Analyzing vocational outcomes of individuals with psychiatric disabilities who received state vocational rehabilitation services: a data mining approach

This study examines factors affecting vocational outcomes in the vocational rehabilitation process for individuals experiencing psychiatric disabilities who had received state vocational rehabilitation (VR) services. A data mining approach was used to analyze the Rehabilitation Services Administration FY 2001 Case Service Report (RSA-911). Receiving job placement services was found to be the most important variable differentiating individuals who were working from those who were not working. Results regarding vocational outcomes suggest a positive effect for persons receiving job placement services.     

Prospects and services for medical rehabilitation.

In the developed world, comprehensive services for disabled patients are usually well established for children and elderly people. Services for rehabilitation of middle-aged patients generally consist of specific treatment facilities, such as for physiotherapy. On the other hand, a range of services of psychiatric patients is now established, with a model suitable for most disorders. Arrangements are flexible, ranging from crisis intervention to long-term care, in some places being remarkably comprehensive and well coordinated. There is a need to plan development of medical and social services for patients prone to chronic morbidity from whatever cause; this plan for the physicially disabled should take account of their many needs, and of the many facilities now available, some statutory, some voluntary. There is reason to believe that redeployment of resources existing in many countries could improve the standard of medical rehabilitation for patients of all ages.     

Supplementing supported employment with workplace skills training

Introduction by the column editors: Supported employment, as designed for persons with serious and persistent mental illness, has been termed individual placement and support. In two randomized controlled trials (1,2), clients who received individual placement and support services were more likely to obtain at least one job in the competitive sector, to work more hours, and to have a higher total income than their counterparts who received more traditional types of vocational rehabilitation. However, individual placement and support did not improve the length of time the employed participants kept their jobs.An adjunctive or additional element of individual placement and support, aimed at improving the job tenure of individuals with mental illness, would be a constructive contribution to the vocational rehabilitation for this population. In a previous Rehab Rounds column, Wallace and colleagues (3) described the development of the workplace fundamental skills module, a highly structured and user-friendly curriculum designed to teach workers with mental illness the social and workplace skills needed to keep their jobs. The workplace fundamental skills module supplements individual placement and support by conveying specific skills that enable workers to learn the requirements of their jobs, anticipate the stressors associated with their jobs, and cope with stressors by using a problem-solving process. The earlier report described the production and validation of the module's content. The purpose of this month's column is to present the preliminary results of a randomized comparison of the module's effects on job retention, symptoms, and community functioning when coupled with individual placement and support. To enable wide generalization of the findings of the study, the program was conducted in a typical community mental health center.     

Recovery in Israel: a legislative recovery response to the needs-rights paradox

This paper uses the framework of the applied social science needs/rights antinomy to describe the efforts of Israel's mental health system in transforming a hospital-based orientation to services for individuals with a severe mental illness, to a community-based recovery orientation. On the one hand, a rationale for the provision of services to individuals with a severe mental illness that stresses these individuals' needs can justify the allocation of society's limited resources by referring to an objectively determinable set of psychiatric needs. However, this rationale may establish an inherent asymmetry between the adequate help provider and deficient help user. On the other hand, a rationale for providing psychiatric rehabilitation services that stresses the fundamental symmetry between the help provider and the help user is empowering, thus consistent with the recovery approach. However, this rationale does not provide a mechanism for negotiating the vague boundary between mental health and mental illness. Israel's mental health system has operationalized a policy that emphasizes rights as well as needs by legislating for a comprehensive set of rehabilitation services that individuals meeting the eligibility criteria may receive. This paper discusses this approach's achievements, challenges and implications for future policy, research, and practice.     

