Financial incentives promote engagement in employment services for unemployed adults in treatment for opioid use disorder.

BACKGROUND: Promoting employment among unemployed adults with substance use disorder is a difficult challenge for which existing interventions have had limited effects. This study examined whether financial incentives could increase engagement in employment services for unemployed adults in treatment for opioid use disorder. METHODS: The study was conducted from 2014 to 2019 in Baltimore, MD. After a 3-month abstinence initiation and training period, participants (N = 91) were randomly assigned to a Control group or an Incentive group and were invited to work with an employment specialist to seek employment in a community job for 12 months. Participants assigned to the Control group (n = 47) did not receive incentives for working with the employment specialist. Participants assigned to the Incentive group (n = 44) could earn financial incentives for working with the employment specialist, but had to provide opiate- and cocaine-negative urine samples to maximize pay. RESULTS: Incentive participants attended the employment services and worked with the employment specialist on significantly more days than Control participants (41.8 % versus 1.1 % of days; OR = 40.42, 95 % CI = 32.46-48.38, p < .001), and for significantly more hours than Control participants (3.58 versus 1.25 h, on average; OR=2.34, 95 % CI=1.83-2.85, p < .001). Incentive participants were more likely to be retained than Control participants when analyses were based solely on attendance (HR=0.12, 95 % CI=0.06-0.25, p < .001) and attendance and employment combined (HR=0.15, 95 % CI=0.07-0.31, p < .001). CONCLUSIONS: Financial incentives were effective in promoting engagement in employment services for individuals who often do not utilize employment services.

'Placement budgets' for supported employment: impact on employment rates in a multicentre randomised controlled trial.

BACKGROUND: The most effective rehabilitation model for job (re-)entry of people with mental illness is supported employment. A barrier to introducing supported employment into standard care is its temporally unlimited provision, which conflicts with health and social legislation in many European countries. AIMS: To test the impact of different 'placement budgets', i.e. a predefined maximum time budget for job seeking until take-up of competitive employment. METHOD: Participants (116) were randomly assigned to 25 h, 40 h or 55 h placement budgets in an intent-to-treat analysis. We applied the individual placement and support model over 24 months, following participants for 36 months. Primary outcome was employment in the labour market for at least 3 months. RESULTS: The proportion of participants obtaining competitive employment was 55.1% in the 25 h group, 37.8% in the 40 h group and 35.8% in the 55 h group. In a Cox regression analysis, time to employment was slightly lower in the 25 h group relative to the 40 h (hazard ratio 1.78, 95% CI 0.88-3.57, P = 0.107) and 55 h groups (hazard ratio 1.74, 95% CI 0.86-3.49, P = 0.122), but this was not statistically significant. The vast majority of all participants who found a job did so within the first 12 months (80.4%). CONCLUSION: A restricted time budget for job finding and placement does not affect the rate of successful employment. In accordance with legislation, a restriction of care provision seems justified and enhances the chances of supported employment being introduced in statutory services.

Long-Term Follow-Up of a Randomized Trial of Supported Employment for SSDI Beneficiaries With Mental Illness.

OBJECTIVE: In this study, the authors assessed the long-term impact of the Mental Health Treatment Study (MHTS), a randomized controlled trial testing the effects of providing 2 years of employment services based on the evidence-based individualized placement and support model to Social Security Disability Insurance (SSDI) recipients with serious mental illness. Treatment recipients also received systematic medication management, supplemental health care supports, and short-term relief from medical continuing disability review by the Social Security Administration (SSA). METHODS: MHTS site data for 2,160 participants were linked to SSA administrative data from 2011 to 2015, 1 to 5 years after the original study concluded. Univariate and multivariate models were used to assess the MHTS effects on employment, earnings, and disability benefit suspension-termination up to 7 years after services ended. RESULTS: The analyses showed that the treatment group was more likely than the control group to work, and average earnings among the treatment group increased more over time than earnings among the control group. Disability benefit suspension/termination did not differ between groups. CONCLUSIONS: Providing the demonstration's package of services and support to SSDI beneficiaries with psychiatric disabilities for up to 2 years may have a long-term impact on employment and earnings. Under the SSDI program as currently structured, however, even after receiving 2 years of evidence-based supported employment and high-quality mental health services, SSDI beneficiaries with psychiatric conditions are unlikely to achieve economic independence within 5 years.

