Veterans Coordinated Approach to Recovery and Employment (Veterans CARE)
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Share PrintMany veterans returning home from deployment face new battles, including unemployment, mental illness, problems with relationships, and difficulties readjusting to community life. Our mission is to help Veterans living with post-traumatic stress disorder (PTSD) obtain well-matched and meaningful competitive employment that is sustainable and also helps keep them engaged with treatment and improve their relationships and quality of life. Our solution is called Individual Placement and Support (IPS). IPS is a person-centered approach that is integrated within a treatment team. Also known as supported employment, IPS prioritizes rapid job search for employment opportunities that match with a Veteran’s needs, talents, and preferences and provides ongoing support until steady employment is achieved. Serving Veterans with PTSD for the past several years, IPS has been adopted at several large VA healthcare systems with the help of funding by the first ever VA Pay-for-Success social impact bond project, called Veterans Coordinated Approach to Recovery and Employment (Veterans CARE). Our Pay-for-Success project is a demonstration of real-world implementation of IPS that provides a roadmap for further expansion of IPS services for Veterans with PTSD across VA. IPS has also been implemented under the Whole Health initiative at a large metropolitan VA.
Origin:
June 2018, Tuscaloosa VA Medical Center
Adoptions:
6 successful
Awards and Recognition:
Pay-for-Success Social Impact Bond
Partners:
Health Services Research & Development, Quality Enhancement Research Initiative
Recent Updates
Overview
The problem
Veterans living with PTSD often have difficulty finding and sustaining employment. Currently, the usual care VA vocational rehabilitation services do not meet the needs of Veterans with PTSD. Over 50% of those offered transitional work assignments within the Compensated Work Therapy program decline or refuse to accept the low-wage low-skilled temporary job.
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Veterans living with PTSD often have difficulty finding and sustaining employment. Currently, the usual care VA vocational rehabilitation services do not meet the needs of Veterans with PTSD. Over 50% of those offered transitional work assignments within the Compensated Work Therapy program decline or refuse to accept the low-wage low-skilled temporary job. If they find a job in the community on their own, the veteran may struggle with symptoms of PTSD at work which causes issues with keeping that job.
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The solution
Veterans CARE addresses the lack of access to IPS employment services for Veterans living with PTSD with the aim of providing these services to help unemployed veterans get back to well-matched community-based competitive employment. Once employed and with integrated supports from an IPS specialist and their PTSD treatment team, Veterans find a new trajector
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Veterans CARE addresses the lack of access to IPS employment services for Veterans living with PTSD with the aim of providing these services to help unemployed veterans get back to well-matched community-based competitive employment. Once employed and with integrated supports from an IPS specialist and their PTSD treatment team, Veterans find a new trajectory of recovery and enjoy an improved sense of self and more meaningful relationships and quality of life.
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The results
Veterans with PTSD are twice as likely to become steady workers when given IPS services compared to the usual care VA vocational rehabilitation services. Compared to the usual care services, IPS also leads to significantly more full time work, greater levels of income, and more days worked over the year followed. Veterans experience improved satisfaction wi
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Veterans with PTSD are twice as likely to become steady workers when given IPS services compared to the usual care VA vocational rehabilitation services. Compared to the usual care services, IPS also leads to significantly more full time work, greater levels of income, and more days worked over the year followed. Veterans experience improved satisfaction with relationships and quality of life in their community. "Work is my therapy. Work is my life."
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Metrics
- We have conducted a cost-efficacy analysis and find that IPS is not much more expensive than usual care services.
- IPS is cost-effective and has very good return on investment.
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
Videos
Above:
A veteran expresses the meaningful impact of IPS.
Implementation
Timeline
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Months 0-3
Hire IPS specialist and provide orientation & training on the Integration of IPS through CWT within mental health MH/PTSD Services in the VA: Our team can provide orientation to your local CWT and MH/PTSD teams regarding the IPS model and its health and social impact. In addition, VACO Therapeutic and Supported Employment Services Program Office is available for consultation on IPS in Veterans Health Administration (VHA). Leadership Development: Establish a pledge of commitment from local VA Medical Center, CWT, and Mental Health Services leadership to implement IPS within the MH and/or PTSD treatment teams. IPS Specialist Position Recruitment or Identification of Existing Staff to be Trained on IPS: Identify or hire one or two IPS Specialists who will serve Veterans with a diagnosis of PTSD. With guidance from our team of IPS experts, the local VA Medical Center and CWT program management can identify an incumbent and/or establish a new position to provide IPS services to Veterans diagnosed with PTSD. Our team of experts will assist in initial orientation to IPS manuals and training materials. At a nominal fee, our IPS trainer can provide additional training, consultation, and on-site visits. -
Months 3-6
Logistics: IPS Specialist should be aligned under CWT and co-located in office space within proximity to the PTSD and/or MH teams. The IPS Specialist needs access to a Government vehicle for his/her community-based work and to transport Veterans when needed. IPS Specialist needs a PIV card, CPRS access/encounter coding, consult management privileges, and approvals for VA requirements for employment. There are designated supported employment encounter stop codes and procedure codes; and the consults come through the CWT service. Referral Pipeline: IPS Specialist(s) needs access to Veteran population and engagement with PTSD and/or MH teams (i.e. attending team meetings, receiving referrals of Veterans, integrating with the treatment teams to manage the Veteran needs). IPS Service Delivery: Optimal IPS Start-up occurs with a phase up of the caseload (average of 1-2 referral per week). The steady phasing up of caseloads allow for maximum intensity of support in the early stages of the service, creating a balanced caseload (1/3 working with follow-along supports, 1/3 in active job search and 1/3 in the initial assessment phase). Strategic Job Development and simultaneous collaboration with clinical providers is a cornerstone of a high fidelity IPS practice, requiring coordination from MH Leadership, CWT Vocational Program Manager, Clinical Team Leads and the IPS Specialists. Given good coordination, the IPS Specialist can take an active role in the community to develop a network of employers who have opportunities to meet the job interests and preferences of the Veterans, while insuring the continuation of clinical care to effectively manage symptoms. -
