Sustaining Individual Placement and Support (IPS) services: the IPS Learning Community

Worldwide, the deficiencies in community mental health services are well known: despite the development of many evidence‐based practices, few clients with severe mental illness actually receive effective, recovery‐oriented services1. Evidence‐based practices are often implemented poorly and rarely endure beyond initial enthusiasm and grant funding. We examined two‐year sustainment rates for a network of programs implementing Individual Placement and Support (IPS), an evidence‐based practice to help people achieve competitive employment2. IPS is spreading in the U.S. and internationally3, including in Europe, Australia, Asia, and North America. Yet, long‐term continuation of these services has been uncertain.

Because multiple factors influence a program's long‐term survival, a comprehensive international learning community has been developed to ensure sustainability of IPS. Beginning in the U.S. in 2001, the Dartmouth Psychiatric Research Center and the Johnson & Johnson Office of Corporate Contributions partnered to develop a multifaceted program to strengthen state and local infrastructures to promote access to IPS through broad dissemination, high‐quality implementation, and long‐term sustainment. After starting as a small demonstration in three states, the program has evolved internationally into a network of 19 states and 3 European countries known as the IPS Learning Community4.

Historically, the term learning collaborative has been used to define a network of organizations with a shared goal of improving treatment for a specific medical condition, facilitated by regular communication and collection and dissemination of objective information about procedures and outcomes, typically over a few months5. The IPS group adopted the term learning community to signify their long‐term commitment to quality and intention to expand to other states and countries. The term differentiates our approach from time‐limited quality‐improvement learning collaboratives, such as those sponsored by the Institute for Healthcare Improvement6.

The IPS Learning Community has encompassed a two‐tiered, decentralized approach. In the U.S., Dartmouth trainers and researchers bring together state leaders and help them to build a viable infrastructure for implementing and sustaining IPS services within their states4. For international partners, regional administrators are the counterparts to these state leaders. In each state, the leadership team establishes liaisons with the two key state agencies responsible for employment services (i.e., mental health and vocational rehabilitation) and one or more state trainers. State leaders create parallel learning communities consisting of IPS programs within their states.

As part of their participation in the learning community, state leaders collect and submit employment outcome data for IPS programs within their states; Dartmouth analyzes and distributes the data back to the states7. State trainers conduct periodic fidelity reviews of both new and established IPS programs, using a validated fidelity scale8. Fidelity reviews evaluate the quality of program implementation. IPS programs are considered active participants once they begin submitting outcome reports, typically about nine months after start‐up.

Altogether 157 programs joined the IPS Learning Community in the U.S. from its inception until 2012. However, we had not systematically tracked how long programs continued to provide IPS services after joining the learning community, or the rate of discontinuing programs. We therefore conducted a prospective study to determine the two‐year sustainment rate of participating sites in the U.S.. We operationally defined sustainment as follows: a program is sustained if it continues to employ staff, maintains an active client caseload, and provides direct services.

We identified all programs participating in the learning community in the U.S. as of January 2012. The sample, consisting of 129 sites in 13 states, had participated in the learning community on average for 4.5 years (SD = 2.7, median = 3.9). Two years later we contacted these sites to determine which were still providing IPS services. A total of 124 sites (96%) were sustained over the 2‐year period. This sustainment rate is higher than the 80% rate over a two‐year period after the termination of the formal implementation phase in a national study of 49 sites implementing a new evidence‐based practice9, and also exceeds the 76% two‐year rate in an evaluation of 33 demonstration projects10.

Statistics on sustainability of evidence‐based practices are rarely published. Many studies make it clear, however, that enthusiasm for an innovative program model often fades over time11. Funding initiatives targeting specific program models often spawn growth, followed by rapid dissolution when a state‐sponsored funding ends. For example, over a span of less than a decade, one state experienced a cycle of rapid growth followed by a collapse of services for an evidence‐based practice when the targeted funding for this program was abruptly curtailed12. To our knowledge, no one has examined the empirical literature on sustainment to establish benchmarks for target rates for sustaining programs over time.

Bolstering the case for sustainability in the IPS learning community, the 124 sustaining sites had been in existence for an average of 4.5 years at the inception of the study. In other words, taking into account the arbitrary start date for the 2012 interviews, the total length of time for sustaining IPS services was substantially longer, on average 6.5 years. The number of sites still active in 2014 represent 79% of the entire group of 157 programs joining the community over its 13 years of existence, further documenting the role of the learning community in helping to sustain a practice.

Throughout Europe, Australia, and the U.S., program leaders are developing regional and national learning communities of IPS programs. Another ambitious example, in an early stage of development, is an international network of advocates for IPS services in early intervention programs for first episode psychosis13. In the U.S., one state recently launched a statewide IPS initiative modeled after the IPS Learning Community. This initiative includes a technical assistance center that provides training and monitors fidelity and employment outcomes. Its initial employment outcomes have been similar to those in the national learning community14. It also established a dedicated IPS funding mechanism, which has contributed to the rapid growth of IPS services. By the end of 2014, 59 (69%) of 86 eligible programs had joined the initiative.

Sustainability of evidence‐based practices appears to be enhanced through the mechanism of a learning community. Originating in the U.S., the IPS Learning Community is now spreading internationally, with preliminary reports that the concepts transfer readily to other cultures and service systems. The learning community approach has been relatively untested with other evidence‐based practices, but its basic concepts are promising. The field needs controlled studies of long‐term learning communities in comparison with usual methods. Replications are needed before drawing firm conclusions.

Gary R. Bond, Robert E. Drake, Deborah R. Becker, Valerie A. Noel
Dartmouth Psychiatric Research Center, Geisel Medical School at Dartmouth, Lebanon, NH, USA