Effects of Vocational Re-training on Employment Outcomes Among Persons with Disabilities in Germany: A Quasi-Experiment.

Purpose To investigate how completing vocational re-training influenced income and employment days of working-age people with disabilities in the first 8 years after program admission. The investigation also included the influence of vocational re-training on the likelihood of receiving an earnings incapacity pension and on social security benefit receipt. Methods This retrospective cohort study with 8 years follow up was based on data from 2399 individuals who had completed either a 1-year vocational re-training program (n = 278), or a 2-year vocational re-training program (n = 1754) or who were admitted into re-training but never completed the program (n = 367). A propensity score-based method was used to account for observed differences and establish comparability between program graduates and program dropouts. Changes in outcomes were examined using the inverse probability-weighted regression adjustment method. Results After controlling for other factors, over the 8 years after program admission, graduates of 1-year re-training, on average, were employed for an additional 405 days, 95% CI [249 days, 561 days], and had earned €24,260 more than without completed re-training, 95% CI [€12,805, €35,715]. Two-year program completers, on average, were employed for 441 additional days, 95% CI [349 days, 534 days], and had earned €35,972 more than without completed re-training, 95% CI [€27,743, €44,202]. The programs also significantly reduced the number of days on social-security and unemployment benefits and lowered the likelihood of an earnings incapacity pension. Conclusion Policies to promote the labor market re-integration of persons with disabilities should consider that vocational re-training may be an effective tool for sustainably improving work participation outcomes.

A systematic review of work accommodations for people with mental disorders.

BACKGROUND: Work accommodations are adjustments made in the work place or to policies surrounding employment to accommodate an individual with a mental disorder to be successful in completing work related tasks. OBJECTIVE: The purpose of this systematic review is to identify work accommodations that are available and that are provided to individuals with mental disorders. In addition, associated cost-effectiveness and cost-benefits of these accommodations are examined. METHODS: Studies published between 1990-2016 from four databases were reviewed. From these databases, studies that specified accommodations that were available/provided and/or addressed cost-effectiveness or cost-benefit analysis of work accommodations were included. RESULTS: Of the 1362 eligible studies, only 15 were included. Work accommodations that were provided to individuals assisted in mitigating limitations in the work place and improved length of job tenure, as well as reduced the severity of certain mental disorders. The costs associated with these accommodations were found to be minimal and had positive economic benefits for employers. CONCLUSION: Work accommodations help individuals with mental disorders meet employment expectations with minimal cost.

Supported employment: Meta-analysis and review of randomized controlled trials of individual placement and support.

Supported employment is a treatment whereby those with severe mental illness (or other disabilities) receive aid searching for competitive employment and mental health (or other) treatments concurrently. The most popular implementation of supported employment is individual placement and support (IPS). We conducted meta-analytic analyses of the randomized controlled trials of IPS. We found that subjects in IPS, compared to usual treatment conditions, had better vocational outcomes (obtained any competitive employment: RR = 1.63, 95%CI = [1.46, 1.82]; job tenure: d = 0.55, 95%CI = [0.33, 0.79]; job length: d = 0.46, 95%CI = [0.35, 0.57]; income: d = 0.48, 95%CI = [0.36, 0.59]) Non-vocational outcomes estimates, while favoring IPS, included the null (quality of life: d = 0.30, 95%CI = [-0.07, 0.67]; global functioning: d = 0.09, 95%CI = [-0.09, 0.27]; mental health: d = 0.03, 95%CI = [-0.15, 0.21]). Analysis of the expected proportion of studies with a true effect on non-vocational outcomes with d>0.2 showed some reason to expect a possible improvement for quality of life for at least some settings (Prop = 0.57, 95%CI = [0.30, 0.84]).

Cost-effectiveness of supported employment adapted for people with affective disorders.

