Systematic reviews and meta-analysis

There were 20,249 records found after the initial search. After screening, 70 records remained to be evaluated in full-text. Of those 70, 58 records were excluded with reasons. This left 12 studies to be evaluated in the quantitative synthesis. Of the 10 studies that included measures of employment status, those that were randomized controlled trials (RCTs) showed no significant difference when examined alone. When combined with Quasi Experimental Designs (QEDs) the weighted mean effect size for employment status was OR= 2.18, p=.002. Two studies measured number of hours worked, and showed no significant results, OR = 0.89, p =.67. Four RCTs measured sick leave and results were nonsignificant OR = 1.18, p =.39.

Implementing supported employment services with high fidelity to the IPS model clearly improves competitive employment outcomes.

The most consistent predictors and indicators of employment outcomes included premorbid occupational status, functional status at discharge, global cognitive functioning, perceptual functioning, executive functioning, involvement in vocational rehabilitation services and emotional status. The authors note that although the presence of specific characteristics may be a predictor for failure to return to work the absence of a factor does not guarantee return to work.
There is little evidence to support cognitive rehabilitation. The most successful programs target problems with motivation and emotional disturbance. Interventions to modify the social environment need to occur on multiple levels. A person's preferences for employment impact job retention. Supported employment has been described however, further evaluation of outcomes is needed. At a policy level a major barrier exists in the current service delivery system in which individuals do not have access to long term rehabilitation or specialized vocational support. Changes in public policy and funding could improve service delivery. Developing disability management programs may also assist those at risk for chronic unemployment post TBI.

Results indicated that the average rate of any employment after SCI was approximately 35%. The review of literature indicates that there are 11 factors associated with employability of individuals with SCI. This includes education, type of employment, severity of disability, age, time post injury, sex, marital status, social support, vocational counseling, medical problems associated with SCI, employer role, environment, and professional interests. Individuals with college backgrounds are more likely to return to work. Being younger at the time of injury is associated with the best employment outcomes. The probability of employment after SCI improves with increasing time since injury. Race is also associated with obtaining employment after SCI. Individuals who are white are more likely to be employment than those from minorities. Evidence-based supported employment seems to be the most applicable model for assisting individuals with SCI in restoring meaningful employment.

The search led to 22,878 autism related intervention studies. After reviewed using a broad inclusion criteria, the number was reduced to 3974. Of the 3974, 501 targeted individuals 18 and over. These were reviewed for specific elements related to vocational intervention and outcome. In total 10 articles were identified. The following categories were found: supported employment comprising of community placement and jobcoaching (8 studies); technology-related applications including media and online use (2 studies).Of the 10 studies identified four focused on individuals with Asperger's Syndrome, and most include a substantial portion of more cognitively able adults with ASD. The literature focuses on using a supported employment approach with an emerging focus on technology related tools.

Only five studies, related to on the job supports and employment and vocational interventions were found. All of these received a poor quality rating by the reviewers which may be due to the fact that this is a new area of research. The studies included one non randomized trial that looked at the impact of supported employment versus sheltered work settings for 55 young adults with autism. A related study from the same researchers looked at the effect of supported employment versus sheltered work on the cognitive development of 44 young adults with autism. Two cohort studies and one cross sectional study reported on the influence of vocational interventions on independent living outcomes.

A review of the literature identified 16 evidence-based in school predictors of post-school outcomes. These include: career awareness, community experiences, exit exam requirements/high school diploma status, inclusion in general education, interagency collaboration, occupational courses, paid employment/work experience, parental involvement, program of study, self advocacy/self determination, self-care/independent living skills, social skills, student support, transition program, vocational education and work study. Some negative findings were also found. Two studies reported negative relationships between secondary transition predictors and one or more post school outcomes. Among the 16 predictor categories: inclusion in general education, paid employment and work experience, self care/independent living, and student support improved outcomes in all 3 post school outcome areas.

Job development helped participants obtain competitive employment. Individuals who received job development sere almost five times more likely to obtain competitive employment than individuals who not received job development. Individuals with no previous work experience had virtually no chance of acquiring competitive employment without job development.
A significant association between months in the first competitive job and receipt of job support was found.

Rehabilitation counselors in state vocational rehabilitation agencies use some services that are supported by strong scientific evidence. These include: counseling, skills training, and supported employment. Several researchers have also investigated the overall effect of state vocational rehabilitation services.
In addition, promising practices have been identified by four state case studies that resulted from research by the Rehabilitation Research and Training Center on Evidenced Based Practices in Vocational Rehabilitation. From this work, a number of promising practices, that are currently used by state vocational rehabilitation emerged. Related to organizational and management, best practices included: advocacy, culture leads to innovation, outcome focused business models, advanced information technology, collaborative partnerships that enhance results, staff training and development. Transition from school to adulthood, individual placement and supported employment model, workplace specialized skills training, benefits counseling and workplace supports were identified as clinical service delivery promising practices.

The research team reviewed, analyzed and discussed the findings from this and other studies to identify gaps in research and make recommendations about future directions.
These included investigating the Human Service Value Curve framework to identify where human service agencies fall and move beyond the use of the basic regulatory collaborative business model towards a integrative/generative business model. In terms of the gaps in research there is a need to convene a panel of scholars, policymakers and administrators representing business, management, human service administration, vocational rehabilitation, and information technology fields. This panel would identify essential features of an integrative/generative business model for leadership and management in state vocational rehabilitation. Research is also needed to develop and validate an effective diffusion of innovation measure in vocational rehabilitation agencies. Instead of relying on old business systems vocational rehabilitation needs to investigate advanced health technologies aimed at becoming more consumer rather than professional centric. Research is needed about how to recruit, retain and engage vocational rehabilitation professionals to provide customized and effective services based on innovations and communication technologies. Some of the evidenced based practices identified have not been comprehensively evaluated. Using the International Classification of Functioning, Disability and Health (ICF) model to develop a systematic vocational rehabilitation agenda may allow researchers to quickly identify and validate best practices that can be integrated into state vocational rehabilitation practices. Knowledge translation is gaining recognition in the field. The Knowledge to Action framework may prove useful. Knowledge Translation should be bidirectional and participatory in nature. Embedding such methods into future research and program evaluation should promote continued collaboration between researchers and practitioners and transfer research findings to practice. It should also help improve outcomes, including relationships with employers. And again, providing evidenced based tools and practices to vocational rehabilitation counselors and administrators to improve employment outcomes for individuals with disabilities will result from Knowledge Translation.

The evidence base for the effectiveness of IPS within a UK context is small. There is promising evidence, including from a high quality RCT, that IPS is more effective than conventional training and place vocational rehabilitation in placing people into competitive employment. However, the quality of the evidence was generally weak. Several studies lacked adequate controls, meaning potential confounding factors were not controlled for.