Intensity and continuity of services and functional outcomes in the rehabilitation of persons with schizophrenia

OBJECTIVE: The intensity and continuity of services delivered to individual clients in a community-based psychosocial rehabilitation program were examined in relationship to functional changes in the clients that occurred during the first 12 months of the program. METHODS: Subjects were 41 clients with schizophrenia or schizoaffective disorder who were admitted to an intensive psychosocial rehabilitation program. Measures of clinical and psychosocial functioning were derived from client interviews administered at baseline and six and 12 months later. Measures of service intensity and continuity came from data gathered daily by staff over 12 months. RESULTS: The results supported the hypotheses that greater intensity and longitudinal continuity of services are related to more client improvement as indicated by reduced rates of hospitalization and improved psychosocial functioning after both six and 12 months. Although clients' symptom levels increased over time, a significant relationship was noted between service intensity and continuity and better symptom outcomes after 12 months. Multiple regression analyses indicated that an average of 22 percent, and as much as 28 percent, of the change in clinical and functional outcomes after 12 months of rehabilitation was explained by the intensity and longitudinal continuity of services. CONCLUSIONS: Clients who received more contact hours with staff and who had fewer gaps in service delivery achieved greater rehabilitative improvement in social, work, and independent-living domains and had fewer days of hospitalization. Based on these findings, clinicians, administrators, and researchers can assume that the intensity and longitudinal continuity of services are important to achieving rehabilitative outcomes in some community-based psychosocial rehabilitation models.     

The effects of vocational services provided to the mentally disabled

The purpose of this study was to evaluate the effects of vocational services provided to mentally disabled clients of the Fresno County Department of Health by the California State Department of Vocational Rehabilitation located in Fresno, California. The findings were (a) 46% were discharged as employed; (b) cost per client was $1,590; (c) cost per success was $3,448; (d) the employed persons entered a variety of competitive jobs; (e) average annual income for persons employed at discharge was $5,539; (f) persons who were employed were less psychiatrically disabled and had a better work history; (g) only 26% of the severely disabled were employed, compared to 50% of the persons who were mildly or moderately disabled; (h) the main benefit of the program appeared to be that of returning less disabled clients with better work histories to work at normative levels shown prior to vocational services; and (i) cost-benefit analysis showed that annual earned income exceeded program cost.     

Epilepsy rehabilitation: evaluating specialized versus general agency outcome

This 1982 study was a retrospective comparison of vocational outcome between eight state rehabilitation agencies and the University of Washington Epilepsy Center's Vocational Unit for the years 1977-1978. Hypotheses included: (a) A significantly higher portion of those with epilepsy will find employment through a specialized (i.e., Epilepsy Center) versus a general rehabilitation program. (b) A specialized program will have a significantly lower proportion of program dropouts. (c) Those finding jobs through a specialized program will earn higher salaries and have better job retention than those employing a general agency program. On several comparisons the specialized program outperformed the general agencies--higher proportion of successful job placements and lower proportions of dropouts and those remaining in process (all chi2 tests significant at the p less than 0.001 level). Placement rates for specialized programs have traditionally approximated 50%, whereas these state agencies placed from 9 to 21%. Salary level and job retention differences were inconclusive. Data implications are discussed.     

Vocational outcomes among formerly homeless persons with severe mental illness in the access program

OBJECTIVE: This study examined the vocational outcomes of 4,778 formerly homeless individuals with severe mental illness who were enrolled in the Access to Community Care and Effective Services and Support (ACCESS) program, a multisite demonstration project designed to provide services to this population. METHODS: Participants were interviewed at the time of enrollment and again three months and 12 months later by trained researchers who were not part of the treatment team to determine their employment status. At 12 months, participants were also asked about the types of services they had received during the past 60 days. Multiple logistic regression analysis was used to predict employment at 12 months. RESULTS: ACCESS participants reported receiving relatively few job-related services. Nonetheless, modest but significant increases occurred between baseline and three months and between three months and 12 months in the total proportion of participants who were employed and who were employed full-time and in hourly earnings and estimated monthly earnings. The number of hours worked per week increased significantly between three months and 12 months. When the analysis controlled for site, study condition (whether the ACCESS site received or did not receive extra funds to improve service integration), minority status, addiction treatment, and mental health treatment, participants who were employed at 12 months were more likely to have received job training and job placement services. CONCLUSIONS: Programs that work with homeless mentally ill persons may better serve their clients by placing as great an emphasis on providing employment services as on providing housing and clinical treatment.     