OBJECTIVE: The individual enabling and support (IES) model was effective in gaining competitive employment for people with affective disorders compared with traditional vocational rehabilitation (TVR) services in a randomized controlled trial in a Swedish setting. The object of this study is to perform a cost-effectiveness analysis of IES comparing to TVR. METHODS: We considered the costs of intervention and productivity gain due to increased competitive employment. We estimated quality of life using EuroQol 5 Dimension (EQ-5D) and Manchester Short Assessment of Quality of Life (MANSA) scale. EQ-5D was translated into quality-adjusted life-years (QALY), using the UK, Danish, and Swedish tariffs. We performed the analysis from a societal perspective with a one-year timeframe. RESULTS: The cost of IES was €7247 lower per person per year (2014 prices) compared to TVR. There were no significant differences in QALY improvement within or between groups. However, quality of life measured by the MANSA scale significantly improved over the study period in IES. LIMITATIONS: Besides the small sample size, details on the intervention costs for both IES and TVR group were unavailable and had to be obtained from external sources. CONCLUSIONS: Implementation of IES for people with affective disorders is most likely cost-saving and is potentially even dominating TVR, although a larger trial is required to establish this.

Preventing unemployment and disability benefit receipt among people with mental illness: Evidence review and policy significance.

OBJECTIVE: We identify effective services to assist 3 groups of people with mental illnesses become or remain employed and prevent dependence on disability cash benefits: (a) individuals, including youth, who are experiencing an initial episode of psychosis; (b) employed individuals at risk of losing jobs due to mental illness; and (c) individuals who are or may become long-term clients of mental health services and are likely to apply for disability benefits. METHOD: We searched for articles published between 1992 and 2015 using key word terminology related to employment support services and each subgroup, and prioritized articles by study design. RESULTS: The individual placement and support model of supported employment is more effective than traditional vocational programs in helping people with serious mental illnesses who are engaged in treatment or receiving disability benefits obtain competitive employment. Some early intervention programs effectively serve people who experience a first episode of mental illness, but more research is needed to demonstrate long-term outcomes. Less is known about the effectiveness of employment interventions in preventing unemployment and use of disability benefits among individuals at risk for job loss or long-term mental illness. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: States can fund employment supports to help prevent the need for disability benefit receipt by creatively combining federal sources, but the funding picture is imperfect. Medicaid expansion and other provisions of the Affordable Care Act may fund employment supports and assist in reducing dependence on disability benefits. (PsycINFO Database Record

Cost-effectiveness of cognitive remediation and supported employment for people with mental illness: a randomized controlled trial.

BACKGROUND: Little is known about the economic benefits of cognitive remediation and supported employment (CR + SE). The present study aimed to investigate the cost-effectiveness of CR + SE compared with traditional vocational services (TVS). METHOD: Individuals with mental illness and low cognitive function were recruited at six sites in Japan. A total of 111 participants were randomly allocated to the CR + SE group or the TVS group. Clinical and vocational outcomes were assessed at baseline and 12-month follow-up. Service utilization data were collected monthly. The data on outcomes and costs were combined to examine cost-effectiveness. RESULTS: The data were obtained from a total of 92 participants. The CR + SE group resulted in better vocational and clinical outcomes (employment rate, 62.2%; work tenures, 78.6 days; cognitive improvement, 0.5) than the TVS group (19.1%, 24.9 days and 0.2). There was no significant difference in mean total costs between the groups (CR + SE group: $9823, s.d. = $6372, TVS group: $11 063, s.d. = $11 263) with and without adjustment for covariates. However, mean cost for medical services in the CR + SE group was significantly lower than that in the TVS group after adjusting covariates (Β = -$3979, 95% confidence interval -$7816 to -$143, p = 0.042). Cost-effectiveness acceptability curves for vocational outcomes illustrated the high probabilities (approximately 70%) of the CR + SE group being more cost-effective than TVS when society is not willing to pay additional costs. CONCLUSIONS: CR + SE appears to be a cost-effective option for people with mental illness who have low cognitive functioning when compared with TVS.

Protocol for the SEED-trial: Supported Employment and preventing Early Disability.

BACKGROUND: Early withdrawal or exclusion from the labor market leads to significant personal and societal costs. In Norway, the increasing numbers of young adults receiving disability pension is a growing problem. While a large body of research demonstrates positive effects of Supported Employment (SE) in patients with severe mental illness, no studies have yet investigated the effectiveness of SE in young adults with a range of social and health conditions who are receiving benefits. METHODS/DESIGN: The SEED-trial is a randomized controlled trial (RCT) comparing traditional vocational rehabilitation (TVR) to SE in 124 unemployed individuals between the ages of 18-29 who are receiving benefits due to various social- or health-related problems. The primary outcome is labor market participation during the first year after enrollment. Secondary outcomes include physical and mental health, health behaviors, and well-being, collected at baseline, 6, and 12 months. A cost-benefit analysis will also be conducted. DISCUSSION: The SEED-trial is the first RCT to compare SE to TVR in this important and vulnerable group, at risk of being excluded from working life at an early age. TRIAL REGISTRATION: Clinicaltrials.gov, registration number NCT02375074 . Registered on December 3rd 2014.