Months 6-9
Ongoing Job Placement and Support: IPS Specialist facilitates the Veterans’ successful placement and retention in meaningful and well-matched competitive employment. Fidelity Monitoring and Quality Improvement Guidance: Using the IPS Fidelity Scale, the local site can be evaluated by external IPS experts to provide qualitative and quantitative feedback on the quality of IPS implementation. This feedback also serves as a quality improvement tool to the IPS Specialists on the primary services elements, MH teams on the importance of integration and Medical Center Leadership on supporting a culture of employability while assisting Veterans to manage symptoms and improve their quality of life. -
Months 9-12
Quality Improvement Interventions: As expanded IPS programs are established and the subsequent feedback is provided as a result of the six-month Fidelity Review. Corrective actions or course corrections are commonly needed. Guidance is offered to the referrals team, CWT managers, IPS Specialists, and Medical Center & MH Leadership regarding strategies for assertive engagement and outreach, better integrated team designs and methods for improved employer networking. Caseload Management: The caseload size per IPS Specialist will typically reach the maximum 1:20 to 25 ratio during this time period and require action. As demand increases for IPS, CWT Program Managers assess staffing resources and services for proper alignment of vocational staff. The MH/PTSD team and IPS Specialist may be guided through a “stepdown“ process for those Veterans who require less intensity to sustain their employment.
Departments
- Patient services
- PTSD treatment
- Vocational rehabilitation and employment programs
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
|
Files
- Develop a brochure to advertise services. Veterans CARE Recruitment Brochure
Risks and mitigations
| Risk | Mitigation |
|---|---|
| Lack of support within the PTSD treatment team to adopt IPS. |
Early engagement with PTSD or Mental Health team champions. Co-locate the IPS specialist within the same clinic area as the PTSD/MH team. |
| Hiring the IPS Specialist(s) with skills and abilities. |
Work with us to get position description. Work in advance with HR to establish priority to hire. Consult with us to help understand best characteristics of IPS specialist to help you make the best selection among the candidate to hire. |
| Marketing to Veterans with PTSD to fill the IPS caseload. |
Reduce barriers to Veteran engagement and have broad eligibility definitions (zero exclusions). Offer services when the veteran presents for care in primary care setting. |
About
Origin story
As witness to Veterans’ marginal response to medications, and non-evidence-based psychotherapies in the treatment of PTSD, Dr. Davis searched for an intervention that would have much higher social and clinical impact for the Veterans in her care. While attending the VA rollout of IPS for Veterans with serious mental illness in 2004, she discovered the pivota
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As witness to Veterans’ marginal response to medications, and non-evidence-based psychotherapies in the treatment of PTSD, Dr. Davis searched for an intervention that would have much higher social and clinical impact for the Veterans in her care. While attending the VA rollout of IPS for Veterans with serious mental illness in 2004, she discovered the pivotal work in IPS of Robert Drake and Debbie Becker. Under the mentorship by Dr. Drake, and in collaboration with Rich Toscano, Dr. Davis began a decade of research to fill the gap in knowledge as to the therapeutic effects of IPS in the PTSD population. While the evidence is unquestionable that IPS works better than standard approaches for Veterans with PTSD, the individual case vignettes of the life-transforming effects of IPS are inspirational and provide renewed hope to stakeholders, Veterans, and their families. IPS is an integration of community-based individual support within the context of the PTSD treatment team. Aside from a source of income, mainstream competitive employment provides the Veteran with a sense of purpose and personal pride, a means to reintegrate with friends and family, a way to move beyond preoccupation with symptoms and disability, and a sustained path to pursue life goals. Dr. Davis is a Professor of Psychiatry and the Associate Chief of Staff for Research at the Tuscaloosa VA Medical Center. She has been a VA psychiatrist and clinical researcher for over 25 years. Her Tuscaloosa collaborator, Rich Toscano, has been involved with the national implementation, training, and fidelity monitoring of Individual Placement and Support for over 30 years, including non-VA and VA populations spanning from individuals with serious mental illness, PTSD, and spinal cord injury. Since 2004, Dr. Lori Davis has been a pioneer in the study of the efficacy of IPS for Veterans with PTSD. Comparing IPS to transitional work, Dr. Davis conducted a single-site study at the Tuscaloosa VA, a three-site study at Birmingham, Tuscaloosa, and Bedford VA Medical Centers, and a 12- site VA Cooperative Program Study. She also led a VA Office of Rural Health initiative to provide IPS to Veterans with PTSD who lived in rural areas. She is currently conducting research of IPS implementation in primary care settings and a VA Health Services Research and Development (R&D) project evaluating the cost efficacy of IPS in the PTSD population. The current Pay-for-Success project called Veterans CARE involves the implementation of IPS. The Pay-for-Success project required a non-VA match to the VA funds which, after a nation-wide search for partners, resulted in the selection of VA Boston, Central Western Massachusetts, and New York Harbor sites since the outcome payors were the City of Boston, Commonwealth of Massachusetts, and City of New York. The Tuscaloosa site serves as the hub for implementation leadership, research and data coordination, and keeping all sites aligned with timelines and performance targets.
Original team
Lori Davis, MD
Lead Clinician
Rich Toscano, M.Ed.
IPS Supervisor/Trainer/Fidelity
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