Implementation of Evidence‐Based Employment Services in Specialty Mental Health

Abstract

Objective Study a quality improvement approach for implementing evidence-based employment services at specialty mental health clinics. Data Sources/Study Setting Semistructured interviews with clinicians and administrators before, during, and after implementation. Qualitative field notes, structured baseline and follow-up interviews with patients, semistructured interviews with patients after implementation, and administrative data. Study Design Site-level controlled trial at four implementation and four control sites. Hybrid implementation–effectiveness study with mixed methods intervention evaluation design. Data Collection/Extraction Methods Site visits, in-person and telephone interviews, patient surveys, patient self-assessment. A total of 801 patients completed baseline surveys and 53 clinicians and other clinical key stakeholders completed longitudinal qualitative interviews. Principal Findings At baseline, sites varied in the availability, utilization, and quality of supported employment. Each site needed quality improvement for this service, though for differing reasons, with some needing development of the service itself and others needing increased service capacity. Improvements in knowledge, attitudes, beliefs, and referral behaviors were evident in mid- and postimplementation interviews, though some barriers persisted. Half of patients expressed an interest in working at baseline. Patients at implementation sites were 2.3 times more likely to receive employment services during the study year. Those who had a service visit were more likely to be employed at follow-up than those who did not. Conclusions Studies of implementation and effectiveness require mixed methods to both enhance implementation in real time and provide context for interpretation of complex results. In this study, a quality improvement approach resulted in superior patient-level outcomes and improved clinician knowledge, attitudes, and behaviors, in the context of substantial variation among sites.

Quality Improvement in Behavioral Health

“…Weight outcomes were signifi cantly improved at all sites by study end (Cohen, Chinman, Hamilton, Whelan, & Young, 2013 ;Hamilton et al, 2013 ). In comparison to the prior EQUIP pilot, this was larger in scope and more sophisticated in its evaluation.…”

“…Some have been highly effective, while others have been frustrated, mostly by organizational or fi nancial constraints (Drake et al, 2013;Frey et al, 2008Frey et al, , 2011Hamilton et al, 2013 ;McHugo et al, 2007 ). This consists of assistance obtaining and maintaining competitive employment.…”

Improving the Quality of Care for Serious Mental Illness

“…Improvement in the distal outcome of competitive employment was limited to one site that had a high level of treatment fi delity. Weight outcomes were signifi cantly improved at all sites by study end (Cohen, Chinman, Hamilton, Whelan, & Young, 2013 ;Hamilton et al, 2013 ). Process evaluations indicated that the PAS was useful and feasible in usual care settings (Cohen, Chinman et al, 2013 ).…”

“…There have been numerous efforts to engage in QI focused on supported employment. Some have been highly effective, while others have been frustrated, mostly by organizational or fi nancial constraints (Drake et al, 2013;Frey et al, 2008Frey et al, , 2011Hamilton et al, 2013 ;McHugo et al, 2007 ).…”

Integrating Mixed Methods in Health Services and Delivery System Research

“…Hamilton et al. () illustrate the use of mixed methods in quality improvement research using a convergent design within an intervention framework. The results are a great example of using a contiguous narrative to present their key findings for care of veterans with mental health problems.…”