Promoting mental health through employment and developing healthy workplaces: the potential of natural supports at work

Authors: 
Siporin, S. and Lysack, C.
Year Published: 
2003
Publication: 
Health Education Research
Volume: 
18
Number: 
2
Pages: 
207-215
Publisher: 
Oxford University Press
Background: 

In England, policy developments in the field of mental health are stimulating interest in employment for mental health service users as a means of mental health promotion. To date, research that might assist in increasing employment rates amongst this group has focused largely on the question of which service users are most likely to benefit from vocational interventions and, more recently, on models of vocational support. Less is known about how employers can assist people in their transition or return to work.

Purpose: 

This study draws on the accounts of 17 employment project clients to identify workplace factors that were associated with job retention. Specific objectives were:
(1) To identify a sample of employment support service users who had retained open, competitive employment for 12 months or longer.
(2) To identify a sample where employment had broken down after a period of less than 12 months employment.
(3) To explore the experiences of both groups from their own perspective.
(4) To explore the perspectives of the other key individuals involved, including employment project workers and workplace managers.
(5) To identify factors associated with the success or breakdown of supported employment on the basis of the accounts obtained.

Setting: 

The study was conducted at five project sites in England. Of the five projects, two were based in geographically and demographically diverse areas of outer London (Projects A and B), one operated in a semi-rural area of southeast England (Project C), and one in an urban area of the southeast (Project D). The fifth project (Project E) was based in a Midlands city.

Sample: 

Clients of the five projects who had current or recent experience of open employment were invited to a meeting at their project where the research and what would be involved was explained. As a result of the meetings some clients decided not to take part because they had not disclosed their mental health problems at work, while others who were currently employed had not yet been in their job for a year. These clients therefore withdrew from the study. In total, 10 male clients and seven female clients did take part. Eleven clients had been able to retain open employment for 12 months or longer, while the other six clients jobs had ended within 12 months for reasons they themselves saw as problematic.

Data Collection: 

With participants permission, the interviews were tape recorded and transcribed verbatim. A staged analysis was then carried out. Initially, each job was treated as a case and the 17 cases were divided into jobs that had been retained and jobs that had broken down. Data relating to each case (i.e. the client‚, project worker‚ and manager‚ accounts of a job) were then grouped under broad categories according to whether they related to employment support, workplaces or service users personal circumstances. Data within each category were analysed to generate subcategories within each main category, e.g. workplace factors relating to managers, colleagues and conditions of employment. These were then compared across cases in order to identify those factors that were associated with job retention and job breakdown. As noted earlier, in this article we focus on clients accounts of those factors relating to the workplace.

Intervention: 

Since the aim was to explore clients perceptions of their employment experiences, a semi-structured interview schedule was developed to enable each participant to tell the story of the job concerned from its beginning in the assessment and preparation stage leading up to the job, through its development to its end or to the present time in the case of ongoing jobs. The schedule explored key events during each stage of the job, including client first meetings with their manager and colleagues, their induction, and subsequent significant developments identified by participants themselves. Throughout the interview, participants feelings and attitudes, their accounts of factors which had either positive or negative effects, and their views about what else might have been helpful were explored. Questions were also included to obtain background data, including clients employment and mental health history. The interviews varied in length from 40 min to just over 3 hour.

Control: 

There was no control or comparison condition.

Findings: 

Specific adjustments such as flexibility about working hours, work schedules and job tasks emerged as crucial in enabling clients to deal with the effects of medication, and to regain stamina and confidence. Over and above these, however natural supports of a kind from which any employee would arguably benefit were equally important. In this respect the main themes revolved around training and support to learn the job, supportive interpersonal relationships at work, workplace culture, and approaches to staff management. Themes from the findings might equally provide a productive focus for workplace health promotion more generally, using organization development approaches.

Conclusions: 

On the basis of this study, four organizational initiatives in particular might help to ensure that workplaces are mentally healthy, both for mental health service users starting or returning to work, and for other employees:
Ensuring that a formal period of induction, of sufficient length, is routine practice for all new employees. For many jobs, induction will need to include formal training geared to the employee‚ pace of learning, opportunities to observe colleagues work and the explicit identification of sources of support for tackling problems that arise.
Embedding attention to employees ongoing development in routine workplace practice through formal supervision and appraisal procedures.
Team building aimed at creating a welcoming workplace where difference is accepted and employees strengths are valued.
Training and other learning opportunities, e.g. action learning sets, for managers, covering mental health and safety at work, team building, and individual staff management. Opportunities to explore the boundaries between a friendly, supportive approach and ensuring that work is completed would be particularly valuable, as would training in techniques for providing constructive criticism for employees.