Individual Placement And Support Services Boost Employment For People With Serious Mental Illnesses, But Funding Is Lacking.

The majority of people with serious mental illnesses want to work. Individual placement and support services, an evidence-based supported employment intervention, enables about 60 percent of people with serious mental illnesses who receive the services to gain competitive employment and improve their lives, but the approach does not lead to fewer people on government-funded disability rolls. Yet individual placement and support employment services are still unavailable to a large majority of people with serious mental illnesses in the United States. Disability policies and lack of a simple funding mechanism remain the chief barriers. A recent federal emphasis on early-intervention programs may increase access to employment services for people with early psychosis, but whether these interventions will prevent disability over time is unknown.

Long-Term Effects of Evidence-Based Supported Employment on Earnings and on SSI and SSDI Participation Among Individuals With Psychiatric Disabilities.

OBJECTIVE: This study examines the long-term effects of evidence-based supported employment services on three vocational outcomes: labor force participation, earnings, and attainment of Social Security Administration (SSA) nonbeneficiary status through suspension or termination of disability cash payments due to work (NSTW). METHOD: Data from 449 individuals with psychiatric disabilities who participated in a multisite controlled trial of supported employment were matched to SSA data over a 13-year period (2000-2012) following supported employment services. Long-term outcomes were analyzed using random effects regression models comparing participants in the experimental and control conditions on measures of employment, earnings, and attainment of NSTW. The authors adjusted for time, age, race/ethnicity, gender, education, schizophrenia diagnosis, substance abuse history, and geographic region. RESULTS: Overall outcomes were modest across the 13-year follow-up, with 32.9% of participants having any earned income and 13.1% ever attaining NSTW. Supported employment recipients were almost three times as likely as control subjects to be employed over 13 years (odds ratio=2.89). Although earnings were low, supported employment participants had significantly higher earnings per month than control subjects over time (parameter estimate=$23.82) and were more likely than control subjects to attain NSTW (odds ratio=12.99). The supported employment effect diminished and was completely attenuated over time. CONCLUSIONS: The study's findings indicate a small but significant vocational advantage accruing to recipients of evidence-based supported employment in the decade following service delivery, adding to the evidence on the durability of supported employment effects. Results can inform policies designed to help workers enhance economic security and reduce dependence on Social Security disability benefits.

Cost effectiveness and budgetary impact of the Boston University approach to Psychiatric Rehabilitation for societal participation in people with severe mental illness: a randomised controlled trial protocol.

BACKGROUND: People with Severe Mental Illness (SMI) frequently experience problems with regard to societal participation (i.e. work, education and daily activities outside the home), and require professional support in this area. The Boston University approach to Psychiatric Rehabilitation (BPR) is a comprehensive methodology that can offer this type of support. To date, several Randomised Controlled Trials (RCT's) investigating the effectiveness of BPR have yielded positive outcomes with regard to societal participation. However, information about the cost-effectiveness and budgetary impact of the methodology, which may be important for broader dissemination of the approach, is lacking. BPR may be more cost effective than Care As Usual (CAU) because an increase in participation and independence may reduce the costs to society. Therefore, the aim of this study is to investigate, from a societal perspective, the cost-effectiveness of BPR for people with SMI who wish to increase their societal participation. In addition, the budget impact of implementing BPR in the Dutch healthcare setting will be assessed by means of a budget impact analysis (BIA) after completion of the trial. METHODS: In a multisite RCT, 225 adults (18-64 years of age) with SMI will be randomly allocated to the experimental (BPR) or the control condition (CAU). Additionally, a pilot study will be conducted with a group of 25 patients with severe and enduring eating disorders. All participants will be offered support aimed at personal rehabilitation goals, and will be monitored over a period of a year. Outcomes will be measured at baseline, and at 6 and 12 months after enrolment. Based on trial results, further analyses will be performed to assess cost-effectiveness and the budgetary impact of implementation scenarios. DISCUSSION: The trial results will provide insight into the cost-effectiveness of BPR in supporting people with SMI who would like to increase their level of societal participation. These results can be used to make decisions about further implementation of the method. Also, assessing budgetary impact will facilitate policymaking. The large sample size, geographic coverage and heterogeneity of the study group will ensure reliable generalisation of the study results. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN88987322. Registered 13 May 2014.