Rehabilitation of the disabled mentally III in the community

The purpose of this article is to review the latest developments in the area of rehabilitation of disabled mentally ill patients. Rehabilitation is a comprehensive and multi-disciplinary treatment. It involves a wide variety of interventions. These interventions are designed to enable the client to integrate into the normal life of the community and to improve his quality of life. This review discusses the different approaches and their effectiveness. The approaches that are described include comprehensive psychiatric, psycho-social and psycho-educational interventions including family therapy, training in social skills, and vocational intervention in programs and services in the community. The approaches that have been shown to be the most effective in controlled studies include: follow-up psychiatric drug treatment, individual and family psycho-educational treatment; social skills training; community sheltered-housing facilities and vocational rehabilitation programs. It has been emphasized that the effectiveness of treatment is conditional not only on the client's resilience and a comprehensive and multidisciplinary treatment approach, but also on the community financial resources and the level of training of the professionals.     

The job developer's presence in the job interview: is it helpful or harmful to persons with psychiatric disabilities seeking employment?

This study examines the effect of having an employment specialist join supported employment participants at job interviews. The sample consists of 45 individuals with psychiatric disabilities who sought job placement services during a 28-month period between December 1991 and March 1994. Seventy-nine percent of the job offers occurred when the job developer was present in the interview as compared to only 21% when the job applicants went alone. The finding challenges "current" conventional wisdom about having rehabilitation staff at the worksite. Rehabilitation professionals need to take a fresh look at program policies and practices regarding on-site services to SE participants.     

Repeated self-injury and its management

Abstract

This paper uses the framework of the applied social science needs/rights antinomy to describe the efforts of Israel's mental health system in transforming a hospital-based orientation to services for individuals with a severe mental illness, to a community-based recovery orientation. On the one hand, a rationale for the provision of services to individuals with a severe mental illness that stresses these individuals’ needs can justify the allocation of society's limited resources by referring to an objectively determinable set of psychiatric needs. However, this rationale may establish an inherent asymmetry between the adequate help provider and deficient help user. On the other hand, a rationale for providing psychiatric rehabilitation services that stresses the fundamental symmetry between the help provider and the help user is empowering, thus consistent with the recovery approach. However, this rationale does not provide a mechanism for negotiating the vague boundary between mental health and mental illness. Israel's mental health system has operationalized a policy that emphasizes rights as well as needs by legislating for a comprehensive set of rehabilitation services that individuals meeting the eligibility criteria may receive. This paper discusses this approach's achievements, challenges and implications for future policy, research, and practice.     

Toward a health services research capacity in spinal cord injury

Health services research (HSR) is the research field that seeks to examine systematically the organisation, provision, and financing of health care services. There currently is only a rudimentary HSR capacity in the area of spinal cord injury (SCI). To a large extent, the HSR community has not addressed issues concerning persons with SCI, and the disability research and medical rehabilitation communities have not considered issues of HSR that affect the SCI population. However, due to recent changes in (1) the clinical management of SCI; (2) the expectations of persons with SCI, and (3) health care delivery and finance, the time is now ripe for the development of a HSR capacity in SCI. This article summarises current efforts at HSR in SCI in the United States, which have been primarily in the areas of trauma care and medical rehabilitation. It considers an agenda for future health services research in SCI, which must include research on post-rehabilitation health care and personal assistance needs. Finally, this article suggests strategies for developing a comprehensive HSR capacity in SCI.     

Predictors of outcomes for users of mental health rehabilitation services: a 5-year retrospective cohort study in inner London, UK

Objective

There have been few recent studies reporting on the outcomes for users of psychiatric rehabilitation services. This group has complex, longer-term mental health problems. We aimed to investigate 5-year outcomes for this group and identify factors associated with outcome.

Method

Clinical outcome data on 141 users of a mental health rehabilitation service in inner London, UK, surveyed in 2005, were collected retrospectively 5 years later. Positive outcome was defined for those who were inpatients in 2005 as achieving and sustaining community discharge, and for those who were community patients, as progressing to and sustaining a less supported community placement. Negative outcome was defined as remaining in the same placement, moving to more supported placement or having a psychiatric admission.

