Access,retention,and effectiveness of Individual Placement and Support in the U.S.: Are there racial or ethnic differences?

Abstract

BACKGROUND:

Increased federal attention to advancing racial equity and support for underserved communities suggests the need for data on racial and ethnic differences in evidence-based employment services for people with serious mental illness. Individual Placement and Support (IPS) is an evidence-based model of supported employment for this population.

OBJECTIVE:

The objective was to identify differences based on race and ethnicity in IPS services.

METHODS:

This narrative review examined the empirical literature on IPS services in the U.S., assessing evidence of differences in access, retention, and effectiveness for Black and Hispanic IPS clients, relative to non-Hispanic Whites.

RESULTS:

We identified 12 studies examining racial and ethnic differences in access (4 studies), retention (3 studies), and effectiveness (6 studies). The findings for access to IPS were mixed, with two studies showing no differences, one finding less access for Blacks, and another finding greater access for Blacks but less access for Hispanics. Three studies found better retention rates for clients enrolled in IPS regardless of race or ethnicity. Compared to clients receiving usual vocational services, all studies found better employment outcomes for IPS clients regardless of race or ethnicity.

CONCLUSION:

Unlike for most of health care, few racial and ethnic differences have been found for IPS employment services in the U.S. Access to IPS is inadequate for all groups, with conflicting evidence whether Blacks and Hispanics have even less access. Based on the available evidence, Black and Hispanic clients have comparable retention and employment outcomes in IPS as non-Hispanic White clients. State and local mental health leaders responsible for monitoring IPS outcomes should routinely report statistics on race and ethnicity. They should also give active attention to client needs and equity. Research designs should answer multifaceted questions regarding disparities for historically underserved populations.

Keywords

Individual Placement and Support supported employment employment race Hispanic equity access

1 Introduction

A large body of research documents the profound and negative effect centuries of structural racism in the United States has had on racial and ethnic minorities, including disparities in health coverage, chronic health conditions, mental health, and mortality (Bignall et al., 2019; Braveman et al., 2022; Churchwell et al., 2020; Kalin, 2021; Yearby et al., 2022). Healthcare disparities include “inequities in the delivery of healthcare [which] are unjust differences between populations in the access, use, quality, and outcomes of care” (Institute of Medicine, 2003). Healthy People 2020 defines health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion” (U.S. Department of Health and Human Services, 2008).

Numerous studies show mental health care disparities for Blacks and Hispanics (Cook et al., 2017; Creedon & Cook, 2016; Maura & Weisman de Mamani, 2017; Mongelli et al., 2020). For example, studies have found that Black clients have higher treatment disengagement rates (Fischer et al., 2008; Fortuna et al., 2010) and poorer functional outcomes after receiving treatment (Eack & Newhill, 2012; Phillips et al., 2001) than White clients. Factors contributing to these disparities include poverty, patient distrust, treatment expenses, and distance of medical services from the communities where many historically underserved groups live (Bignall et al., 2019; Maura & Weisman de Mamani, 2017).

Mental health policymakers recognize employment as a central social determinant of health (Drake & Wallach, 2020; Pinto et al., 2018). Yet people with serious mental illness have much poorer employment outcomes than the general adult population. Less than 15%of people with schizophrenia and 40%of people with bipolar disorders maintain competitive employment over their lifetime (Hakulinen et al., 2020). Employment outcomes are even poorer for Black and Hispanic clients with mental illness (Ehntholt et al., 2022), mirroring labor force participation in the general population (BLS, 2022). Regardless of race or ethnicity, people with mental illness who want to work should have access to effective employment services (Drake & Wallach, 2020).

A handful of studies have examined racial and ethnic disparities in vocational rehabilitation, including a recent national study of the federal-state vocational rehabilitation (VR) system, which found that Whites were less likely to apply for VR services than were their Black, American Indian/Alaska Native, and Hispanic counterparts (Shaewitz & Yin, 2021; Yin et al., 2022). However, among those who applied, disproportionately more Whites were found eligible for services than the other three subgroups. Further, among those found eligible, Whites received more employment services and had better outcomes than the other three groups (Shaewitz & Yin, 2021; Yin et al., 2022). Other large-sample studies of VR clients have similarly found poorer competitive employment outcomes for Black clients than for White clients (Lukyanova et al., 2014; Salzer et al., 2011). Disparities are especially pronounced for young Black men with mental health conditions (Delman & Adams, 2022; Vryhof & Balcazar, 2020). Racial and ethnic disparities in access to vocational programs are not attributable to a disinterest in receiving help; one study of a homeless population found that non-Whites were more likely than Whites to seek referrals for employment services (Brown et al., 2019).

None of the cited studies, however, examined differences for clients receiving evidence-based employment services. Extensive research has established that people with serious mental illness can hold competitive jobs if they receive appropriate help (Bond et al., 2020). The Individual Placement and Support (IPS) model of supported employment is an evidence-based practice that increases competitive employment for people with mental health conditions (Drake et al., 2012). Initially developed and researched in community mental health centers in the 1990s, IPS has become a standardized model of supported employment for people with serious mental illness, such as schizophrenia and bipolar disorder (Drake et al., 2012). IPS incorporates eight core principles: (1) Focus on the goal of competitive employment. Agencies providing IPS are committed to regular jobs in the community as an attainable goal for clients seeking employment. (2) Zero exclusion/eligibility follows client choice. Every client who wants to work is eligible for services regardless of “readiness,” work experience, symptoms, or any other issue. (3) Attention to client preferences. Services align with clients’ preferences and choices, rather than practitioners’ expertise or judgments. IPS specialists help clients find jobs that fit their preferences and skills. (4) Rapid job search. IPS programs help clients look for jobs soon after a client expresses interest in working, rather than providing lengthy pre-employment assessment, training, and counseling. (5) Targeted job development. Based on finding jobs that align with clients’ interests, IPS specialists build relationships with employers through ongoing contact, learning about the business needs of employers and introducing employers to qualified job seekers. (6) Integration of employment services with mental health treatment. IPS programs closely integrate with mental health treatment teams. (7) Personalized benefits counseling. IPS specialists help clients obtain personalized, understandable, and accurate information about how working may impact their disability benefits and other government entitlements. (8) Individualized long-term support. Individualized, follow-along supports that match clients’ preferences continue for as long as the client wants and needs the support to keep a job or advance career opportunities.

The foundational IPS principle of client choice means that anyone interested in competitive employment, without regard to race or ethnicity, should be eligible for services. Despite this aspiration, the potential pool of IPS participants is subject to several stages of selection, each of which is subject to potential disparities. With the current federal emphasis on racial equity (Executive Order 13985, 2021), research on disparities in IPS for historically underserved groups should be of particular interest to federal, state, and local leaders responsible for planning and implementing evidence-based services. While disparities are well established throughout health care, researchers have given little attention to disparities in IPS services based on race and ethnicity.

1.1 Objective

In this paper we review IPS research conducted in the U.S., examining racial and ethnic differences in IPS services for clients with serious mental illness from two historically underserved groups –Blacks and Hispanics –in comparison to Whites. We examine three performance indicators –access, retention, and effectiveness –identified by the Institute of Medicine (2003). To date, researchers have not systematically reviewed the IPS literature on this issue. IPS is the most researched of all employment models for people with mental illness, providing a large corpus of studies with potentially relevant information. Nevertheless, IPS researchers have not specifically designed studies to evaluate differences based on race and ethnicity, nor have IPS studies employed analytic methods that adequately address complex disparity questions (Baumann & Cabassa, 2020; Jeffries et al., 2019). Therefore, in this review we report the presence or absence of statistical differences without making any attributions of disparity in the sense of social injustice, as that term is commonly defined (Braveman, 2014).

2 Methods

2.1 Search procedures

This review examined IPS studies conducted in the U.S. The time frame for the search included papers published between 1993 (the year of the first IPS publication) (Becker & Drake, 1993) to September 2022. While IPS was developed for people with serious mental illness, it is increasingly being offered to people with other conditions. Therefore, we did not restrict the target population studied.

As is true more generally in the psychiatric rehabilitation literature, few IPS studies have made racial and ethnic disparities a primary focus. Researchers typically report statistics on race and ethnicity in tables summarizing sample background characteristics with no further details. Thus, a conventional electronic search was not an optimal strategy for locating potentially relevant studies. Consequently, we opted to rely primarily a non-electronic search procedure consisting of a manual scan of a comprehensive and up-to-date bibliography of IPS studies (Bond, 2022), which we methodically reviewed for this paper. The bibliography included 190 papers, of which 108 were quantitative IPS studies, 65 conducted in the US and 43 outside the US. The remaining 82 papers were reviews, theoretical papers, or empirical papers not specific to IPS. Next, we examined randomized controlled trials (RCTs) of IPS identified in recent systematic reviews (Brinchmann et al., 2020; de Winter et al., 2022; Frederick & VanderWeele, 2019; Metcalfe et al., 2018; Weld-Blundell et al., 2021). Altogether we identified 18 RCTs of IPS conducted in the U.S. between 1996 and 2022.

As a final step, we conducted a systematic electronic search for additional relevant publications using Google Scholar. This search used the key phrase “individual placement and support” in combination with “Black,” ”Hispanic,” “Latino,” “Latinx,” “race,” “ethnicity,” “racial disparity,” “ethnic disparity,” “disparities,” “disparity,” “equity,” “inequity,” and “barrier.” This set of searches identified two studies not identified through the non-electronic methods. The first was a report on a multi-site study that combined data from four RCTs of supported employment that did not follow the IPS model and three RCTs already included in this review (Cook et al., 2005). We excluded this study. The second was a small retrospective observational study of IPS that found nonsignificant correlations between a dichotomous measure of race (White versus non-White) and five employment outcomes (Lucca et al., 2004). We excluded this study because it was not an RCT.

As a literature review, the current study was exempt from Institutional Review Board approval.

2.2 Measures

2.2.1 Access

We define access rate as the number of people in a group receiving IPS divided by the population from which this group is drawn. To evaluate differences in access to IPS, researchers must indicate the population used for comparison purposes. Comparators typically include the proportion of Blacks, Hispanics, and non-Hispanic Whites in populations from which IPS clients are drawn, such as (1) the general adult population in the local community or service area where the IPS program is located; (2) clients enrolled in the community mental health center that provides most referrals to the IPS program; and (3) Medicaid patients with mental health diagnoses in a state or service area.

Observational studies under natural conditions are the best source of evidence for evaluating differences in access. By contrast, formal research studies, such as RCTs, are problematic for assessing access because many research-related factors (e.g., recruitment methods, screening criteria, participation requirements, reluctance to participate in research) may influence client decisions to enroll in a study (Salkever et al., 2014).

2.2.2 Retention

We define retention rate in IPS as the number of clients in a target group who are receiving IPS at a fixed follow-up period divided by the number who enrolled in IPS services. (Retention rate is equal to 1.0 minus the dropout rate.) Studies vary in follow-up periods for assessing retention rates. The best evidence for evaluating differences in retention is found in prospective studies (such as RCTs) that systematically assess retention rates by different racial and ethnic groups over fixed intervals of time. RCTs permit comparisons between IPS and control participants within specific groups. We searched for and tabulated findings for all such studies.

2.2.3 Effectiveness

We examined competitive employment outcomes only. The simplest of many measures used to assess the effectiveness of IPS is the competitive employment rate, defined as the number of clients with at least one day of competitive employment during a fixed follow-up period after enrollment in IPS divided by the total number enrolled. We restricted our review of differences in IPS effectiveness to RCTs (and secondary analyses of RCTs), because they provide the best evidence. Analytic methods for assessing differences have varied, including: (1) stratifying on race and/or ethnicity and conducting subgroup analyses, comparing outcomes for IPS to control groups within specified subgroups; (2) comparing outcomes within the IPS sample between racial and ethnic groups within study condition (that is, the IPS and control groups); and (3) examining interactions between race/ethnicity and study condition (IPS versus control).

2.3 Data extraction

One researcher (GB) conducted the literature search, identified the studies for inclusion, and summarized the findings from these studies. A second reviewer (JM) reviewed this summary for accuracy, correcting two minor errors.

2.4 Data analyses

The current paper includes descriptive summary statistics (percentages, means, standard deviations, odds ratios, and d effect sizes), as reported in the original articles.

3 Results

3.1 Search results

The search yielded four studies assessing access (two from the IPS bibliography and two from contacts with colleagues), three RCTs assessing differences in retention, and eight RCTs assessing differences in effectiveness. Although the parameters for the literature search included studies without regard to target population served, the only studies providing relevant information were for people with serious mental illness.