URL: 
http://her.oxfordjournals.org/content/18/2/207.full
Disabilities: 
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Efficacy of the customized employment supports(CES) model of vocational rehabilitation for unemployed methadone patients: Preliminary results

Authors: 
Strickland, D., Coles, C., & Southern, L.
Year Published: 
2004
Publication: 
Substance Use and Misuse
Volume: 
39
Number: 
13
Pages: 
2261-2285
Publisher: 
Informa Healthcare
Background: 

Methadone-maintained patients experience great difficulty with gaining and maintaining competitive employment due to personal barriers and limited vocational services. Federal and state policy reforms require substance users to obtain work or risk losing public benefits. Innovative vocational rehabilitation models need to be tested in order to improve employment outcomes for patients enrolled in addiction treatment programs.

Purpose: 

The purpose of the study was to evaluate a Customized Employment Supports (CES) model designed to improve employment outcomes for unemployed methadone-maintained patients.

Setting: 

The study was implemented at two sites in Manhattan. One is a free-standing methadone clinic operated by Greenwich House, a nonprofit social services agency. The other methadone clinic is operated by Harlem Hospital but is located separately from the hospital.

Sample: 

The study eligibility criteria for methadone patients included the following: unemployed or remarkably underemployed; stabilized on an appropriate methadone dose; negative urine toxicologies for both opiates and cocaine for last 4 tests; absence of any condition that would preclude working (e.g., serious mental illness, developmental disability, severe physical health problem, or time-intensive dependent care responsibilities) and willingness to participate and be randomly assigned to either the innovative vocational program or the clinic‚ existing vocational counseling program. The participants included at total of 135 patients: 79 at Greenwich House's methadone clinic and 56 at the Harlem Hospital's methadone clinic. Participants were randomly assigned to either the customized employment supports vocational model or the clinic's standard vocational program. The final sample included 55 in the experimental group and 66 in the control or a total of 121 patients. Some of the key characteristics of the overall sample at baseline included the following: male (58%); minority group (68%); mean age 44 years (s.d.¬º8.8 years); high school graduate/GED (65%); no paid job within last 6 months (60%); unemployed at study entry (100%); ever arrested (81%); rates own overall health as excellent, very good, or good (62%), but reports having trouble standing for long periods (67%), climbing stairs (73%) and lifting a medium weight (90%); received prior treatment for substance misuse (67%) and mental health problems (53%); has attended some form of 12-step program (79%); and has received public assistance benefits in the past year (82%).

Data Collection: 

The study collected data on patient employment and behaviors from the following sources: baseline interviews of patients prior to before random assignment; patient follow-up interviews at 6, 12, and 18 months later using the same procedure as the baseline but adding measures about the intervention; review of vocational activities log kept by both CES and standard counselors as well as employment documentation. The employment measures drew on and integrated information from these sources since no single source was completed using the combined ordinal outcome measure, the initial analysis was a cross-tabulation of the highest level of vocational activity attained by study condition using the combined ordinal outcome measure. Next, cross-tabulations were conducted between experimental condition and four separate indices of vocational outcomes. Pearson chi square provided the tests of statistical significance across the board. Since the hypotheses involving vocational outcomes were directional predictions (i.e., better outcomes were predicted for the experimental group), single-tailed significance tests were reported. Four dichotomous measures of vocational activities, which constitute the outcome measures for this analysis, were obtained at baseline and at 6-month follow-up: 1. Whether the patient attained any paid job in the previous 6 months. 2. Whether the patient attained a competitive job in the previous 6 months. 3. Whether the patient attained an informal job in the previous 6 months. 4. Whether the patient participated in any other socially constructive, vocationally relevant activity in the previous 6 months. The three basic vocational measures (i.e., competitive, informal, constructive activity) were not significantly associated with each other (p>0.05). To provide a single overall index of vocational outcomes, they were combined into a four-level, ordinal measure of highest level of vocational attainment: 1. Attained a competitive job (highest). 2. Attained an informal job. 3. Performed constructive activity other than paid employment. 4. None of the above (lowest).

Intervention: 

The intervention, the Customized Employment Supports (CES) model, is designed to help patients overcome these employment barriers and attain paid work as soon as possible. The model assigns CES counselors small caseloads so that, using intensive interventions, they can engage patients and enhance their self-efficacy. Methods used to help patients increase their self-efficacy included: role modeling, persuasion, and minimizing emotional arousal.

Control: 

The participants were randomized into intervention and control groups.

Findings: 

Consistent with the study‚ main hypothesis, the experimental group achieved significantly higher levels of vocational activities than the comparison group during the 6-month follow-up. Each of the four measures of vocational outcomes was also evaluated individually. Compared with the standard vocational services group, patients in the CES program were significantly more likely to have obtained any form of paid employment, competitive employment, and informal employment. However, the two groups did not differ significantly on engaging in constructive vocational activities other than paid work.

Conclusions: 

The preliminary results supported the hypothesis for two indices of paid employment, i.e., the CES group was more likely to obtain both competitive employment and informal paid employment. More research is needed.