Results

Over 5 years, 17 (12 %) people died, 50 (40 %) had a positive outcome, 33 (27 %) remained in a placement with a similar level of support and 41 (38 %) moved to a more supported placement and/or had a psychiatric admission. Thirteen (10 %) people moved to independent accommodation and sustained their tenancy successfully. Those with a record of non-adherence with medication during the 5 years were more likely to have a negative outcome (OR 8.60, 95 % CI 3.41 to 21.70).

Conclusion

Adherence to medication is an important factor in facilitating successful community discharge for people with complex mental health problems who require psychiatric rehabilitation.     

Screening for depression in stroke: Relationship to rehabilitation efficiency.

Depression is common after stroke but is often not diagnosed. Its presence may impair progress during rehabilitation and limit functional improvement after discharge. We investigated the use of the Geriatric Depression Scale (GDS) to screen for depression among acute stroke patients. All stroke patients in an acute rehabilitation hospital who were referred for assessment of cognitive deficits were also screened for depression with the GDS. By using a modified cutoff score to account for items that could reflect physical effects of the stroke rather than depression, 22% of patients screened were classified as depressed. The rate of depression was higher among women (36%) than men (10%). Patients with elevated GDS scores (>/=15) stayed in the hospital an average of 5.76 days longer than patients whose scores fell below this cut-off. Higher GDS scores were also associated with less efficient use of rehabilitation services as measured by the Functional Independence Measure. Screening stroke patients for depression at the time of admission to rehabilitation may identify individuals at risk to progress more slowly, may initiate more comprehensive assessment, and, if appropriate, may initiate rapid intervention.     

A Social-Learning Approach to the Rehabilitation of Individuals with Severe Mental Disorders who Reside in Forensic Facilities

Abstract

With steadily growing populations of individuals with severe mental illnesses in forensic hospitals and correctional institutions, there is a need for effective rehabilitation services in these facilities. Individuals in such facilities have many of the same rehabilitation needs as people with severe mental illnesses in other settings. This paper describes the use of a comprehensive social-learning approach to rehabilitation that has been implemented in forensic facilities with documented success. The effectiveness of the social-learning approach has been well established for individuals with the most severe mental illnesses in public psychiatric hospitals. The application of this approach within the Forensic Services of the Missouri Department of Mental Health is outlined, and some of the challenges associated with implementing psychosocial rehabilitation technologies within highly secure facilities are discussed.     

A case report of the conversion of sheltered employment to evidence-based supported employment in Canada

This case report describes the transformation of a sheltered workshop program to a program that provides evidence-based supported employment services in partnership with five community treatment teams. Over a 15-year period, a Canadian nonprofit agency that provides employment services for persons with severe mental illness made a series of programmatic changes to increase the effectiveness of the services. The agency initially modified its facility-based sheltered workshop to include a prevocationally oriented work preparation program, later added brokered supported employment services, and finally completely transformed its organization by relocating its vocational rehabilitation counselors to five community mental health teams, in order to implement an evidence-based supported employment program that is based on the individual placement and support model. During the initial period in which the sheltered employment program was utilized, less than 5 percent of clients who were unemployed when they entered the workshop achieved competitive employment annually. The annual competitive employment rate did not increase during the prevocational phase; it increased during the brokered supported employment phase but did not exceed 25 percent. By contrast, after shifting to evidence-based supported employment, 84 (50 percent) of 168 unemployed clients who received between six and 27 months of individual placement and support services achieved competitive employment. This article also documents the role of agency planning and commitment quality improvement in implementing change.     