Time utilisation trends of supported employment services by persons with mental disability in South Africa.

BACKGROUND: This paper reports on the second phase of a two-phased study that was undertaken to determine the feasibility of supported employment (SE) as a strategy with which to facilitate the employment of persons with disability in competitive work contexts. The study population comprised people with mental disabilities receiving SE in the Western Cape Province, South Africa. OBJECTIVE: To describe the components of SE utilised by persons with mental disability (i.e. psychiatric or intellectual disability) in terms of type and time utilisation patterns over 12 months. METHODS: Criterion sampling, a form of purposive sampling, was used to identify 29 study participants - 19 with intellectual disability and 10 with psychiatric disability. Data collection commenced for each participant when a work placement had been identified and preparation for such ensued. Data was collected prospectively for a period of 12 months. SE service components utilised by participants were captured using a data capture sheet that was developed for this purpose. RESULTS: Time utilisation indicated a steep downwards trend for both cohorts. The decrease in utilisation of SE service components over a period of one year was more pronounced in the psychiatric disability (PD) cohort, who utilized almost half the total SE services in the first month. CONCLUSIONS: SE services can be considered as a viable option for return to work in resource-constrained environments. Providers of SE services will need to modify approaches in order to meet contextual realities.

Contemporary vocational rehabilitation in Australia.

PURPOSE: There is a strong connection between disability and decreased participation rates in the Australian labour market. Australian government policy recognises vocational rehabilitation as a key strategy to increase employment rates of people with disabilities. METHODS: This paper examines current Australian disability employment policies and practices. It also reviews vocational rehabilitation competency research to identify knowledge and skill domains central to quality service provision, and explores the delivery of tertiary level vocational rehabilitation education. RESULTS: Policy changes in Australia over the last decade have been aimed at addressing the unsustainable increase in disability benefits. In this context vocational rehabilitation services continue to be viewed as crucial in assisting people with disabilities to maintain employment and reduce disengagement. Competencies research has consistently identified vocational counselling, personal counselling, professional practice and case management as central to quality vocational rehabilitation service provision. Two competencies identified in recent research, workplace disability case management and workplace interventions and program management, reflect the centrality of vocational rehabilitation to disability management. CONCLUSIONS: Changes in the policy environment to reduce the number of disability pension recipients will inevitably lead to an increased demand for trained vocational rehabilitation personnel. Given the development of strong accreditation standards for vocational rehabilitation education and practice that underpin the provision of tertiary level rehabilitation counselling training programs, professionally qualified rehabilitation counsellors are ideally placed to address the complex employment needs of people with a disability. IMPLICATIONS FOR REHABILITATION: It is important to understand changes that may occur in policy environments in terms of their impact on vocational rehabilitation service delivery for people with disabilities. Variable levels of training in the vocational rehabilitation sector result in people with complex needs not consistently receiving the services they need to access and maintain employment. Practitioners need to focus increasingly on individualized service delivery where the client has significant control over decisions about their rehabilitation program.

How does outcome-based funding affect service delivery? An analysis of consequences within employment services for people living with serious mental illness.

This paper explores the impact of outcome-based funding on service delivery within employment services for people with serious mental illness. It draws on a case study of a policy change in the provincial disability support program in Ontario, Canada where funding for employment programs and services was changed from a fee-for-service to an outcome-based model. The findings highlight that the financial imperative for programs to meet employment targets in order to secure their funding has shifted the focus away from the provision of pre-employment supports to job development and job placements. However, there remains little attention to job matching and career development, and there is concern about access to services among those with complex barriers to employment. There is a need to reconcile tensions between the goals of outcome-based funding and on-the-ground service delivery to promote ongoing innovation in employment services for people with serious mental illness.

Protocol for the effect evaluation of Individual Placement and Support (IPS): a randomized controlled multicenter trial of IPS versus treatment as usual for patients with moderate to severe mental illness in Norway.

