1100 — Implementation of Evidence-Based Employment Services for Veterans with Serious Mental Illness
Young AS, Greater Los Angeles VA & UCLA; Cohen AN, Greater Los Angeles VA & UCLA; Whelan F, UCLA; Hamilton AB, Greater Los Angeles VA;
Unemployment is very common among Veterans with serious mental illness. Supported Employment is an evidence-based practice that substantially increases rates of competitive employment in this population, while improving symptoms and reducing treatment costs. It is indicated for Veterans who want to work. However, Veteran preferences regarding work are often not assessed or documented, and Supported Employment is rarely provided. The EQUIP project sought to produce routine information about Veterans' needs and preferences, and to use this to implement system change at VA mental health clinics.
EQUIP was a site-level controlled trial. Within 4 VISNs, pairs of sites were assigned to intervention or usual care. At intervention sites, a mixed-method assessment of organizational readiness for change was conducted. Patient-facing kiosks were installed, and used to systematically elicit Veteran needs and preferences at each visit. Sites used quality improvement tools to identify why appropriate Veterans were not being referred to Supported Employment. Partnering with leadership, gaps in care processes were identified, and knowledge deficiencies addressed. Patients and clinicians were interviewed at baseline and 15 months regarding need, use, and impact.
801 adults with schizophrenia and 171 clinicians enrolled. A logistic model predicted utilization of Supported Employment based on group status (intervention/control) while controlling for baseline utilization and desire to work. Individuals at intervention sites were 2.3 times more likely to utilize Supported Employment during the study compared to individuals at control sites. Formative evaluation indicated increased capacity at intervention sites, including the addition of a Supported Employment worker, training for additional providers, and adjustments to caseloads to allow for new patients. Employment differences were only evident when examining site-level differences; the intervention site with good fidelity showed significant increases in employment (p = .004).
Implementation resulted in superior patient-level outcomes and improved clinician knowledge, attitudes, and behaviors, in the context of substantial variation among sites.
Studies of implementation and effectiveness require mixed methods to both enhance implementation in real time and provide context for interpretation of complex results. Successful uptake may require assessment of readiness for change and utilization of tools to identify and address shortcomings in knowledge, attitudes, and capacity.