Cognitive mechanisms,psychosocial functioning,and neurocognitive rehabilitation in schizophrenia

The aim of the present study is to test Brenner's model of cognitive functioning in schizophrenia. It is assumed that elementary cognitive disorders (attention and encoding) and complex cognitive disorders (recall, concept formation) reinforce each other. Cognitive disorders are supposed to cause detrimental effects on functional outcome. We used cognitive rehabilitation as a strategy to induce cognitive changes in 27 patients assigned to treatment groups following the cognitive modules of the Integrated Psychological Treatment (IPT). Ten schizophrenic patients without cognitive impairments worked as a control group. With only one minor conceptual change (replacing concept formation with executive function, a more comprehensive construct), we found that our data fitted with Brenner's model. A relationship has been found between neuropsychological improvements and higher levels of autonomy and social functioning. These findings have important implications not only for cognitive assessment but also for selecting targets in cognitive rehabilitation.     

Community psychiatric services for the elderly: the Sunnybrook experience.

This paper describes the first three years of a community outreach service for psychogeriatric assessment and treatment, provided by a multidisciplinary team in an urban area. As one component of a comprehensive geriatric psychiatry service within a general hospital, this program provides a long-term link between patient, family, community agencies and hospital. The paper describes the functioning of the team, including its relationships with other hospital and community services. An overview is given of patient characteristics, referral sources, services provided, and outcomes at discharge from the program. Educational opportunities for students and staff in various health professions and settings are discussed.     

Cognitive strategies versus self-management skills as adjunct to vocational rehabilitation

Cognitive dysfunctions and negative symptoms are "rate-limiting factors" for community outcome and response to psychosocial intervention in people with schizophrenia. Therefore, two cognitive-behavioral group therapies were developed-computer-assisted cognitive strategy training (CAST) and training of self-management skills for negative symptoms (TSSN)-to target these barriers to rehabilitation readiness. One hundred thirty-eight DSM-IV schizophrenia inpatients on a rehabilitation ward were randomly assigned to CAST plus vocational rehabilitation, TSSN plus vocational rehabilitation, or vocational rehabilitation alone. CAST included computer-based training in coping strategies focusing on deficits in attention, verbal memory, and planning. TSSN focused on social withdrawal/social anhedonia, lack of drive/volition, and affect flattening using techniques such as time scheduling, mastery, and pleasure techniques. Treatment outcome was assessed at intake and at discharge after 8 weeks. Analyses of covariance controlling for basis-level functioning demonstrated that patients receiving CAST plus vocational rehabilitation showed greater improvement on attention and verbal memory but not on planning ability. Patients receiving TSSN plus vocational rehabilitation failed to demonstrate improvement in negative symptoms. CAST plus vocational rehabilitation was found to be associated with a higher rate of successful job placement at the 12-month followup interval. Hierarchical logistic regression analyses demonstrated that improvement in short- and long-term verbal memory predicted a higher proportion of variance of successful job placement in the followup than pretreatment history of employment alone. Cognitive training as an adjunct to inpatient vocational rehabilitation demonstrated cognitive improvement, which was found to be associated with successful job placement in the followup. TSSN's efficacy was less clear; reasons for this uncertainty are provided.     

Utilization of ambulatory health services by patients with disseminated sclerosis among the population of Lód?

The reported study included patients with multiple sclerosis with a history of at least 5 years of the disease and aged 46 years or less, living in a big city. On the ground of history data obtained from the patients it was estimated that in the calendar year preceding the study one patient obtained about 11 medical services (in the office of a physician or in the patient's home) and about 10 of these services were given by the doctors of the public health service. The main role in the care of the patients was played by neurologists from the public health service, but the number of house visits provided by physicians of the basic health service was slightly higher than that provided by neurologists. Among the physicians working in medical cooperative or in private practice only the dentists had a more important role in providing of health services to the patients. Thirty percent of patients had no medical visits in outpatient clinics of social health service within a year preceding the study, despite a need for them, and 9% of them had no house visits of physicians. The percent of patients informed about the usefulness of motor rehabilitation treatment was at least half the proportion of patients with walking disturbances. The results indicate inadequate availability of health services for this group of outpatients, similarly as outpatient rehabilitation treatment and treatment in sanatorium, despite the index of employed medical personnel per population which is higher in this city than the average index for the whole country. These results suggest a necessity of undertaking of actions for improving the care of these patients.     

