Feasibility of Expanding Self-Directed Services to People with Serious Mental Illness. 5.2. Independence, Employment, Education, and Health


SDC participants would be expected to have greater functional and residential independence and greater participation in competitive employment and education compared to participants in traditional mental health services. SDC programs are designed to advance these recovery goals through the person-centered planning process. SDC would, for example, be expected to result in greater independent living skills, such as cooking meals and using public transportation, greater numbers of starts in new jobs, and greater numbers of courses taken in community colleges and other educational programs. In relation to health outcomes, participation in SDC would be expected to result in increases in the amount of time spent in physical exercise and in greater participation in weight loss programs, since these are common recovery goals chosen by participants. However, evaluations of such changes have been rare.

Cook and colleagues58 reported results from an analysis of (n=106) Florida SDC participants' days spent in the community (i.e., days not spent in institutions) in the 1-year period after they entered the Florida SDC program compared to 1-year period immediately prior entering the program. Participants spent 17 more days in the in the community during the first year of participation in the program compared to the year prior to participation (354 days in the first year of participation versus 337 days in the prior year).

In a report on the Iowa SDC program,69 Ellison and colleagues examined participants' residential status, employment status and earnings in the 12 months after entering the SDC program, using information self-reported by program participants. Compared to the period prior to entering the program, participants reported greater residential independence and slight improvements in employment participation and earnings.

Results from the pre-/post-studies by Cook and colleagues58 and Ellison and colleagues,69 summarized in the preceding paragraphs, are intriguing because they suggest that the SDC approach could have substantial benefits in relation to improved independence, quality of life, employment and housing stability and could result in lower health care costs. However, the relationships between SDC program participation and outcomes that were reported in these studies may not be causal. Comparisons of participants' outcomes after the start of program participation to measures taken prior to participation are vulnerable to biases resulting from association between program participation and unmeasured factors that are related to participants' outcomes after program entry. For example, Cook and colleagues could not rule out the possibility that Florida SDC participants' days spent in institutions would have decreased even if participants had not started the Florida SDC program. As a result, it is difficult to know whether SDC program participation has any direct effect on participants' days spent in institutions, housing stability, or employment participation.

SDC programs could also result in better physical health outcomes and greater health-related quality of life if goals for personal wellness, such as increased physical exercise, weight loss, or reduced smoking, are achieved. SDC might also result in better control of psychiatric symptoms and reduced use of inpatient mental health care, as SDC participants may adhere more consistently to treatment plans that they select and that reflect their individualized goals for recovery compared to traditional treatment services.

Greater standardization of data on SDC participants' outcomes in SDC would seem to greatly facilitate opportunities for SDC program evaluation and quality improvement. In an evaluation report on the Florida SDC program,67 the authors concluded that measures of functional independence, participation in employment/education, and health were not systematically collected by Florida SDC. Consequently, they could not assess program impacts on participants' outcomes in key domains of interest to policymakers. In a letter of response to the OPPAGA report,67 the Florida Department of Children and Families, the state agency that initially funded the Florida SDC program, indicated that no funding was available to create a data system for the collection of participant outcome data, although the agency was taking steps to improve data collection in the future. Systematic collection of data on SDC participants' outcomes is not standard practice in other states' programs, either.

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