URL: 
http://www.tandfonline.com/doi/abs/10.1081/JA-200034618?journalCode=isum20
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Evidence-based secondary transition predictors for improving post-school outcomes for students with disabilities

Authors: 
Texler, L. E., Texler, L. C., Malec, J. F., Klyce, D., & Parrott, D.
Year Published: 
2009
Publication: 
Career Development for Exceptional Individuals
Volume: 
32
Number: 
3
Pages: 
1-22
Publisher: 
Hammill Institute on Disabilities and Sage
Background: 

Post secondary school outcomes for youth with disabilities are poor. For example, the National Longitudinal Transition Study 2 Wave 3 data indicated students continue to live with their parents, did not attend post secondary education and had high rates of unemployment as compared to their non disabled peers, after exiting school. The National Secondary Transition Technical Assistance Center had been identifying evidenced based practices to help improve these and other outcomes. The Council for Exceptional Children was also looking for evidenced based practices in Special Education.

Purpose: 

The purpose of this study was to conduct a systematic review of the secondary transition correlational literature using recommended quality indicators to identify in-school predictors of improved post school outcomes for students with disabilities.

Setting: 

This study is a systematic review. The included studies were undertaken in various locations and settings.

Sample: 

One hundred and sixty two articles were identified for review. Sixty three passed an analyses and were passed on for further review. Among these, 35 were excluded which left 28 articles for comparison against a quality of evidence checklist for correlational research. This resulted in 22 articles for final review. Three were exploratory studies and the others were a priori studies related to students with disabilities.

Data Collection: 

The remaining studies were examined for the following: population, sample size, predictor variables, postschool outcome variables, type of statistical analysis used, relationships among variables, significance levels, and data that allowed for calculation of effect sizes. It was not possible to extract conclusions across studies, so the researchers chose to convert significant relationships to standardize effect size measures to allow comparisons. Various conversions were calculated.

Intervention: 

The interventions were various transition practices.

Control: 

There were no comparison or control conditions.

Findings: 

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.

Conclusions: 

The results from this review provide information to help practitioners improve post school outcomes for students with disabilities. Combining knowledge gained from this review with evidenced based instructional practices should provide state and local education agencies with a foundation to improve programs and thereby increase post school outcomes.

URL: 
http://sites.bu.edu/miccr/files/2015/03/Evidence-based-secondary-transition-predictors-for-improving-post-school-outcomes-for-students-with-disabilities.pdf
NIDILRR Funded: 
Peer Reviewed: 
Yes

Workforce re-entry for people with HIV/AIDS: Intervention effects and predictors of success

Authors: 
Martin, D., Chernoff, R., & Buitron, M.
Year Published: 
2006
Publication: 
Work
Volume: 
27
Number: 
3
Pages: 
221-233
Publisher: 
IOS Press
Background: 

Treatment that prolongs the lives of people with HIV/AIDS and improves their quality of life is relatively recent. Little is known about factors that may predict their successful re-entry to the workforce. No data exist concerning the effectiveness of programs to assist people with HIV/AIDS in their efforts to return to work.

Purpose: 

The purposes of this study were to (1) identify factors predicting workforce re-entry among a group of participants in a workforce-reentry demonstration project for people with HIV/AIDS; and (2) determine whether an intervention designed to help people with HIV/AIDS return to work was successful.

Setting: 

Participants were recruited from community-based service agencies in the southern region of Los Angeles County, CA. The intervention was coordinated by the Career Transition Center (CTC) in Long Beach, CA but was delivered at various local centers. The CTC offers an array of services, including resume writing, guided and self-directed job search, vocational counseling, job training and job placement.

Sample: 

A total of 235 participants were recruited into the workforce reentry demonstration project from local community agencies. Entry criteria included the following: (1) an HIV/AIDS
diagnosis, (2) disabled/unemployed (exceptions to this were individuals working part time under the table or volunteering), (3) receiving medical care for their HIV/AIDS conditions, (4) enrolled in an HIV/AIDS case management program, and (5) contemplating workforce re-entry. The mean age was 40, and was predominantly males who were sexually active with other males.

Data Collection: 

Program participants and comparison respondents completed questionnaires that included demographic questions, measures of income and income source, health indices, an interview and a questionnaire related to current and prior employment status. Descriptive statistics were calculated for all variables. Chi-square tests were used to compare the intervention group with the comparison group for categorical variables and a combination of t-tests and Wilcoxon rank-sum tests were used for continuous variables.

Intervention: 

The intervention tested was a work re-entry program that included vocational assessments, counseling, case management, job search assistance, and job placement. In addition, tuition assistance was provided for training through independent training institutions and local community colleges.

Control: 

Fifty-one comparison respondents were recruited from the same community agencies as the intervention participants. These individuals met the same requirements as intervention participants with the exception that they were not seeking to re-enter the workforce. They were not provided with an alternative treatment.

