In this section, we review the literature on services and interventions for people who are now or who are expected to be long-term clients of traditional mental health services and who are in the process of applying for SSDI or SSI (Appendix A, Table A.3). Because these individuals have not been studied as a group, we considered research on specific subpopulations likely to comprise such individuals, including new SSDI beneficiaries and people who are homeless, military veterans, and ex-offenders with SMI who may eventually turn to disability benefits for support.
1. Vocational and other support services provided along with health insurance may lead to improved short-term employment outcomes for new SSDI beneficiaries with mental health impairments. Providing health insurance alone had no impact.
The Accelerated Benefits (AB) demonstration project, funded by SSA, was designed primarily to test the effects of providing health insurance to new SSDI beneficiaries without having to wait the required 24 months before becoming eligible for Medicare. We include this study because the circumstances of new SSDI beneficiaries, particularly those without health care, might be similar to applicants for SSDI benefits. Demonstration participants were randomly assigned into a AB group who received health insurance (N=400); an AB Plus group who received health insurance as well as medical case management, employment and benefits counseling services, and Progressive Goal Attainment Program3 services (N=611); and a control-group (N=983). The AB Plus group participated in employment or VR services at a significantly greater rate (p=.005) at one and two years after random assignment than either the AB group or the control-group. The AB Plus program led to a 5.3 percentage point, or nearly a 50 percent increase, in employment and to an $831 increase in annual earnings in the second calendar year following enrollment. Access to health care plus vocational and support services were necessary to produce these results.
These positive effects disappear in Year 3, either due to SSA work disincentives (the timing is consistent with the loss of SSDI cash benefits due to work activity), the end of program services, or worsening of beneficiaries' health condition (Michalopoulous 2011; Stegman & Weathers 2013). Findings for the 22 percent of the study sample with mental health impairments mirror this pattern.
2. Limited evidence suggests that providing SE along with housing supports may improve employment outcomes for people with SMI who are homeless.
We identified three promising approaches that assist people with SMI who are homeless to find employment. The most rigorously evaluated of these, Los Angeles' (LA's) HOPE, provided SE, supportive housing, and direct payment for such items as vocational classes, work clothing, and equipment to people with SMI who were formerly homeless. LA County designated three of its 18 programs that provide supportive services and housing assistance to homeless individuals with SMI as LA's HOPE sites. The overall employment rate for LA's HOPE clients was more than double that of the comparison group who received housing services at other sites (57 percent versus 22 percent), as was the competitive employment rate (27 percent versus 13 percent) (Burt 2012).
3. Limited evidence suggests that evidence-based SE may be effective for veterans with SMI.
A recent systematic review suggests limited knowledge of how to reintegrate veterans with mental disorders into a new workplace after an absence of more than a year (Vantil et al. 2012). Of the 97 studies of programs for people with mental disorders reviewed, ten were studies of veterans. The review concluded that although the evidence-based model of SE has the strongest evidence base for facilitating workplace reintegration for individuals with SMI, the literature dealing with reintegration, especially for veterans, is sparse.
The most promising study included in the review was a RTC focused on veterans with post-traumatic stress disorder (PTSD) conducted at the Tuscaloosa Veterans Affairs (VA) Medical Center between 2006 and 2010 (Davis et al. 2012). Eighty-five veterans with PTSD were randomly assigned to receive either SE services or the standard VA VR Program, which provided work therapy through set-aside temporary jobs. Veterans in the SE group were significantly more likely to gain competitive employment, competitive employment more quickly, work in a competitive job more weeks, and earn higher wages.
A study of SE for homeless veterans with psychiatric or addiction disorders, not covered in the systematic review, showed similar results (Rosenheck & Mares 2007). The intervention tested a low-intensity teleconference training approach (average cost of $6,033 per site) for implementing the SE model at nine VA programs and compared outcomes before and after implementation. The post-implementation group of veterans engaged in significantly more days of competitive employment, higher levels of competitive employment, and earned higher wages than the pre-implementation group over the two-year follow-up period.
4. We found no studies examining the effectiveness of employment interventions for ex-offenders.
Individuals with SMI are overrepresented in the criminal justice system (Schnittker et al. 2011), and having a criminal record presents additional challenges for finding employment upon release from jail or prison. Without supports to aid in overcoming these challenges, ex-offenders with SMI may seek SSI or SSDI as a source of income support and a route to health insurance. Promising efforts are demonstrating the effectiveness of cooperation between the criminal justice and mental health systems to provide services to individuals with SMI upon their release. These efforts involve cognitive behavioral therapy, case management, medication and substance abuse monitoring, and referral to community agencies (Osher et al. 2012). Consistent with the findings of Anthony (2006) and Osher & Steadman (2007), however, we were not able to identify any published studies regarding the effective employment supports for this population.