TUSCALOOSA, AL—With the Veterans Coordinated Approach to Recovery and Employment project, Lori Davis, MD, knows she has her work cut out for her.
Not only does she have to prove that individual placement and support employment services can help veterans with post-traumatic stress disorder better than traditional employment support models can, but that the first VA pay for success project can provide a return to its investors.
Davis, the associate chief of staff for research and development at the Tuscaloosa VAMC, can trace her path to Veterans CARE back to immediately after her residency. It was then that she found her first job with VA, where a strong intramural research program and important early-career mentors kept her on board as a clinical investigator with VA.
“Mood and anxiety disorders appeal to me more than psychotic disorders, and you kind of make that first fork in the road of your career, so I went with mood and anxiety and PTSD,” she explained. “I had mentors in PTSD and major depression, and I’ve done a lot of work with treatment-resistant major depression as well.”
About 15 years ago, Davis was in the midst of working on drug studies and research into biological markers when a series of RFPs came out that focused on outcomes through vocational rehabilitation.
“I was kind of growing discouraged by the effects we could get with medicine,” Davis explained. “I wanted something with a more meaningful impact on people’s lives. So I started becoming a quick study of all the various vocational rehabilitation interventions.”
She happened to be present at a meeting where VA researchers were launching a project using IPS for veterans with schizophrenia. Someone in the crowd asked the researchers if veterans with PTSD could be enrolled in the program, and the answer was no. The program was specifically for veterans with schizophrenia, because that was the population where the research had been done and where evidence showed IPS could be effective.
Afterward, Davis introduced herself to the program’s creators and said she wanted to start doing research immediately on how what seemed to be a highly effective vocational rehabilitation program could be used for patients with PTSD.
“It was upsetting that VA was rolling out something like this where veterans with PTSD couldn’t be included,” she declared. “I got very passionate and stirred up about the whole thing. I still am.”
Before VA would offer the IPS to veterans with PTSD, the department needed to see evidence that it works. Davis and her collaborators started with a single-site study, the success of which they leveraged to put together a 12-site VA cooperative study.
IPS services are integrated into a veteran’s mental health services. Veterans partner with employment specialists who take into account that veteran’s specific needs and preferences and work with them to rapidly find employment that matches their needs.
While traditional vocational rehabilitation has long been a part of the services offered by VBA, veterans struggling with serious mental health issues frequently have difficulties with those programs.
“For those patients who don’t abide by more traditional vocational rehab models—they get left behind. With IPS, we’re taking those veterans who are entrenched in unemployment and disability. IPS is employment services for the most challenged veterans,” Davis explained. “With PTSD, one of the core features is avoidance. They become isolated. They do not want to go out in public. A veteran with PTSD is galvanized by their illness to remain isolated, avoidant and not seek out novel environments, environments that would trigger their hyperreactivity and hypervigilance. We are overcoming a lot.”
Davis described IPS as the cognitive behavioral model of vocational rehabilitation—a goal-oriented model that works to change a veteran’s patterns of behavior and helps them to better function in stressful environments.
“IPS specialists are out there in the community, taking veterans for a drive-by of the employment environment, doing a secret shopper of that environment with the veteran before they go on their interview,” Davis said. “This is the best cognitive behavioral approach to recovery of illness I know of.”
It was while the results from the 12-site cooperative study were in the process of being published that Davis was approached by Social Finance, a non-profit organization that brings partners together under pay for success initiatives designed to help drive social programs.
“What happens is that private capital is invested in an evidence-based, social rehabilitation service. They pay for the service. They pay for all the people. And the government entities—in this case the VA partnered with the cities of New York and Bost and the commonwealth of Massachusetts—will pay back the investors for benchmarks of success. But only if it’s successful,” Davis explained.
That VA is partnering with city and state governments is a requirement of social finance, which wanted a broad buy-in from multiple organizations.
“It’s a very high profile project,” she added. “It’s not only me trying to make sure IPS works for veterans with PTSD so VA will disseminate it more broadly. But it’s me also having to demonstrate that PFS is viable.”
Veterans CARE is a three-year project funded with $5.1 million through the PFS. While the project is still finishing enrollment, it has already hit its first milestones, triggering payments to investors from VA and its government partners.
If Veterans CARE is the success she expects it to be, Davis hopes to see IPS offered at VA facilities across the country.
“Is the leadership behind it? Are the PTSD providers interested in allowing an employment specialist as part of their team and not just siloed off? Those two criteria are important for the quality and sustainability. Then we can train the IPS specialist and the veterans can come to it,” Davis said.