Findings: 

Of the 235 enrolled participants, 172 completed at least one follow-up. Of this group, 90 were in some form of work at baseline, but 46 stopped working at some time later in the study and their time to return to work was reset to start at the time that they stopped working. Participants in the intervention condition were more likely to return to work than those in the comparison group. In addition, men, those in relatively poor health, those receiving either Social Security or state disability income and those with higher incomes at baseline were less likely to return to work.

Conclusions: 

The study provides evidence for the efficacy of return to work services for individuals with HIV/AIDS. Those who completed the intervention were more likely to return to work and to return to work more quickly. Although lengthier interventions may be needed for some individuals with HIV/AIDS seeking workforce re-entry, the ?findings suggest that even limited assistance may be useful to individuals seeking to return to work following a period of disability.

URL: 
http://content.iospress.com/articles/work/wor00565
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Tailoring a vocational rehabilitation program to the needs of people with HIV/AIDS: The Harbor-UCLA experience

Authors: 
Mateer, C. A. & Sira, C. S.
Year Published: 
2005
Publication: 
Journal of Vocational Rehabilitation
Volume: 
22
Number: 
2
Pages: 
95-103
Publisher: 
IOS Press
Background: 

New treatments introduced in the early to mid-1990s have led to improved health and quality of life for many people with HIV/AIDS. These increased health and quality of life improvements have prompted some to consider workforce reentry.

Purpose: 

The purpose of the paper is to provide an overview of the work done in the three study projects to assist people with HIV/AIDS in reentering the workforce.

Setting: 

The setting was various community mental health centers.

Sample: 

Three projects were undertaken. The first included a series of focus groups of people with HIV/AIDS that had contemplated going back to work and a survey of HIV/AIDS case management clients. The second project was a 5 year demonstration program to integrate vocational rehabilitation services, psychosocial care, and HIV treatment. The program accepted referrals from community agencies in the Long Beach area of Los Angeles County. The third project was a clinical trial of an intervention to address issues observed in the demonstration project.

Data Collection: 

Participants are followed for 24 months by a case manager to gather employment data.

Intervention: 

The intervention was vocational rehabilitation and job training services in conjunction with HIV/AIDS related services.

Control: 

The control group received standard treatment conditions available in the community.

Findings: 

Of the first forty-seven people randomized into the enhanced condition, over a third have made some measurable progress. The return to work rates of the two conditions have not been compared yet.

Conclusions: 

There is a continued need for workforce reentry services for individuals with HIV/AIDS.

URL: 
http://content.iospress.com/articles/journal-of-vocational-rehabilitation/jvr00277
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Vocational rehabilitation service patterns related to successful competitive employment outcomes of persons with spinal cord injury

Authors: 
Martin, D. J., Arns, P. G., Batterham, P. J., Afifi, A. A., & Steckart, M. J.
Year Published: 
2008
Publication: 
Journal of Vocational Rehabilitation
Volume: 
28
Number: 
1
Pages: 
1-13
Publisher: 
IOS Press
Background: 

It is well documented in the literature that the employment rate of people with spinal cord injuries (SCI) decreases drastically after their injuries. Because of the importance of work to the physiological and psychological health and well being of persons with a disability, considerable research efforts have been devoted to studying the employment problems of persons with a spinal cord injury. Over a half of a million individuals are served by state vocational rehabilitation agencies each year, making it possible to study a large number of persons with SCI who are living in the community.

Purpose: 

To examine the effect of demographic, work disincentives, and service variables on employment outcomes of persons with spinal cord injury in state vocational rehabilitation agencies.

Setting: 

This study included individuals with SCI served by multiple vocational rehabilitation agencies in various settings.

Sample: 

10,901 persons with spinal cord injury whose cases were closed either as employed (54%) or not employed (46%) by state vocational rehabilitation agencies in the fiscal year 2001.

Data Collection: 

An ex post facto design, using data mining as a statistical analysis strategy. Data was taken from the RSA-911 report for all the persons with SCI closed by State Vocational Rehabilitation agencies in 2001. A chi-squared automatic interaction detector (CHAID) based data mining analysis was used to identify the strongest associations between predictors (VR services) and the outcome variable (employment outcomes).

Intervention: 

The interventions were the range of Vocational Rehabilitation Services received by the study sample of persons with a Spinal Cord Injury. These services included, but were not limited to, rehabilitation engineering, personal assistance services, assistive technology services, job placement, counseling and guidance, and assessment services.

Findings: 

The CHAID data mining analysis revealed that job placement services, work disincentives, and case expenditures as the most important predictors of employment outcomes. In addition, physical restoration, substantial counseling, and assistive technology services all led to positive employment outcomes. Importantly, the CHAID analysis segmented the sample into 45 mutually exclusive homogeneous end groups, with a wide range of employment outcomes. The CHAID analysis indicated that demographic variables interacted with rehabilitation services to affect employment outcomes.

Conclusions: 

The results confirmed substantial counseling, assistive technology, and job placement and support services are important to the return-to-work success of persons with SCI.

