Dr. Geoff Waghorn on The Queensland Employment Specialist Initiative

Enhancing recovery and social inclusion through competitive employment: The Queensland Employment Specialist Initiative (ESI-12) Geoff Waghorn PhD The Queensland Centre for Mental Health Research (QCMHR) and The University of Queensland Supported by Queensland Health (The Directorate of Mental Health) and QCMHR

Outline
Target group
SPMI (Serious and Persistent Mental Illness) and labour force exclusion
Desire to work
Principles of EBP in SE
Preliminary results
Challenges and opportunities
Conclusions

Target group
The focus of this presentation is on people with SPMI who want a working life as part of their recovery
So this means ‘volunteers’ most likely to have substantial psychiatric disabilities due to:
Schizophrenia
Schizoaffective disorder
Bipolar affective disorder (with psychotic features)
First episode psychosis
Other severe psychiatric disorders (that cause major impairment of social or occupational functioning)
Major depression and anxiety disorders
Other psychiatric disorders (e.g. eating disorders, personality disorders)
Complex co-morbid disorders and multi-morbidities
These are the people most in need of intensive disability employment services who do not currently get sufficient access to those services

Where are Australians with SPMI?
People with psychiatric/psychological disabilities make up of 28% of all DSP recipients in Australia;
If seeking employment, they are found in DES, JSA and Business Service systems, or may not seek help at all.
Most clients of Community Mental Health Teams have SPMI;
A large proportion of homeless people have untreated or undiagnosed SPMI;
Estimate that over 100,000 Australians of working age have SPMI.

Labour force exclusion by diagnostic category Persons aged 15-64 years Not in the labour Force (%) Looking for work (%) Employed part-time or full-time (%) Source 1,2 Healthy Australians 19.1 4.0 76.9 Waghorn et al., 2009. Anxiety disorders 46.1 4.2 49.7 Waghorn et al., 2009. Mood disorders (excluding post-natal) 51.6 6.6 41.8 Waghorn et al., 2009. Bipolar affective disorder (with psychosis) [1998] 61.8 4.5 28.0 Jablensky et al., 1999; Waghorn et al., 2005 Psychotic disorders [1998] 75.2 3.7 21.1 Jablensky et al., 1999; Waghorn et al., 2002 Schizophrenia 73.5 10.7 15.9 Waghorn et al., 2009 1. Primary data source: Australian Bureau of Statistics Survey of Disability, Ageing and Carers, N =36,088. One 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 adults with schizophrenia, aged 18-60 years, showed:
12% were employed;
59% were interested in employment;
18% indicated no interest,
11% indicated ‘did not know’.
Labour force exclusion does not imply that people with SPMI do not want to work or cannot work.
The problem must be about access to more effective 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

Evidence
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

Summary
11 of 16 RCTs compared high fidelity services to the best available local traditional services:
More participants commenced competitive employment (62% vs. 25%)
More participants worked 20 or more hours per week
(66% vs. 14.2%)
Less days to first job (144.5 vs. 214.0 days)
Similar accumulated employment following commencement of first job (24.5 vs. 25.0 weeks)
More weeks worked at longest job (22.0 vs. 16.3 weeks)
Time to first job and job retention remain major challenges

Disability Employment Services employment outcomes 1,2,3 DEN Funding level Employment milestone Psychological or Psychiatric (% attaining) All other disability categories (% attaining) Level 3 4 weeks employment 44.3 50.5 26 weeks employment 26.5 33.3 Level 4 4 weeks employment 40.8 48.0 26 weeks employment 24.0 35.2 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), 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 (11 in Queensland, 1 in Hobart-Bellerive (4 sites are RCTs), outcomes tracked over 2 years
Preliminary results from the West Moreton RCT, show that at 12 months, 54% of integrated service clients ( n =24) commenced competitive employment, compared to 36% ( n =22) among those receiving brokered assistance
Brokered assistance, where MH team members are coached by the employment specialist, is a promising second strategy for responding to increased demand, and for developing industry capability to work with this client group
Data collection will be complete by 30 June 2010 and results for 350 clients with SPMI will be reported later this year

Positive Comments ‘ 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)

Top five reported barriers to referring clients to the IEP

Seven lowest reported barriers to referring clients to the IEP

Challenges and opportunities
All necessary ingredients present in Australia:
Community mental health services
Disability employment services
Over 3 years experience in Qld at integrating services
Most sites successful, and none want to turn back the clock
A demand-driven DES program to provide new funded places for clients
International studies provide:
Evidence for what works
Fidelity scales to assess practices
Benchmarks to assess performance (national and international)
Therefore, this is a good time to encourage more partnerships between DES services and Community Mental Health teams in Queensland

Conclusions
Co-location (with a focus on EBP) can enhance both employment and mental health services
Integrated services promise more efficiency than segregated services
Service integration (shared clients, shared decision making, and coordinated care) is developed over time and requires good joint management and leadership

Questions and comments?
Contact details:
[email_address]
Tel. +61 07 3271 8673
Fax. +61 07 3271 8698

Further reading
Browne, D., Stephenson, A., Wright, J., and Waghorn, G. (2009). Developing high performing employment services for people with mental illness. International Journal of Therapy and Rehabilitation, 16 (9), 502-511 .
King, R., Waghorn, G., Lloyd, C., McMah, T., McCloud, P., & Leong, C. (2006). Enhancing employment services for people with severe mental illness: the challenge of the Australian service environment. Australian and New Zealand Journal of Psychiatry, 40, 471-477.
Porteous, N., Waghorn, G. (2009). Developing evidence-based supported employment services for young adults receiving public mental health services. New Zealand Journal of Occupational Therapy, 56 (1), 34-39 .

Further reading continued
Waghorn, G., Collister, L., Killackey, E., and Sherring, J. (2007). Challenges to the implementation of evidence-based employment services in Australia. Journal of Vocational Rehabilitation, 27, 29-37.
Waghorn, G., & Lloyd, C. (2005). The employment of people with mental illness. Australian e-Journal for the Advancement of Mental Health , 4(2) Supplement, 1-43.
Waghorn G., Lloyd C., & Clune A. (2009). Reviewing the theory and practice of occupational therapy in mental health rehabilitation. British Journal of Occupational Therapy, 72 (7), 314-322.
Waghorn, G., Spowart, C. (in press). Managing personal information in supported employment for people with psychiatric disabilities. Chris Lloyd (Ed): V ocational rehabilitation and Mental Health. New York: Wiley-Blackwell.

Dr. Geoff Waghorn on The Queensland Employment Specialist Initiative

by Centre for Mental Health on Mar 09, 2011

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Dr. Geoff Waghorn on The Queensland Employment Specialist Initiative — Presentation Transcript

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