2005Waghorn et al., 2005

Psychotic disorders Psychotic disorders [1998][1998]

75.275.2 3.73.7 21.121.1 Jablensky et al., 1999; Jablensky et al., 1999; Waghorn et al., 2002Waghorn et al., 2002

SchizophreniaSchizophrenia 73.573.5 10.710.7 15.915.9 Waghorn et al., 2009 Waghorn et al., 2009

1. Primary data source: Australian Bureau of Statistics Survey of Disability, Ageing and Carers, 1. Primary data source: Australian Bureau of Statistics Survey of Disability, Ageing and Carers, NN=36,088. One =36,088. One in 400 households sampled throughout Australia. 2. References available on request. in 400 households sampled throughout Australia. 2. References available on request.

Do people with SPMI want to work?

A recent QCMHR survey of 301 Brisbane region A recent QCMHR survey of 301 Brisbane region adults with schizophrenia, aged 18-60 years, showed: adults with schizophrenia, aged 18-60 years, showed: 12% were employed;12% were employed; 59% were interested in employment;59% were interested in employment; 18% indicated no interest, 18% indicated no interest, 11% indicated ‘did not know’. 11% indicated ‘did not know’.

Labour force exclusion does not imply that people Labour force exclusion does not imply that people with SPMI do not want to work or cannot work. with SPMI do not want to work or cannot work.

The problem must be about access to more effective The problem must be about access to more effective forms of employment assistance. forms of employment assistance.

Supported employment designed for people with psychiatric disabilities

Seven evidence-based principles 1. Eligibility is based on consumer choice 2. Supported employment is integrated with treatment 3. Competitive employment is the primary goal 4. Rapid job search (first employer contact within 4 weeks) 5. Job finding, and all assistance, is individualised 6. Follow-along supports are continuous 7. Financial planning is provided

Principle 2 is most often missing in Australia, although all others can be weak in practice

Service characteristics rather than client characteristics, are stronger predictors of employment outcomes

Client characteristics are more relevant to the cost of service delivery than outcomes

New practices are being identified due to extensive international research

EvidenceEvidence Randomised controlled trials (RCT) are the strongest

scientific design for evaluating whether an intervention works

16 published and qualifying RCTs (Bond et al 2008): 12 in USA 1 in Hong Kong 1 in Canada 1 in Europe (six European countries, published in Lancet) 1 in Australia

Figure 1. Competitive Employment Rates in 16 Randomized Controlled Trials of Supported Employment

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

96 NH (IPS)

07 Aust (IPS)

94 NY (SE)

07 IL

(IPS)

04 CT

(IPS)

05 HK (IPS)

06 SC

(IPS)

06MA

(ACT)

99 DC (IPS)

07 CA

(IPS)

95 IN

(SE)

07EUR(IPS)

06QUE(IPS)

00 NY (SE)

97 CA (SE)

02MD(IPS)

Supported Employment Control Control 2

SummarySummary 11 of 16 RCTs compared high fidelity services to the 11 of 16 RCTs compared high fidelity services to the

best available local traditional services:best available local traditional services: More participants commenced competitive employment More participants commenced competitive employment

(62% vs. 25%)(62% vs. 25%) More participants worked 20 or more hours per week More participants worked 20 or more hours per week

(66% vs. 14.2%)(66% vs. 14.2%) Less days to first job (144.5 vs. 214.0 days)Less days to first job (144.5 vs. 214.0 days) Similar accumulated employment following Similar accumulated employment following

commencement of first job (24.5 vs. 25.0 weeks)commencement of first job (24.5 vs. 25.0 weeks) More weeks worked at longest job (22.0 vs. 16.3 weeks)More weeks worked at longest job (22.0 vs. 16.3 weeks)

Time to first job and job retention remain major Time to first job and job retention remain major challenges challenges

Disability Employment Services employment outcomes1,2,3

DEN Funding levelDEN Funding level Employment Employment milestone milestone

Psychological or Psychological or PsychiatricPsychiatric(% attaining)(% attaining)