URL: 
http://content.iospress.com/articles/journal-of-vocational-rehabilitation/jvr00399
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

The effectiveness of artificial intelligent 3-D virtual reality vocational problem-solving training in enhancing employment opportunities for people with traumatic brain injury

Authors: 
Marini, I., Lee, G. K., Chan, F., Chapin, M. H., & Romero, M. G.
Year Published: 
2013
Publication: 
Brain Injury
Volume: 
27
Number: 
9
Pages: 
1016-1025
Publisher: 
Informa Healthcare
Background: 

Individuals who sustain traumatic brain injuries face a myriad of cognitive and other disabilities post injury. Deficits in executive functioning are one of the major problems that impact work. Psychosocial educational interventions and computer assisted training have helped some individuals learn to problem solve. Virtual reality may also be a useful tool.

Purpose: 

This study explored whether or not participants with artificially intelligent VR based vocational problem solving skill training would show better problem solving skills and employment outcomes, than those who received conventional psychosocial program.

Setting: 

The training modules were developed at a University lab in Hong Kong. Where the study took place was not clear.

Sample: 

The study sample included 40 people from Hong Kong with mild (N=20)and moderate (N=20) traumatic brain injury. Participants were randomly assigned to one of the two study groups.

Data Collection: 

The Wisconsin Card Sorting Test and the Tower of London Test were administered to participants. In addition, the Vocational Cognitive Rating Scale was completed by the participant's case manager or supervisor of a rehabilitation facility or center. After the pretest each participant started either the virtual or psychosocial training. The content and structure of the two programs were similar. Each included an introduction to training objectives, training in specific vocational skills and practice and a review of those skills. The virtual program was interactive in nature. The psycho educational vocational training system included a training manual and was delivered under the guidance of a trainer. Post test were also conducted on the previously cited measures. Information about the participants employment status was collected at one, three and six month intervals. Statistical analysis were performed using SPSS for Windows Version 17.

Intervention: 

The intervention was an artificial intelligent virtual reality-based vocational problem solving training program. Participants took part in 12 sessions that lasted 20 to 25 minutes each.

Control: 

The control condition was traditional psycho-educational training.

Findings: 

There was no significant differences in the participants in screening criteria or baseline of outcomes between the virtual training and psycho education program. Those who participated in the virtual training showed improvements in selective cognitive functioning. However, the training did not transfer to functional real world outcomes, as indicated by limited success in vocational outcomes. The virtual training was more cost effective than workshop based training.

Conclusions: 

Virtual reality training may improve memory functioning and have other applications for vocational rehabilitation. More research is needed.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/23662639
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

A medical/vocational case coordination system for persons with brain injury: An evaluation of employment outcomes

Authors: 
Man, D. W. K., Poon, W. S., & Lam, C.
Year Published: 
2000
Publication: 
Archives of Physical Medicine and Rehabilitation
Volume: 
81
Number: 
8
Pages: 
1007-1015
Publisher: 
Elsevier
Background: 

The present study tested a Medical/Vocational Case Coordination System (MVCCS) designed for persons with brain injury. The MVCSS, which was based on knowledge gained from the research literature and from clinical experience in medical and vocational rehabilitation for persons with BI, emphasize early intervention and coordinated service delivery through integrated medical center based and community-based services. Early intervention was emphasized to reduce the time between injury and community reintegration and to reduce the associated psychosocial complications that may result from lack of early intervention. The MVCCS was expected to maximize participants vocational and independent living outcomes and to minimize the use of medical and community resources.

The researchers review of previous research supported the belief that an intervention system for improving vocational outcomes of persons with BI must include these features: (1) early case identification and coordination, (2) appropriate medical and vocational rehabilitation interventions, (3) work trials, and (4) temporary or long-term supported employment in appropriate cases. To be viable, the system must significantly improve on the benchmark of 60% unemployment with results at least equivalent to those of earlier intervention studies; that is, approximately 75% of participants in community-based employment: approximately 50% working without long-term supports and approximately 25% in long-term, community-based, supported employment or in educational or training programs. They studied vocational outcomes of the MVCCS over a 4-year period.

Purpose: 

To evaluate initial placement and 1-year employment outcomes of a Medical/Vocational Case Coordination System (MVCCS) for persons with brain injury (BI) that provides: (1) early case identification and coordination, (2) appropriate medical and vocational rehabilitation interventions, (3) work trials, and (4) supported employment interventions including job coaching. The study design evaluated 2 hypotheses. The first hypothesis was that vocational outcomes will meet or exceed those reported previously, that is, (1) 75% of participants in community-based independent or supported community-based employment or education/training programs (Vocational Independence Scale [VIS] levels 3 to 5); and (2) 50% of participants in independent community-based employment (VIS level 5). The second hypothesis was that vocational outcomes will be related to (1) severity of injury, (2) severity of impairment/disability, (3) ISA, (4) time since injury, (5) presence of additional non-brain injuries, and (6) preinjury educational/vocational status.