Inpatient Hospitalizations and Emergency Service Visits Among Participants in an Individual Placement and Support (IPS) Model Program

Supported employment (SE) is considered an "evidence-based" practice for people with serious mental illness. We examined inpatient hospitalizations and emergency service visits among clients in a SE program based on the Individual Placement and Support (IPS) model in comparison to a propensity score matched group of clients who did not participate in IPS. A significant interaction showed that only IPS/SE clients who were also high in regular mental health services had fewer hospitalizations and emergency service visits than matched controls. The interaction effect was moderate, even when we controlled for client functioning. These findings provide support for the integration of mental health and vocational rehabilitation services, a key feature of evidence-based SE services.     

The job-finding module: training skills for seeking competitive community employment.

The opportunity to return to work is often the culmination of extensive and collaborative efforts by clients, psychiatrists, and allied mental health and rehabilitation practitioners. Successful vocational placement and tenure is a victory not only for each individual client but also for the comprehensive set of services and supports established to foster this self-determination. Much as a chain is only as strong as its links, successful job placement must be viewed as but one link in a comprehensive rehabilitation program. Our research in competitive community employment placement over the past decade has resulted in the development of the Job Finding Module, as our contribution to one link of this evolving chain of necessary treatment and rehabilitation services for the seriously mentally ill.     

Program characteristics for successful treatment of adolescent drug abuse

The relationship to treatment outcome, as measured by reduction in drug use, of specific characteristics and elements of 30 drug-free outpatient programs for adolescents is reported. Admission and discharge data were obtained from National Institute on Drug Abuse-Client Oriented Data Acquisition Process on 5789 adolescents in the 30 programs. A partial cross-validation study was conducted by analyzing separately for two annual client subsamples. The program, not the individual clients, was the unit of analysis. While controlling for differences between programs on their client populations, multiple regression analysis indicated that the following characteristics of programs were found to predict the outcome criterion variable, to a statistically significant degree: treat a large number of adolescent clients; have a special school for school dropouts; have a relatively large budget; employ counselors or therapists who have at least 2 years' experience in working with adolescent drug abusers; provide special services such as vocational counseling, recreational services, and birth control services; use such therapy methods as crisis intervention, gestalt therapy, music/art therapy, and group confrontation; and be perceived by the clients as allowing and encouraging free expression and spontaneous action by clients. There was a high degree of replication of these findings across the two annual subsamples of clients; and the amount of variance in the treatment outcome criterion variable accounted for by the above-listed program characteristics was quite impressive.     

The effectiveness of skills training for improving outcomes in supported employment

OBJECTIVE: This study evaluated whether a supplementary skills training program improved work outcomes for clients enrolled in supported employment programs. METHODS: Thirty-five recently employed clients with severe mental illness who were receiving supported employment services at a free-standing agency were randomly assigned to participate in either the workplace fundamentals program, a skills training program designed to make work more "successful and satisfying," or treatment as usual. Knowledge of workplace fundamentals (for example, identifying workplace stressors, problem solving, and improving job performance) was assessed at baseline and at nine months; employment outcomes and use of additional vocational services were tracked for 18 months. RESULTS: Clients in the workplace fundamentals group (N=17) improved more in knowledge of workplace fundamentals than those in the control group (N=18) at the nine-month follow-up, but the two groups did not differ in the number of hours or days worked, salary earned, or receipt of additional vocational services over the 18-month period. In general, clients in this study had higher educational levels and better employment outcomes than clients in most previous studies of supported employment, making it difficult to detect possible effects of the skills training intervention on work. CONCLUSIONS: Supplementary skills training did not improve work outcomes for clients who were receiving supported employment.     

The problem is outside: Staff and client behavior as a function of external events

Data collected in the process of studying the development and functioning of a prerelease program for adjudicated adult offenders provided the opportunity to test the hypothesis that the actions of a parent organization influence the within program behaviors of clients and rehabilitation staff. It is demonstrated that changes in the parent organization's behavior toward the program were accompanied by changes in (a) the staff's perceptions of clients, (b) the staffs actions toward clients, (c) client attitudes, and (d) client behaviors. Discussion focuses on the need to view rehabilitative programs as continually influenced by external and extrinisic factors.This research was supported by grant #70-DF296 from the U.S. Department of Justice, Law Enforcement Assistance Agency.     

An economic analysis of psychosocial rehabilitation

The author examines three studies of the major monetary costs and benefits of psychosocial rehabilitation of the mentally ill; he focuses on hospitalization costs, costs of community treatment, and earnings from competitive employment. In the first study, which compared the effects of psychosocial rehabilitation with those of a support group over a nine-month period, an estimated savings of +1,880 per client was found among the clients receiving psychosocial rehabilitation. In the second study of treatment costs for 40 chronic psychiatric recidivists who were involved in an aggressive home outreach program, an estimated annual savings of +5,000 per client was found. In the third study 101 clients were interviewed six months after they had left a psychosocial rehabilitation program. Their earnings from competitive employment were linearly related to their length of participation in the program. The author concludes that these studies offer substantial evidence for the economic advantages of psychosocial rehabilitation.