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Progress Toward Recovery Transformation in Mental Health

A decade ago, the President's New Freedom Commission outlined a vision of recovery-oriented mental health services. As part of the "recovery transformation," the commission foresaw a future in which "everyone of all ages with a mental illness would have access to effective treatments and supports—the essentials for living, working, learning and participating fully in the community." 1 Although VA is a national leader for many indicators of care quality, improving mental health care has proven challenging. To determine whether patients are receiving appropriate mental health treatment, it is often necessary to know patients' preferences, outcomes, and history of psychosocial services. Given that such information is often not documented in medical records, policymakers have struggled to identify gaps in mental health service provision and to tailor the delivery of needed services. One approach to implementing recovery-oriented care calls for informing patients of potentially beneficial services, educating clinicians about new evidence-based practices, and monitoring implementation to ensure the delivery of services that improve outcomes.

Recovery transformation includes returning Veterans to mainstream jobs, also known as "competitive employment." VA has a national program of individual placement and support, an evidence-based approach to supported employment (SE) for individuals with serious mental illness. This SE model has the singular goal of competitive employment and is characterized by rapid job search, an alliance between an SE specialist and the Veteran's treatment team, and ongoing support of the individual during employment. Eligibility for SE is based only on an individual's expressed interest in returning to work; there are no requirements regarding the presence of symptoms, for example. Evidence shows that SE helps about 60 percent of enrollees secure competitive employment while traditional rehabilitation programs help approximately 10 to 20 percent of enrollees find employment. In fact, receipt of SE is the single best predictor of employment among individuals with serious mental illness. Employment can improve symptoms and social skills, increase self-efficacy, and reduce costs.

Despite evidence of its effectiveness, SE has been vastly underused. A 2009 SAMHSA survey indicated that only 2 percent of individuals with serious mental illness nationally receive SE services. Several factors may contribute to underuse of SE services, including: (1) in usual mental health care settings, individuals are not routinely asked if they would like to return to work; (2) many individuals with serious mental illness are not strong advocates for themselves; (3) many clinicians are not knowledgeable about the eligibility requirements for SE; and (4) caseloads for SE specialists are typically full, with a waiting list for enrollment.

The overarching aim of the VA HSR&D QUERI project, "Enhancing Quality of Care in Psychosis (EQUIP)," was to improve the use of evidence-based recovery-oriented services by Veterans with schizophrenia. This 15-month, clinic-level, controlled trial engaged four VISNs and enrolled 801 adults with schizophrenia and 171 clinicians across eight specialty mental health clinics. Each VISN selected two services to be targeted, and each VISN selected SE as one of the services.

Each site used evidence-based quality improvement tools to determine why eligible Veterans were not using SE. Researchers partnered with leaders at each site to identify gaps in care processes and to address deficiencies in knowledge. Sites installed patient-facing kiosks that permitted patients to self-report their clinical status, preferences, and treatment use. The kiosks queried patients about their interest in returning to work, whether they had received a referral to SE, and, if yes, how many SE appointments they had attended in the previous month. The kiosk printed reports for patients on the spot. If appropriate, the patient-level report provided either "talking points" that patients could use with their clinicians to discuss an SE referral or written encouragement for beginning or sustaining the use of SE services. The study also generated reports for clinicians with names and dates of their patients who reported interest in returning to work or who were previously referred, along with their attendance rate.

Study results indicated that Veterans at intervention sites were twice as likely to use SE services during the study compared to Veterans at control sites. A formative evaluation indicated an increase in SE capacity at intervention sites, including the addition of an SE worker, SE training for additional clinicians, and adjustments to SE caseloads to allow for new patients. Employment differences, a more distal outcome, were evident when examining site-level differences; an intervention site with good fidelity to the SE model showed significant increases in employment.

  1. President's New Freedom Commission on Mental Health (2004). Achieving the Promise: Transforming Mental Health Care in America. Final Report.
  2. Drake, R.E., Bond, G.R., Becker, D.R. et al. (2012). Individual Placement and Support: An Evidence-Based Approach to Supported Employment New York: Oxford University Press.
  3. Hamilton, A.B. et al. "Implementation of Evidence-Based Employment Services in Specialty Mental Health: Mixed Methods Research," Health Services Research. In press.