Setting: 

The setting was a large urban medical center.

Sample: 

One hundred fourteen Minnesota residents with traumatic or other acquired brain injury between the ages of 18 and 65 years. The majority (or 64%) had TBI followed by CVA (26%) and other (10%). The largest portion (36%) of the sample was referred for vocational services through outpatient rehabilitation evaluations. Severity of injury was classified only in TBI cases, based on results of available initial Glasgow Coma Scale (GCS) score and duration of loss of consciousness (LOC) at the time of injury; 56% were classified as severe TBI. Among all participants N=114, the majority (61%) were male. Mean age was 37.4. Preinjury education was less than 12 (22 %); 12 to 15 years (61%) and greater than 16 years (17%). Sixty nine percent were working prior to injury and 77% had an independent living status. The mean time since injury for the group was 65.5 months with a median of 12.7 months.

Data Collection: 

Vocational outcome at time of initial placement and at 1-year follow-up was measured using the Vocational Integration Scale. The Mayo-Portland Adaptability Inventory (MPAI), a scale based on the Portland Adaptability Inventory was used for rating the range of physical, cognitive, emotional, and social impairments and disabilities resulting from BI. It was completed by rehabilitation staff, the patient and a significant other. Rating scale (Rasch) analyses of the Staff MPAI based on 305 assessments led to a reduction in the number of items from 30 to 22 by eliminating non-contributing items. An indicator of Impaired self-awareness ISA was item 24 from the Staff MPAI, which rates level of indifference or lack of awareness of deficits. The second indicator of ISA used was the difference between the Rasch-converted score for 22-item Staff MPAI and the Rasch-converted score for the 22-item Survivor MPAI. Preinjury vocational status, the presence of other non-brain injuries, time since injury, and the Rasch-transformed Staff MPAI appeared to have some value in predicting the level of initial vocational placement. At 1-year follow-up, vocational status was predicted by time since injury and Rasch Staff MPAI. The VIS at initial placement also significantly predicted VIS at follow-up (Spearman coefficient 5 .75, n 5 101, p, .0001). The efficiency of services (i.e., months to placement) was significantly predicted by preinjury education, injury severity, time since injury, Rasch Staff MPAI, Rasch Survivor MPAI, and the difference between the Rasch Staff MPAI and Rasch Survivor MPAI. To control for experiment-wise error, potential predictor variables were further scrutinized using regression analyses.

Intervention: 

The MVCCS interfaced a medical center based BI Nurse Case Coordinator (NCC) with a medical-center based BI Vocational Case Coordinator (VCC) who served as a liaison to community-based services. This interface provided: (1) early identification by the NCC of individuals needing medical
services, medical rehabilitation, vocational rehabilitation, and social services; (2) late identification of other persons with chronic impairments after BI and their service needs by either the NCC or the VCC; (3) personal vocational counseling, consumer advocacy, and on-site consultation to other vocational services provided by the VCC; (4) access to community-based vocational services through the VCC that included: vocational evaluations, supported work trials, long-term community- based supported employment, job coaching, job development, and job placement; (5) access to other community based services that support employment, such as independent living services, community-based social services and mental health services, and traumatic brain injury (TBI) waivered services, including behavioral aide services; and (6) access to medical center services that enhance vocational re-entry for persons with BI, such as a CI day rehabilitation program; a 3-hour weekly community reintegration group; individual cognitive rehabilitation; medical rehabilitation services such as standard rehabilitation therapies, work hardening, and physical work assessments; neuropsychological and psychiatric services, including psychotherapy, family therapy, behavioral medicine, and substance abuse treatment; and other medical diagnostic and therapeutic services, including psychiatric and behavioral neurology services.

In the day-to-day operation of the MVCCS, the NCC, working with emergency room staff, identified all brain-injured
persons admitted to the hospital each working day and served as case coordinator for these cases. She reviewed the medical record, met with the patient, recommended additional services to the primary medical service, obtained consent, and entered participants into the clinical database. The NCC followed the patient after dismissal from acute care. If the patient left from acute care to home, she followed up by telephone within 1 month to identify potential BI sequelae and service needs and to assist in scheduling required services. If the patient left acute service to the rehabilitation unit, the NCC turned medical case coordination over to the rehabilitation social worker. In all cases referred, the VCC met with study participants and obtained consent for study participation, provided all appropriate vocational evaluations and counseling, completed the Staff MPAI with input from other involved rehabilitation staff, obtained the Survivor MPAI, and referred appropriate participants to community-based vocational services. The VCC followed up on each participant 1 year after the person was placed or left the project.

Control: 

There was no comparison condition. Participants served as their own controls.