All other disability All other disability categoriescategories(% attaining)(% attaining)

Level 3Level 3 4 weeks 4 weeks employmentemployment

44.344.3 50.550.5

26 weeks 26 weeks employmentemployment

26.526.5 33.333.3

Level 4Level 4 4 weeks 4 weeks employmentemployment

40.840.8 48.048.0

26 weeks 26 weeks employmentemployment

24.024.0 35.235.2

1. Outcomes by 31 Dec 2007 for new clients entering from July 2005-30 June 2006 1. Outcomes by 31 Dec 2007 for new clients entering from July 2005-30 June 2006 (n=6,750). 2. Unpublished data provided by DEEWR to QCMHR. 3. DEEWR (2007), (n=6,750). 2. Unpublished data provided by DEEWR to QCMHR. 3. DEEWR (2007), Disability Employment Network Case-based Funding Report. Disability Employment Network Case-based Funding Report.

Preliminary outcomes from a Queensland 12-site study

12 employment specialists co-located into 12 mental health teams 12 employment specialists co-located into 12 mental health teams (11 in Queensland, 1 in Hobart-Bellerive (4 sites are RCTs), (11 in Queensland, 1 in Hobart-Bellerive (4 sites are RCTs), outcomes tracked over 2 years outcomes tracked over 2 years

Preliminary results from the West Moreton RCT, show that at 12 Preliminary results from the West Moreton RCT, show that at 12 months, 54% of integrated service clients (months, 54% of integrated service clients (nn=24) commenced =24) commenced competitive employment, compared to 36% (competitive employment, compared to 36% (nn=22) among those =22) among those receiving brokered assistancereceiving brokered assistance

Brokered assistance, where MH team members are coached by Brokered assistance, where MH team members are coached by the employment specialist, the employment specialist, is a promising second strategyis a promising second strategy for for responding to increased demand, and for developing industry responding to increased demand, and for developing industry capability to work with this client group capability to work with this client group

Data collection will be complete by 30 June 2010 and results for Data collection will be complete by 30 June 2010 and results for 350 clients with SPMI will be reported later this year350 clients with SPMI will be reported later this year

‘Extremely beneficial for clients and invaluable resource for adult community Mental Health Team’ (Referrer)

‘Clients I have referred and have gained employment through the program feel it has been a positive experience, it has improved self-esteem and the quality of their lives’ (Referrers)

‘It has been a major turning point in a change of focus for our clients. The buzz word now is work. This is new and helps motivate our clients to get out there and integrate’ (Referrer)

‘Our goal was to achieve more consistent referral flow of consumers with a mental health condition and the project has provided a steady flow of consumers during a time when other similar services were having difficulties with referral flow’ (Team Leader)

‘Most of our staff have reported positive interactions with clinical teams. Personally, I feel clinical teams have embraced this project and any that may have been skeptical initially, have seen the benefits and results and referrals to our program have been forthcoming’ (Team Leader)

‘ [I have achieved a] greater understanding regarding the capacity of clients to participate in competitive employment’ (Employment Consultant)

‘Involvement with the Community team has been very positive and my involvement has included attending their team meeting and community events’ (Employment Consultant)

Positive CommentsPositive Comments

Top five reported barriers to referring clients to the IEP

Seven lowest reported barriers to referring clients to the IEP

Challenges and opportunitiesChallenges and opportunities

All necessary ingredients present in Australia: All necessary ingredients present in Australia: Community mental health servicesCommunity mental health services Disability employment servicesDisability employment services Over 3 years experience in Qld at integrating servicesOver 3 years experience in Qld at integrating services Most sites successful, and none want to turn back the clock Most sites successful, and none want to turn back the clock A demand-driven DES program to provide new funded places for clientsA demand-driven DES program to provide new funded places for clients

International studies provide:International studies provide: Evidence for what worksEvidence for what works Fidelity scales to assess practicesFidelity scales to assess practices Benchmarks to assess performance (national and international)Benchmarks to assess performance (national and international)