BACKGROUND: Roughly one third of disability pensions in Norway are issued for mental and behavioral disorders, and vocational rehabilitation offered to this group has traditionally been dominated by train-and-place approaches with assisted or sheltered employment. Based on a more innovative place-and-train approach, Individual Placement and Support (IPS) involves supported employment in real-life competitive work settings, and has shown great promise for patients with severe mental illness. METHODS/DESIGN: The study is a multicenter Randomized Controlled Trial (RCT) of IPS in a Norwegian context, involving an effect evaluation, a process evaluation, and a cost/benefit analysis. IPS will be compared to high quality treatment as usual (TAU), with labor market participation and educational activity at 12 months post inclusion as the primary outcome. The primary outcome will be measured using register data, and the project will also include complete follow-up up to 4 years after inclusion for long-term outcome data. Secondary outcomes include mental health status, disability and quality of life, collected through survey questionnaires at baseline, and after 6 and 12 months. Participants will include patients undergoing treatment for moderate to severe mental illness who are either unemployed or on sickness or social benefits. The estimated total sample size of 400-500 will be randomly assigned to the interventions. To be eligible, participants must have an expressed desire to work, and sufficient Norwegian reading and writing skills to fill out the questionnaires. DISCUSSION: The Effect Evaluation of Individual Placement and Support (IPS) will be one of the largest randomized controlled trials to date investigating the effectiveness of IPS on competitive employment, and the first study to evaluate the effectiveness of IPS for patients with moderate to severe mental illness within a Norwegian context. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01964092 . Registered October 16th, 2013.

Long-term effectiveness of supported employment: 5-year follow-up of a randomized controlled trial.

OBJECTIVE: The individual placement and support model of supported employment has been shown to be more effective than other vocational approaches in improving competitive work over 1-2 years in persons with severe mental illness. The authors evaluated the longer-term effects of the model compared with traditional vocational rehabilitation over 5 years. METHOD: A randomized controlled trial compared supported employment to traditional vocational rehabilitation in 100 unemployed persons with severe mental illness. Competitive work and hospital admissions were tracked for 5 years, and interviews were conducted at 2 and 5 years to assess recovery attitudes and quality of life. A cost-benefit analysis compared program and total treatment costs to earnings from competitive employment. RESULTS: The beneficial effects of supported employment on work at 2 years were sustained over the 5-year follow-up period. Participants in supported employment were more likely to obtain competitive work than those in traditional vocational rehabilitation (65% compared with 33%), worked more hours and weeks, earned more wages, and had longer job tenures. Reliance on supported employment services for retaining competitive work decreased from 2 years to 5 years for participants in supported employment. Participants were also significantly less likely to be hospitalized, had fewer psychiatric hospital admissions, and spent fewer days in the hospital. The social return on investment was higher for supported employment participants, whether calculated as the ratio of work earnings to vocational program costs or of work earnings to total vocational program and mental health treatment costs. CONCLUSIONS: The results demonstrate that the greater effectiveness of supported employment in improving competitive work outcomes is sustained beyond 2 years and suggest that supported employment programs contribute to reduced hospitalizations and produce a higher social return on investment.

Cost-effectiveness of supported employment for veterans with spinal cord injuries.

OBJECTIVE: To estimate the cost-effectiveness of a supported employment (SE) intervention that had been previously found effective in veterans with spinal cord injuries (SCIs). DESIGN: Cost-effectiveness analysis, using cost and quality-of-life data gathered in a trial of SE for veterans with SCI. SETTING: SCI centers in the Veterans Health Administration. PARTICIPANTS: Subjects (N=157) who completed a study of SE in 6 SCI centers. Subjects were randomly assigned to the intervention of SE (n=81) or treatment as usual (n=76). INTERVENTION: A vocational rehabilitation program of SE for veterans with SCI. MAIN OUTCOME MEASURES: Costs and quality-adjusted life years, which were estimated from the Veterans Rand 36-Item Health Survey, extrapolated to Veterans Rand 6 Dimension utilities. RESULTS: Average cost for the SE intervention was $1821. In 1 year of follow-up, estimated total costs, including health care utilization and travel expenses, and average quality-adjusted life years were not significantly different between groups, suggesting the Spinal Cord Injury Vocational Integration Program intervention was not cost-effective compared with usual care. CONCLUSIONS: An intensive program of SE for veterans with SCI, which is more effective in achieving competitive employment, is not cost-effective after 1 year of follow-up. Longer follow-up and a larger study sample will be necessary to determine whether SE yields benefits and is cost-effective in the long run for a population with SCI.