Findings: 

he MVCCS evaluated in this study appeared to substantially improve employment outcome for persons with BI without interventions. Results were better than projections based on the previous literature 80% of those served were placed in community-based work with 46% in independent community-based employment. Employment outcomes for persons who received vocational services through this project approached or exceeded outcomes reported previously for intensive rehabilitation interventions. Just as importantly, initial vocational placements were maintained at 1-year follow-up. At the follow-up interview, 81% were working in the community and 53% were employed independently without job supports. Although the results were equivalent to those of other rehabilitation programs that are based on best practices the authors could not make direct comparisons with those programs because we did not investigate specific interventions. Primary predictors of initial placement in the present study were time since injury and overall impairment/disability as measured by the Staff MPAI. Return to previous work should be considered especially for the more recently injured who have retained ties to their previous employer. Results indicate that more severe impairments and disabilities, as measured by the MPAI, are significant barriers to employment in the general population of persons with BI. However, for persons with TBI, the presence of additional non-brain injuries appears to be a more important factor.

The best predictor of employment level at 1-year follow-up was the level of initial placement. ISA (as measured by the difference between Rasch Staff MPAI and Rasch Survivor MPAI) did not contribute to the prediction of either initial placement or job maintenance. This finding is inconsistent with some other studies reporting an association between ISA and long-term employment after BI. The results suggest that ISA may be a barrier to employment that can be overcome through rehabilitation, through education and support for employers, and by discriminating placement of those persons with ISA in work environments that are more tolerant of limitations in self-awareness. Overall level of impairment and disability also appears to be a factor in time required for placement. In some cases, more intensive rehabilitation efforts, such as a CI day rehabilitation program, were required for more severely disabled persons so they could develop cognitive compensation, communication, behavioral self-management, social, and other pre-vocational skills required for eventual placement. Because of the time required for participation in such an intensive rehabilitation program, most individuals who participated in CI day rehabilitation required 6 to 12 months from the time they were admitted to services to their eventual placement. Our data suggest that most placements (92%) can be made within 1 year of admission to services. Preinjury years of education also contributed slightly to prediction of time to placement, with more highly educated individuals being placed more quickly.

Conclusions: 

Introducing a VCC into an MVCCS program appears to optimize participants vocational outcome after BI, resulting in community-based employment for 81% of persons served with 53% working independently in the community 1 year after placement. Time since injury and overall level of impairment/ disability were the most significant factors in predicting vocational outcomes. Beyond its association with overall level of disability and chronicity, ISA did not contribute to the prediction of initial placement or job maintenance. The best predictor of employment status at 1 year follow-up was the level of initial placement. Persons with greater overall disability required more extended time and more extensive rehabilitation services before job placement.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/10943747
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Impact of comprehensive day treatment on societal participation for persons with acquired brain injury

Authors: 
Malec, J. F., Buffington, A. L. H., Moessner, A. M., & Degiorgio, L.
Year Published: 
2001
Publication: 
Archives of Physical Medicine and Rehabilitation
Volume: 
82
Number: 
7
Pages: 
885-895
Publisher: 
Elsevier
Background: 

Employment rates for individuals with disabilities are poor and contribute to the ongoing high poverty rates for this group. Although overall employment rates have risen over the years, work outcomes for young adults with disabilities still lag behind those without disabilities. Career development takes place overtime and is influenced by multiple variables such as individual, family, school, and community factors. However, for individuals with disabilities, career development is often complex, nonlinear, and chaotic. High school and post-school services can have a positive impact on employment for youth with disabilities. Students with disabilities who participate in vocational courses and community based work experiences are more likely to obtain and maintain employment after high school. Additionally, participation in adult services like vocational rehabilitation or post secondary education or training can lead to better job opportunities. Research studying patterns of career development for successfully employed adults with disabilities may be able inform clinical practices through the identification of common themes that influence employment in living wage occupations.

Purpose: 

There were 2 hypotheses. The first was that vocational outcomes will meet or exceed those cited in prior research. Specifically, 75% of participants in community-based independent or supported community-based employment or education/training programs; and (b) 50% of individuals in independent community-based employment. The other hypothesis was vocational outcomes will be related to (1) severity of injury, (2) severity of impairment/disability, (3) ISA, (4) time since injury, (5) presence of additional injuries not related to the brain injury, and (6) preinjury educational/vocational status.

Setting: 

The setting was a Rehabilitation Center.

Sample: 

One hundred and thirteen individuals with brain injury, who were consecutively admitted to the CDT program from 1988 to 1998. This included 96 individuals who completed the program and 17 who did not. Traumatic brain injury accounted for the majority or 72% of the participants who completed the program and 71% of the drop outs. The severity of the TBI sample was 82% and 92% respectively. The mean time since injury (TBI, CVA or other) among those who completed the program was 4.6 years.
The subjects had myriad of problems in the following areas post injury: self awareness, cognitive, communication, social skills and emotional/behavioral.
They were also either unemployed or facing failure at work. Participants had mobility, functional communication skills and exhibited some capacity for applying new knowledge. The average length of stay among participants in the CDT program was 189.5.

