Multiple-Impact Effectiveness of a State Supported Employment Policy Initiative

描述（由申请人提供）：我们提出了一项观察性研究，以检查由国家政策倡议产生的广泛影响，该政策倡议增加了马里兰州严重精神疾病（SMI）患者基于证据的个人安置和支持（IPS）模式的可及性和可用性。我们将研究马里兰州的公共精神卫生系统（PMHS）在促进IPS-SE服务在该州的扩散的经验。我们的研究利用了IPS-SE服务的可访问性和可用性的跨时间和地理变化1）在2002-2010年期间，2）在马里兰州的地理区域。我们还研究了不同供应商对IPS-SE模型的忠诚度。我们建议研究这一国家政策举措在其实际操作和影响中观察到的有效性。本研究将扩展IPS-SE的评价性研究，使其超出目前对有限数量临床试验机构的小规模RCT试验中疗效/有效性的关注。我们还建议联合收割机数据从多个公共部门的数据库，扩大范围的SE影响研究，超越目前的研究重点就业成果，包括对心理健康状况的影响，对心理健康和躯体健康治疗费用。 马里兰州精神卫生管理局（MHA）于2002年开始实施一项政策倡议，促进IPS-SE服务的实施和推广。MHA为培训服务提供者和监测提供者是否忠实于IPS-SE模式提供资金。从2006年开始，向提供IPS-SE服务和达到忠诚度基准的供应商提供财政奖励。 这一医疗保健倡议增加了重度精神障碍患者获得社会就业服务机构服务的机会和可用性，2004年至2010年期间出现了重大增长，而且各地理区域也有所不同。我们计划使用2002-2010年期间随访的几个大型、定义明确的队列中SMI患者的数据：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。使用这些数据，我们将评估MHA政策倡议对以下方面的影响：（1）IPS-SE服务的使用率，（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业服务和其他健康服务的治疗费用，及（5）IPS-SE服务使用者与非使用者的就业及收入。我们还将研究不同IPS-SE提供商保真度水平对这些结果的影响。 提出了各种回归分析方法来估计这些政策的影响，包括工具变量-广义矩法（IV-GMM）程序，简化形式的回归模型，模型的基础上汇集的数据对个人随着时间的推移，和分析的基础上的序列的横截面回归。我们提出了IV-GMM方法来考虑影响选择使用IPS-SE服务的不可观察因素，以及对我们假设的IPS-SE使用指标的内隐性的测试。 公共卫生相关性：该提案涉及2010年健康人的一个重点领域，建议保留为2020年健康人：增加就业的严重精神疾病患者的比例。这项研究将研究全州范围内的倡议，以增加提供基于证据的支持就业服务的那些与重度精神障碍在马里兰州的有效性。我们评估了该倡议对多个结果的影响，包括支持就业服务的接收，种族和民族差异的服务接收，就业，收入，心理健康治疗费用，躯体治疗费用，心理健康状况。

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.