Vocational rehabilitation service usage and outcomes for individuals with Autism Spectrum Disorder

BackgroundIn the pursuit of improving employment outcomes for individuals with Autism Spectrum Disorder (ASD), understanding how participants are using Vocational Rehabilitation (VR), and which services result in competitive integrated employment is of great interest to advocates, families, professionals, and policy makers. The primary objective of this study was to examine the relationships between participant characteristics, service delivery, and employment outcomes for individuals with ASD in state VR programs.MethodThe Rehabilitation Services Administration's Case Service Report (RSA-911) database for fiscal year 2013 was examined using a binary logistic regression analysis to explore ASD characteristics and service variables.ResultsResults indicate that ASD characteristics, defined as a source of impairment by VR, had predictive capacity for administrative VR services participants received (e.g. assessment and vocational rehabilitation counseling and guidance (VRCG)), but not for job-related services (e.g. job search, job placement, and on-the-job supports). In addition, job-related VR services were more likely to be associated with integrated employment at closure as compared to administrative VR services. In some cases, additional variables related to gender, race, and state system decreased the likelihood of a VR recipient receivingspecific services or achieving integrated employment.ConclusionDiscussion includes how awareness of service access and equity can assist in improving the quality and outcomes of VR services.     

Professionals' views on the need for psychiatric aftercare services

Psychiatrists and social workers in state-supported hospitals were interviewed concerning their views on the needs of recently released patients for aftercare services. These mental health professionals thought that 95 per cent of the released patients should be receiving more than two and one-half separate services, but that only 77 per cent of the expatients were receiving slightly more than one service. Thus, in terms of number of services, only one-third of the need is being met. Differential needs for specific services are also reported.The findings were interpreted as meaning that new and already existing aftercare facilities might not be used as fully nor as appropriately as originally anticipated unless there is a strengthening of referral procedures and the effecting of a more efficient organization for psychiatric rehabilitation both in the community and in the hospital. Suggested changes are discussed.Mr. Tanaka, a Social Worker, is Executive Director of Hill House.This research was supported in part by grant number MH-818 from the National Institute of Mental Health. Gratitude is expressed to Miriam Grobsmith and S. Richard Hall for their excellent assistance in carrying out this project. The authors are indebted to Netta Berman, Ewing Crawfis, Ira Friedman, John Hurst, and David Sugiuchi for their critical comments on an earlier draft of this paper. Gratitude is expressed to the administration and staffs of Cleveland Psychiatric Institute, Cleveland State Hospital, Fairhill Psychiatric Hospital, Hawthornden State Hospital, and the Hanna Pavilion, University Hospital, for cooperating with us. The interviews were conducted during the summer of 1963.     

Providing medical care to mentally ill women in the community

Medical care is difficult to provide for chronic psychiatric patients in the community, but is easier to provide if it is integrated into a larger program of services. A comprehensive care model for this group should take into account the need for rehabilitation, social services, medication, crisis care, physical medical care and overall continuity. This article describes a multi-service program in Toronto operated by the Friends of Shopping Bag Ladies, and the provision of medical care to the participants of this program by visiting general practitioners.     

Assessment of Service Needs of Adult Psychiatric Inpatients: A Systematic Approach

In this study, a systematic needs-assessment approach to evaluating the institutional and community service requirements of adult psychiatric inpatients is reported. The Community Placement Questionnaire (CPQ) was completed by professional staff on all patients between the ages of 18-65 residing in a publicly-funded psychiatric hospital. Of the 105 patients surveyed, 65.7% were considered potentially hard to place in the community (6.7% were nominated for permanent placement in the institution), and 34.3% were considered easy to place. The findings indicate that successful planning for community-based mental health services requires the four essential elements of the protected hospital environment, treatment, augmentation in psychosocial rehabilitation programming and availability of supports and services in the community. Specific strategies for transition from institutional-based care to community care are discussed.