Data Collection: 

Evaluation and outcome data were analyzed for each participant. For those who completed the program, work outcomes was measured using the Vocational Independence Scale at program end and 1-year follow-up and Rasch-analyzed Mayo-Portland Adaptability Inventory (MPAI-22) and goal attainment scaling (GAS) at program end. Data was collected from the Independent Living Scale, VIS, GAS and MPAI-22 when participants entered and exited the program to measure this factor. Logistic regression analysis was conducted for the ILS and VIS were for those who completed the program one year post completion with potential outcome predictors that included: age, education, severity of injury, type of injury, time post injury, degree of impairment prior to program participation.

Intervention: 

Participants attended a CDT that followed guidelines developed by prior research for post acute brain injury rehabilitation programs, along with the following changes: combination of physical therapy and recreation therapy into a Life Skills Group, family education and use of a vocational counselor to provide employer education and support.

Control: 

There was no control or comparison condition.

Findings: 

Significant goal achievement on GAS and improvement on MPAI-22; increased societal participation at 1-year follow-up for those treated post acutely and many years after injury: 72% of graduates living independently; 39% working independently, 10% in transitional placements, and 18% in supported or volunteer work. Long-term outcomes were modestly related linearly to preadmission MPAI-22 and nonlinearly to time since injury.

Conclusions: 

Community Day Treatment program improves participation in society for individuals with brain injury. Next steps needed are randomized control trials of active treatment components. Relationships of predictors to outcomes are not sufficiently strong for patient selection. More effective interventions for vocational reintegration are needed for individuals with severe brain injury.

URL: 
https://www.archives-pmr.org/article/S0003-9993(01)74722-3/fulltext
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Evidence of the effectiveness of a specialist vocational intervention following first episode psychosis: a naturalistic prospective cohort study

Authors: 
Malec, J. F.
Year Published: 
2010
Publication: 
Social psychiatry and psychiatric epidemiology
Volume: 
45
Number: 
1
Pages: 
1-8
Publisher: 
Springer
Background: 

Employment rates among people with severe mental illness are low and work has beneficial effects on mental health. There is now good evidence of the effectiveness of a specialist vocational intervention (supported employment) in people with schizophrenia. However, the potential benefits of modifying this model for use in first episode psychosis cohorts remain relatively untested.

Purpose: 

The aim of our study was to evaluate the effectiveness of a specialist vocational intervention in aiding vocational recovery following the onset of first episode psychosis. In a naturalistic prospective cohort study, 114 first episode psychosis service users were followed up during 12 months of engagement with an early intervention service; 44 resident in an area where a vocational intervention was available and 70 in an area where it was not.

Setting: 

The study was conducted within an early intervention service serving two multi-ethnic, socioeconomically diverse inner-city London boroughs.

Sample: 

The study sample consisted of consecutive new referrals (age 17–35 years), taken on for case management within the early intervention service between 2003 and 2006, for a period of at least 12 months. Within the service and for the purpose of this study first episode psychosis was as the presence of psychotic symptoms (clinically delusions, hallucinations, passivity experiences or severe thought disorder) that have persisted for at least 1 week and/or resulted in hospital admission or crisis team intervention. Patients were excluded if they had already taken antipsychotic medication at a therapeutic dose for at least 6 weeks, previously been diagnosed with a psychotic illness by a specialist mental health service, were considered to be prodromal, or their symptoms appeared to be secondary to a personality disorder, post-traumatic stress disorder or were clearly drug-induced (narrowly ).

Data Collection: 

Routine standardized data was collected on all clients at baseline and 12 month follow-up using the MiData (minimum dataset) package. This is a Microsoft Access database that was specifically designed as a clinician friendly tool to be incorporated into routine clinical practice

Intervention: 

The intervention represents a locally derived modification of the supported employment model. It is consistent with the model in that the service is embedded within the mental health team. Choices are based on individual preference, competitive employment is a major aim, and follow on support indefinite. Where it differs is in the greater emphasis on education (necessary in view of the typical developmental age of onset of first episode psychoses) and use of a broader approach, beyond just rapid job placement, to address specific areas of vocational functioning in the early stages of recovery (for example rebuilding confidence and structuring time).

Control: 

There was no control or comparison condition.

Findings: 

The main finding in our study was that having access to the specialist vocational intervention was a statistically significant independent predictor of vocational recovery during 12 months of follow-up (after adjusting for confounders). Service users who had access to the intervention had odds of achieving vocational recovery 3.53 times greater than those who did not.

Conclusions: 

This study provides further preliminary evidence of the effectiveness of a specialist vocational intervention following first episode psychosis. This is an important outcome from the perspective of service users and clinicians alike (as well as having wider societal value). Other important predictors of vocational recovery cannot be modified by the time a first episode psychosis emerges.

URL: 
http://link.springer.com/article/10.1007/s00127-009-0034-4#/page-1
Disabilities: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes