The Outcomes Among Persons With Schizophrenia Under the Peer-support Service in Vocational Rehabilitation Program

Background In Taiwan, mental health services are provisioned through hospital-based treatment majorly and shifted to community care gradually in recent decades. In 2020, the totally 7,350 beds of acute wards and 13,559 beds of chronic wards covered the general population in Taiwan with 3.12/10,000 persons and 5.75/10,000 persons rates, respectively. In contrast to hospital treatment, there were 71 community rehabilitation centers and 155 halfway houses in local communities with coverage rate of 1.45/10,000 persons and 2.82/10,000 persons respectively. The sheltered or supported employment in Taiwan is still primarily delivered by trained professionals or paraprofessionals in the community facilities for the persons with severe mental illness. Although the trained peers can deliver vocational supports based on recovery concept as well as professionals at least in the supported employment services, the large absence of peer support workers is rooted in the lack of insurance coverage and limited government budgets in Taiwan. Accordingly, further investigations are warranted to evaluate the effectiveness of peer support services in vocational rehabilitation among persons with severe mental illness under the development of peer-deliver services in Taiwan. Therefore, the investigators designed a 2-phase pilot program: establishment of peer support training curriculum in Phase I to develop peer support services in vocational rehabilitation system feasibly, and measurement of effectiveness under peer codelivered services in Phase II (Protocol). The investigated effectiveness among persons with schizophrenia in this study included the received social supports, mental health, psychiatric symptoms, functional and occupational outcome. Methods Participants The pilot program was held from April 2017 to December 2018 at the Taipei Veterans General Hospital Yuli Branch (TVGH-YL). The hospital provides treatment and community care for patients with mental illness who reside in the rural area of eastern Taiwan. The TVGH-YL administers a half-way house, a community rehabilitation center, and a supported housing program. The hospital also provides sheltered and supported employment as part of its community care services for persons with mental illness. In one month before the program of Phase I or II, the investigators recruited the participants by presenting poster on bulletins in the half-way house and community rehabilitation center. The investigators also invited the participants who had cared elderly persons in the past to join the training curriculum in the Phase I program, because these persons were the candidates of peer support workers to share the previous work experiences in the Phase II program. Pilot program Training for peer support workers Initially, there were 7 professionals who had the experiences in the community facilities for at least 5 years discussing about the framework and contents of training curriculum for peer support workers in the focus groups. These seven professionals specializing in 6 medical disciplines were also the teachers in the curriculum. Table 2 details the themes of curriculum at various intervention levels. In the end of each lecture session, there were four questions being proposed by the teacher to exam the trainees about the core concepts of class. In the practice session, the performance of trainees would be examined by the case discussion or practice in roles playing or situation simulation. No final exam in Phase I program. However, the trainee should pass all class after the teachers' agreement. If someone needed to improve the knowledge or skills, he or she had gotten the personal time to receive more helps from the teacher. The extended vocational rehabilitation services co-led \& assisted by peer support workers The program in Phase II was held twice in August of 2017 and April of 2018. Based on the needs of elderly persons with disability or dementia in local community, the 2 occupational therapists (Ching-Hui Wu \& Meng-Ping Kao) organized the extended work training course which focused on improvements of care skills of Phase II program participants (service users). The 2 occupational therapists also held workplace problem-solving group once per 2 weeks for the service users. The above interventions were originally parts of supported employment service in the community rehabilitation center, but the participated rate was not satisfied previously. Therefore, the investigators integrated the peer support service into this service system. Before each training session, peer support workers discussed with 2 occupational therapists ("stakeholders") to decide on the content and process of the session. Peer support workers' involvement should account for at least 50% of the session time to ensure the intensity of support. The supervisor (Kan Yuan Cheng) discussed with the occupational therapy weekly and the peer support worker monthly based on the feedback in satisfaction questionnaire by service users and the records in group. Four times of observation by the supervision were also arranged to audit the performance of the occupational therapist and peer support workers in the all sessions of Phase II program. More specifics about this phase of the program can be found in study protocol. Process of assessment The pre- and post-intervention self-report questionnaire was assisted by the occupational therapist ( Meng-Ping Kao). The Brief Psychiatric Rating Scale-18 and Global Assessment of Function scale were measured by board psychiatrist (Kan Yuan Cheng) who had experiences in the multiple-center clinical trial. The assistant and investigator both belonged to the intervention group because there was no control group or blind procedure in the study design. Statistical methods As all indicators examined in this study were continuous variables, the investigators used paired t-test to compare the measurements before and after the intervention. IBM (International Business Machines Corporation) SPSS Statistics 16.0 was employed for statistical analysis.