The Texas Demonstration to Maintain Independence and Employment (DMIE) was a randomized, controlled study designed to examine the hypothesis that a coordinated program of employment and health supports could prevent loss of employment for workers with potentially disabling conditions (e.g., severe mental illness or a comorbid behavioral and significant physical health condition).
Method: 1,616 working adults with potentially disabling conditions were recruited and randomly assigned to either intervention (n=904) or control group (n=712). The intervention group received expanded behavioral, medical, and dental health services, improved access to services, case management, and vocational supports. All participants completed a baseline survey at study entry and at 12 and 24 months. Additional data collected included participant demographics, medical and prescription records, case management activity reports, and Social Security Administration data. There were also three rounds of individual process interviews with approximately 40 selected participants, a focus group with Case Managers, interviews with stakeholders, and in-depth narrative interviews with 20 participants. Adjusted means and percents for the intervention and control groups at baseline, 12 and 24 months were computed and tested for statistical significance. Qualitative interviews were transcribed and analyzed using thematic analysis.
Results: DMIE significantly increased access to and use of appropriate health services including mental health and outpatient services, medication adherence, and satisfaction with health care access and quality. DMIE decreased receipt of disability benefits for younger participants (age 20 to 44) (6% intervention vs. 11% control). DMIE had few effects on most quantitative measures of employment and earnings, including number of months and hours worked, earnings, and family income. Process interviews suggested that variation in hours worked was largely due to available hours from employers. Participants typically applied for disability because of a decline in health. Case Managers described clients' employment and health as interdependent and fragile. Narrative interviews suggest that participants weighed a number of factors, such as personal resilience, prior training, education, and work experience, household resources, social support, and job flexibility, in addition to their health, in their decision to continue work or apply for disability.
Conclusions/Implications: Reducing disability receipt among younger workers represents potentially significant cost savings. The limited impact of DMIE on employment and earnings outcomes overall suggests that better access to medical care for people with potentially disabling conditions may be necessary, but not sufficient, for maintaining employment. However, an intervention such as DMIE may show stronger results in the longer-term, as risk for disability-related unemployment increases. Additional interventions and research that focus on these longer-term impacts are needed.