3.2 Differences in IPS access rates

Four U.S. studies have examined differences in receipt of IPS services among Blacks or Hispanics. The first examined a large administrative data comprised of 1,748 admissions to a Chicago-based psychiatric rehabilitation agency providing IPS services (Frounfelker et al., 2011). Among clients enrolled in the psychiatric rehabilitation agency, a significantly higher percentage of White clients than Black clients enrolled in IPS (26%versus 17%, X² = 18.0, p < 0.001). A second study compared demographic characteristics of clients from four Ohio community mental health centers who were either referred to IPS services (N = 113) or who were not referred (N = 78) (Biegel et al., 2009). Race was not associated with referral to IPS.∥

Using a large administrative dataset, a Maryland study examined Medicaid recipients from 2001 to 2010 who had a diagnosis of serious mental illness (Salkever et al., 2017). In this dataset that included over 20,000 Medicaid recipients with serious mental illness, the percentage enrolled in IPS differed neither for Blacks versus all others, nor for Hispanics versus all others. In other words, among Medicaid recipients with serious mental illness, this study found no evidence of differences in IPS access based on race or ethnicity.∥

State mental health agencies typically collect demographic data for mental health service recipients, but state-level statistics on race and ethnicity of IPS clients are rarely available. Recently, however, the state of Tennessee summarized annual statistics for its statewide IPS services, reporting that 1,118 people received IPS services in 2020, including 377 (34%) Blacks and 19 (2%) Hispanics (Liverman, 2021). The percentage of Black IPS clients was twice the percentage of Black citizens in Tennessee in the 2010 census, which was 17%. Conversely, the percentage of Hispanic citizens in Tennessee was 6%, more than twice the percentage in the IPS sample (www.census.gov/quickfacts/fact/table/TN,US/PST045219).

In summary, two of four studies found no differences in access to IPS services based on race or ethnicity. One study found less access for Blacks, while another found less access for Hispanics. On the other hand, one study found enrollment rates for Blacks exceeded the proportion of Blacks in the population used for comparison. The population used for comparison varied widely across studies.

3.3 Differences in IPS retention rates

We found three RCTs examining racial and ethnic data on retention in IPS services. One RCT examined predictors of dropout in a sample of 194 participants that included 51%Black and 37%White participants (Harding et al., 2008). The Hispanic subgroup was too small (8%) for statistical testing. Overall, IPS participants had a significantly lower dropout rate at 6 months than control participants. Black participants did not drop out at a higher rate than Whites, nor was there a significant interaction between race and vocational program assignment.

A second RCT tracked program retention rates over a two-year period for 64 Hispanic clients, 91 non-Hispanic Black clients, and 43 non-Hispanic White clients (Mueser et al., 2014). Overall, the IPS group had a significantly higher retention rate than the control group. Two-year retention rates for IPS did not differ for the three groups (95%, 87%, and 93%, respectively). A third RCT located in a predominantly Black area of Baltimore found no racial differences in retention rates over a two-year study period (Lehman et al., 2002).

In summary, these studies found no racial or ethnic differences in retention in IPS services.

3.4 Differences in effectiveness of IPS

Six IPS studies, including four RCTs and two analyses of multiple RCTs have examined racial and ethnic differences in employment outcomes using a variety of analytic methods. One was a secondary analysis examining job acquisition and job duration in a combined database from four RCTs of IPS (total N = 681) (Campbell, 2007; Campbell et al., 2011). White, Black, and Hispanic subgroups receiving IPS had significantly better employment outcomes than those receiving standard services, as shown in Table 1. Moreover, the effect sizes assessing differences in employment outcomes between IPS and control participants were similar across the subgroups. Among IPS participants, the employment rates at follow-up for Blacks (67%) and Hispanics (59%) did not differ from non-Hispanic Whites (76%). A subsequent study found that neither race nor ethnicity was a significant predictor of either employment outcome in a series of regression analyses within both the IPS and control groups (Campbell et al., 2010).

Table 1
Employment outcomes for White, Black, and Hispanic clients in a meta-analysis of four IPS controlled trials (Adapted from Campbell, 2007 and Campbell et al., 2011)

Job acquisition Weeks worked over 18 months

IPS Control d IPS Control d

White, not Hispanic (N = 265) 76% 32% 1.04 25.0 8.7 0.72

Black (N = 311) 67% 19% 1.21 17.4 2.9 0.82

Hispanic (N = 85) 59% 19% 0.84 17.7 2.8 0.83

	Job acquisition	Weeks worked over 18 months
White, not Hispanic (N = 265)	76%	32%	1.04	25.0	8.7	0.72
Black (N = 311)	67%	19%	1.21	17.4	2.9	0.82
Hispanic (N = 85)	59%	19%	0.84	17.7	2.8	0.83

A multisite RCT of IPS found that the employment rate at follow-up in the total sample for 568 Black clients did not differ from the 1,265 White clients (43%vs. 41%), but 228 Hispanic clients had significantly better employment rates than 1,824 non-Hispanic clients (54%vs. 41%). The better outcomes for Hispanic clients held true in both the IPS group (odds ratio = 1.80) and control group (odds ratio = 1.71) (Metcalfe et al., 2017). IPS clients had significantly better employment outcomes than control clients regardless of race or ethnicity (Metcalfe, personal communication, May 2, 2022).

An RCT of IPS for people with schizophrenia aged 45 and older examined correlations between a range of client background measures and three employment outcomes (attainment of competitive work, weeks worked, and wages) (Twamley et al., 2012). Within both the IPS and control groups, White participants did not differ from non-White participants on any of the three employment outcomes.

Two other RCTs of IPS in predominantly Black communities (one in Baltimore and the other in rural South Carolina) found significantly better employment outcomes for IPS compared to usual vocational services (Gold et al., 2006; Lehman et al., 2002). The first found significantly lower employment rates for Blacks compared to Whites in the total sample, but no significant interactions between race and study condition (Gold et al., 2006). The second found no differences between White to non-White participants on three competitive employment outcomes (job acquisition, hours worked, and wages) (Lehman et al., 2002).

Finally, a meta-analysis of 22 RCTs of IPS evaluated race and ethnicity as potential moderators of employment outcomes based on proportions of different racial and ethnic groups in each study sample (Metcalfe et al., 2021). The total sample included 53%White, 38%Black, and 11%Hispanic participants. The analyses did not find significant differences in effectiveness for IPS based on race or ethnicity.

In summary, these RCTs and secondary analyses of multiple RCTs all found that IPS clients had better outcomes than control clients regardless of race or ethnicity. One study found Hispanic clients had better employment outcomes than non-Hispanic clients.

4 Discussion

IPS research has found that adults with serious mental illness from two historically underserved groups (Blacks and Hispanics) have similar retention rates and employment outcomes in IPS services as Whites. All studies found better retention rates and employment outcomes for IPS clients regardless of race or ethnicity.

The findings were mixed for comparisons of access rates for Blacks, Hispanics, and Whites. Several factors complicate the interpretation of the access rate comparisons. First, access, as defined in this review, refers to receipt of services. Lack of access could result from a multitude of client, program, insurance, cultural, and community factors, including a lack of client awareness, limited IPS program capacity, a lack of client interest, geographic or other logistical barriers, or service provider discrimination. Second, the denominator problem also remains unsolved: To which target population should researchers compare the group receiving services? Discrimination could occur at many levels.

The comparators used in the studies examining access all contained serious selection biases. Population could be defined as all people with a mental health condition who need or want employment services, among whom prevalence, diagnostic bias, insurance, and general access to mental health care may differ across ethno-racial groups. Existing studies only address those who are already insured, already in care, or counted in the U.S. Census, thus ignoring those lacking access to insurance or community mental health centers. Employment, insurance, and mental health care among working-age people with serious mental illness may differ substantially across ethno-racial groups. Thus, studies that do not adjust for these confounds cannot rule out disparities in access among different ethnoracial groups, even if the statistical comparisons show no differences. Ideally, disparity research should consider populations of those who could benefit from IPS. For example, if Blacks with serious mental illness have a much higher rate of unemployment (relative to Whites), they should have a much higher rate of participation in IPS services to prevent disparity. Even an equal participation rate may indicate a significant disparity.

Although these studies mostly found no statistical differences in rates for different racial and ethnic groups, statistical equivalence is not synonymous with equity. Diversity and inclusion of the service population may not address greater needs, a lack of equity, and self-selection. In other words, historically underserved groups may have greater need related to years of poverty and educational, employment, and economic bias resulting in the need for greater or different supports to achieve equity, which connotes creating similar opportunities for success rather than just providing equal access to services (Culyer & Wagstaff, 1993). A critical issue in studying racial and ethnic disparities is differences in need rather than in subpopulation size. For example, if twice as many Blacks as Whites in an area are poor, unemployed, and disabled by a mental health condition, Blacks should have twice the access rate rather than a similar access rate.

A further consideration is that Blacks and Hispanics also have long histories of mistreatment and avoidance of mental health services, which is where IPS services are most often available, and these trends have continued even after the passage of the Affordable Care Act, which was intended to reduce barriers to health care (Cook et al., 2017; Creedon & Cook, 2016). Promoting equity in IPS availability and economic opportunity may require outreach to non-psychiatric settings such as supportive housing programs, justice-system programs, and religious organizations; more diversity of professionals in mental health (Miranda et al., 2008); and greater involvement of peers with lived experience and similar racial and ethnic backgrounds.

While we found minimal evidence of racial or ethnic differences in access to IPS services, all groups have inadequate access. Like other evidence-based practices, IPS is available to only a small fraction (approximately 2%) of mental health clients who could benefit (Bruns et al., 2016). Moreover, the studies of IPS access examined in this review did not compare their findings to racial and ethnic statistics for adult residents of the local community. Many communities with a disproportionately high proportion of people from racial and ethnic minorities lack access to affordable outpatient mental health services (Cook et al., 2007) and many from historically underserved groups avoid mental health services due to stigma or distrust. The distribution of IPS programs by geographic location has not been systematically documented, but greater travel time to IPS programs for racial and ethnic minorities seems likely (Miranda et al., 2020). On the other hand, the literature provides several examples of successful IPS programs located in predominantly Black communities (Bond et al., 2007; Drake et al., 1999; Gold et al., 2006; Lehman et al., 2002). With respect to retention in IPS services, we found no evidence of racial or ethnic differences. Moreover, IPS has far higher retention rates than other vocational services regardless of race or ethnicity, a robust finding across IPS RCTs (Bond et al., 2012).

Our review focused on the U.S. with its unique history of racism and exclusion of ethnic groups. Ethnic and racial conflicts exist everywhere, though in different forms. For example, in the UK, researchers have found inequalities in the pathways to care particularly affecting Blacks (Halvorsrud et al., 2018). Outside the U.S., IPS researchers also have generally not examined disparities among racial and ethnic groups. One exception is a British study examining 779 clients served in two IPS programs that compared IPS enrollment rates for Blacks and other historically underserved racial groups to rates of receipt of mental health services in the corresponding service areas (Perkins et al., 2021). The proportion of Black clients enrolling in IPS was more than 50%greater than the proportion of Black clients receiving mental health services. Another exception was a New Zealand IPS pilot, which showed modest progress toward achieving equity of engagement and outcomes for indigenous Māori people (Priest & Lockett, 2020).

This review has several limitations. We identified few studies of race and ethnicity and limited data within studies. To understand disparities and develop strategies to address equity, we need more studies, larger samples, more relevant comparison groups, and longer follow-ups. We also need to design studies prospectively rather than relying on post hoc analyses of studies designed to answer different questions. For example, several studies included in this review were conducted within racially or ethnically homogeneous communities, which provide limited information regarding disparities in accessing services. We also need to develop research designs that evaluate equity and not simply statistical equivalence; such designs have not yet been adequately formulated.

Despite the limitations of existing research, few racial and ethnic differences have been found for IPS employment services, unlike for most of health care. Equitable health care is of great concern to policy makers, practitioners, clients, and family members. Systematic documentation of IPS access, retention, and outcomes are of paramount importance to ensure that diversity, equity, and inclusion are realities throughout our service systems.

5 Conclusion

IPS services could help people in historically underserved groups with psychiatric disabilities to escape poverty and achieve a meaningful, productive life that enhances self-esteem, autonomy, and community integration. More research on social determinants of health could clarify needed adjustments to the IPS model to promote equity.

Footnotes

Acknowledgments

The authors have no acknowledgments.

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethics statement

This paper was a literature review. The authors did not conduct any data collection on human subjects. As such, this work did not require Institutional Review Board approval.

Funding

This paper was prepared with support from the Office of Disability Employment Policy, U.S. Department of Labor, GSA PSS Contract #GS-00F-009DA, Advancing State Policy Integration for Recovery and Employment (ASPIRE).

Informed consent

Not applicable.

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	Job acquisition			Weeks worked over 18 months
	IPS	Control	d	IPS	Control	d
White, not Hispanic (N = 265)	76%	32%	1.04	25.0	8.7	0.72
Black (N = 311)	67%	19%	1.21	17.4	2.9	0.82
Hispanic (N = 85)	59%	19%	0.84	17.7	2.8	0.83