Therefore, this is a good time to encourage more partnerships Therefore, this is a good time to encourage more partnerships between DES services and Community Mental Health teams in between DES services and Community Mental Health teams in QueenslandQueensland

Conclusions

Co-location (with a focus on EBP) can enhance Co-location (with a focus on EBP) can enhance both employment and mental health servicesboth employment and mental health services

Integrated services promise more efficiency than Integrated services promise more efficiency than segregated servicessegregated services

Service integration (shared clients, shared Service integration (shared clients, shared decision making, and coordinated care) is decision making, and coordinated care) is developed over time and requires good joint developed over time and requires good joint management and leadershipmanagement and leadership

Questions and comments?Questions and comments?

Contact details:Contact details:

geoff_waghorn@qcmhr.uq.edu.augeoff_waghorn@qcmhr.uq.edu.au

Tel. +61 07 3271 8673Tel. +61 07 3271 8673Fax. +61 07 3271 8698Fax. +61 07 3271 8698

Further reading

Browne, D., Stephenson, A., Wright, J., and Waghorn, G. (2009). Browne, D., Stephenson, A., Wright, J., and Waghorn, G. (2009). Developing high performing employment services for people with Developing high performing employment services for people with mental illness. mental illness. International Journal of Therapy and International Journal of Therapy and Rehabilitation, 16Rehabilitation, 16(9), 502-511(9), 502-511..

King, R., Waghorn, G., Lloyd, C., McMah, T., McCloud, P., & Leong, King, R., Waghorn, G., Lloyd, C., McMah, T., McCloud, P., & Leong, C. (2006). Enhancing employment services for people with severe C. (2006). Enhancing employment services for people with severe mental illness: the challenge of the Australian service mental illness: the challenge of the Australian service environment. environment. Australian and New Zealand Journal of Psychiatry, Australian and New Zealand Journal of Psychiatry, 40,40, 471-477. 471-477.

Porteous, N., Waghorn, G. (2009). Developing evidence-based Porteous, N., Waghorn, G. (2009). Developing evidence-based supported employment services for young adults receiving public supported employment services for young adults receiving public mental health services. mental health services. New Zealand Journal of Occupational New Zealand Journal of Occupational Therapy, 56Therapy, 56(1), 34-39(1), 34-39..

Further reading continued

Waghorn, G., Collister, L., Killackey, E., and Sherring, J. (2007). Waghorn, G., Collister, L., Killackey, E., and Sherring, J. (2007). Challenges to the implementation of evidence-based Challenges to the implementation of evidence-based employment services in Australia. employment services in Australia. Journal of Vocational Journal of Vocational Rehabilitation, 27, Rehabilitation, 27, 29-37.29-37.

Waghorn, G., & Lloyd, C. (2005). The employment of people with Waghorn, G., & Lloyd, C. (2005). The employment of people with mental illness. mental illness. Australian e-Journal for the Advancement of Australian e-Journal for the Advancement of Mental HealthMental Health, , 4(2)4(2) Supplement, Supplement, 1-43. 1-43.

Waghorn G., Lloyd C., & Clune A. (2009). Reviewing the theory Waghorn G., Lloyd C., & Clune A. (2009). Reviewing the theory and practice of occupational therapy in mental health and practice of occupational therapy in mental health rehabilitation. rehabilitation. British Journal of Occupational Therapy, 72British Journal of Occupational Therapy, 72(7), 314-(7), 314-322. 322.

Waghorn, G., Spowart, C. (in press). Managing personal Waghorn, G., Spowart, C. (in press). Managing personal information in supported employment for people with psychiatric information in supported employment for people with psychiatric disabilities. Chris Lloyd (Ed): Vdisabilities. Chris Lloyd (Ed): Vocational rehabilitation and Mental ocational rehabilitation and Mental Health.Health. New York: Wiley-Blackwell. New York: Wiley-Blackwell.