Multiple-Impact Effectiveness of a State Supported Employment Policy Initiative

描述(由申请人提供)：我们提议进行一项观察性研究，以考察一项州政策倡议产生的广泛影响，该政策倡议增加了马里兰州为严重精神疾病(SMI)患者提供的基于证据的个人安置和支持(IPS)模式的就业支持(SE)服务的可及性和可用性。我们将学习马里兰州公共精神卫生系统(PMHS)在促进IPS-SE服务在该州传播方面的经验。我们的研究利用了2002年至2010年期间IPS-SE服务的可获得性和可用性的跨时间和地理差异1)以及2)马里兰州的地理区域。我们还检查了不同提供商对IPS-SE模型的保真度。我们建议研究这一国家政策倡议在其实际操作和影响中所观察到的有效性。这项研究将扩展对IPS-SE的评估研究，超越目前在有限数量的地点进行的小规模RCT试验中对疗效/有效性的关注。我们还建议将来自多个公共部门数据库的数据结合在一起，以扩大所研究的社会保障影响的范围，超出目前对就业结果的研究重点，包括对精神健康状况以及对精神健康和躯体健康治疗成本的影响。促进实施和推广IPS-SE服务的政策倡议由马里兰州精神卫生管理局(MHA)承担，于2002年作为试点项目开始实施。MHA为培训服务提供商和监测提供商对IPS-SE模式的保真度提供资金。从2006年开始，为提供IPS-SE服务和达到保真度基准的提供商提供了财政奖励。这一MHA倡议提高了SMI患者获得IPS-SE服务的可及性和可用性，2004年至2010年期间出现了重大增长，这一增长也因地理区域而异。我们计划使用几个大型、明确的队列中有关患有SMI的个人的数据：1)马里兰州医疗补助接受者和2)其他非医疗补助覆盖的PMHS服务用户，在2002-2010年期间进行跟踪。利用这些数据，我们将评估MHA政策倡议对以下方面的影响：(1)IPS-SE服务的接受率，(2)IPS-SE服务使用率的种族和民族差异，(3)IPS-SE用户相对于非用户的心理健康状况，(4)IPS-SE服务用户与非用户的心理健康专科服务和其他健康服务的治疗费用，以及(5)IPS-SE服务用户与非用户的就业和收入。我们还将研究不同的IPS-SE提供商保真度级别对这些结果的影响。人们提出了各种回归分析方法来估计这些政策影响，包括工具变量--广义矩方法(IV-GMM)程序、简化形式的回归模型、基于个人随时间的数据汇集的模型，以及基于横截面回归序列的分析。我们提出了IV-GMM方法来解释影响选择使用IPS-SE服务的不可观察因素，并对我们假设的IPS-SE使用指标的内生性进行了检验。 与公共健康相关：这项提案涉及2010年健康人计划保留的重点领域之一：增加严重精神病患者的就业比例。这项研究将检验一项全州范围的倡议的有效性，该倡议旨在为马里兰州的SMI患者提供基于证据的支持就业服务。我们评估了该倡议对多种结果的影响，包括支持的就业服务接收、在服务接收、就业、收入、心理健康治疗成本、躯体治疗成本、心理健康状况方面的种族和民族差异。

DESCRIPTION (provided by applicant): We propose an observational study to examine a broad range of impacts produced by a state policy initiative that increased accessibility and availability of the evidence-based individual placement and support (IPS) model of supported-employment (SE) services for persons with severe mental illness (SMI) in Maryland. We will study the experience of Maryland's public mental health system (PMHS) in facilitating the diffusion of IPS-SE services in the state. Our research exploits inter-temporal and geographic variations in accessibility and availability of IPS-SE services 1) over time in the period 2002-2010 and 2) across geographic areas of Maryland. We also examine variations across providers in fidelity to the IPS-SE model. We propose to study the observed effectiveness of this state policy initiative in its actual operation and impact. This study will extend evaluative research on IPS-SE beyond the current focus on efficacy/effectiveness in small-scale RCT trials of a limited number of sites. We also propose to combine data from multiple public sector databases to expand the range of SE impacts studied, beyond the current research focus on employment outcomes, to include impacts on mental health status, and on mental health and somatic health treatment costs. The policy initiative that promoted the implementation and diffusion of IPS-SE services, undertaken by the Maryland Mental Hygiene Administration (MHA), began as a pilot project in 2002. MHA provided funding for training service providers and for monitoring providers for fidelity with the IPS-SE model. Beginning in 2006, financial incentives were given to providers for offering IPS-SE services, and for meeting fidelity benchmarks. This MHA initiative increased accessibility and availability of IPS-SE services for persons with SMI, with major increases, occurring in the period from 2004 to 2010, that also varied by geographic area. We plan to use data on individuals with SMI from several large, defined cohorts 1) of Maryland Medicaid recipients and 2) of other non-Medicaid-covered users of PMHS services, followed over the 2002-2010 period. Using these data, we will assess the impacts of the MHA policy initiative on (1) the take-up rate of IPS-SE services, (2) disparities by race and ethnicity in the rate of IPS-SE service use, (3) the mental health status of IPS-SE users relative to non-users, (4) costs of treatment for mental health specialty services and other health services for users vs. non-users of IPS-SE services, and (5) employment and earnings of users vs. non-users of IPS-SE services. We also will examine the impact of varying IPS-SE provider fidelity levels on these outcomes. A variety of regression analysis methods are proposed for estimating these policy impacts, including instrumental variables-generalized method of moments (IV-GMM) procedures, reduced-form regression models, models based on pooling of data on individuals over time, and analyses based on sequences of cross- sectional regressions. We propose IV-GMM methods to account for unobservable factors influencing selection into use of IPS-SE services, as well as tests for our assumption of endogeneity of the indicator of IPS-SE use. PUBLIC HEALTH RELEVANCE: This proposal addresses one the focus areas Healthy People 2010 that is proposed to be retained for Health People 2020: Increase the proportion of persons with serious mental illness (SMI) who are employed. The research will examine the effectiveness of a state-wide initiative to increase the provision of evidence-based supported employment services for those with SMI in the state of Maryland. We assess the initiative's impact on multiple outcomes including supported employment service receipt, race and ethnic disparities in service receipt, employment, earnings, mental health treatment costs, somatic treatment costs, mental health status.