Male &amp; Female

Populations:

Outcomes:

Other

NIDILRR Funded:

Research Design:

Peer Reviewed:

Yes

SESAMI* study of employment support for people with severe mental health problems: 12-month outcomes

Authors:

Schoenbaum, M., Unützer, J., McCaffrey, D., Duan N., Sherbourne, C., & Wells, K.

Year Published:

2009

Publication:

Health & Social Care in the Community

Volume:

Number:

Pages:

151-158

Publisher:

Blackwell Publishing Ltd.

Background:

Individuals with severe mental illness are underrepresented in the workforce in the United Kingdom. A welfare to work policy was implemented. Guidelines recommend using evidenced based practices, the Individual Placement and Support model, to help people with mental health issues with gaining and maintaining work. It is important to understand what is currently going on to improve existing practices.

Purpose:

This study was undertaken to learn about factors associated with successful employment and the impact of work on individuals with mental illness.

Setting:

Six British agencies that specialized in providing services to individuals with mental illness.

Sample:

One hundred and eighty two individuals with mental health problems participated in the study. Follow up interviews were conducted with 85% of this sample. The majority or 84% were White British or European. Ages ranged from 22 to 67 years with an mean of 42 years. About a third, or 32% reported depression, 25% anxiety, 25% schizophrenia, hallucinations or hearing voices, 14% bipolar and 4% other in response to being asked to describe his or her condition. Fifty five percent of the participants were unemployed, 29% were unemployed, 9% were in work placement and 5% in sheltered work.

Data Collection:

The study questionnaire included the following measures. The Empowerment Among Users of Mental Health Services Scale; the Herth Hope Index, Perceived obstacles to work; and behaviours indicating nearness to the labour market. This questionnaire was usually completed during an approximately one hour face to face interview. The first was completed at baseline and another at follow up (12 months later).Statistically significant differences were tested. Analysis of variance was also used. SPSS 15.0 was used to analyze all data.

Intervention:

The intervention was supported employment in the United Kingdom.

Control:

There was no comparison or control group.

Findings:

Eighty two percent of those working at baseline were employed one year later. Twenty five percent of those individuals who were unemployed were assisted with gaining work during this time. Financial satisfaction and self esteem increased among those who went to work. In addition, there was a tendency to work part-time.

Conclusions:

Those who worked reported multiple benefits. The evidence from this study should inform service planning and the Individual Placement and Support model should be implemented in England.

URL:

https://www.researchonline.org.uk/sds/search/taxonomy.do%3Bjsessionid=948B7FBF03C6A71157E4FD25729AE479?action=document&ref=A20206&pager.offset=140&taxonomy=GIN

Disabilities:

Populations:

Outcomes:

NIDILRR Funded:

Research Design:

Observational

Peer Reviewed:

Yes

A comparison of competitive employment outcomes for the clubhouse and PACT models

Authors:

Secker, J., & Membrey, H.

Year Published:

2006

Publication:

Psychiatric services

Volume:

Number:

Pages:

1416-1420

Publisher:

Psychiatric Services

Background:

The unemployment rate among individuals with severe mental illness is high, ranging from 67 to 85 percent. Many studies focus on job placement rates without considering job retention. Supported employment programs vary a lot and no single definition exists. Furthermore, the rapid placement guideline may mean that a lack of job readiness may be impacting an individual's success at work. The clubhouse model to employment may be able to help individuals gain and maintain work at higher rates than other approaches.

Purpose:

The goal of this study was to determine if a clubhouse model could achieve and maintain employment rates comparable to the Program of Assertive Community Treatment model of supported employment.

Setting:

The study was conducted in Western Massachusetts Genesis Club.

Sample:

The study sample included 177 individuals who data was collected over a four year time period. All had a diagnosis of bipolar disorder, depression or schizophrenia and were 18 years of age or older. They were not screened for work readiness and interest in work was not required.

Data Collection:

After acceptance into the study the Positive and Negative Syndrome Scale was conducted. Interviews were also conducted at baseline and then every 6 months over two and half years. Questions related to symptoms, jobs, hospitalizations and more. Program staff tracked job information. Employment data was also provided by staff or through interviews with participants. Each participant was followed for the study period or until he or she exited services. Time based analyses compared weekly employment and job placement rates for participants in each group. Binary employment outcomes were analyzed with generalized estimating equations of the Genmod procedure in SAS with a logit link function. Another group of job based analyses was also conducted to examine average job duration, hours and wages to compare outcomes from participants in the two groups. Spearman rank-order correlations between job duration, hours and wages were estimated to identify potential covariates in the hours and wages test model.

Intervention:

The intervention was Supported Employment services delivered through Club Houses.

Control:

The control was Supported Employment services delivered via Program of Assertive Community Treatment (PACT).

Findings:

The PACT model had a 14% higher job placement rate than the clubhouse model. Participants in either approach maintained weekly employment levels at or exceeding other published reports. On average participants in more than 2 jobs during the study period and worked 20 hours a week. Clubhouse participants remained employed 2 months longer than individuals in PACT, which resulted in a 66% difference in duration.

Conclusions:

No difference was found in job placement rates between clubhouse and PACT participants over two and half years. Clubhouse participants remained employed for more weeks and earned slightly higher wages than participants in PACT.

URL:

http://www.fountainhouse.org/sites/default/files/C.%20Schonebaum%20article.pdf

Disabilities:

Populations:

Outcomes:

NIDILRR Funded:

Research Design:

Peer Reviewed:

Yes

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:

Number:

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:

Outcomes:

Increase in tenure

NIDILRR Funded:

Research Design:

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:

Number:

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:

Other

Outcomes:

Return to work

NIDILRR Funded:

Research Design:

Peer Reviewed:

Yes

Prospective randomized controlled trial of resource facilitation on community participation and vocational outcome following brain injury

Authors:

Tsang H. W, Fung K. M., Leung A. Y., Li S. M., & Cheung W. M.

Year Published:

2010

Publication:

Journal of Head Trauma Rehabilitation

Volume:

Number:

Pages:

440-446

Publisher:

Lippincott, Williams and Wilkins Inc.

Background:

Brain injury has a negative impact on return to work. Past research indicates improved employment outcomes with an integrated medical/vocational case coordination system.

Purpose:

The researchers hypothesized that individuals with brain injury who receive resource facilitation (RF) will have greater success with return to work and participation in community and home activities.

Setting:

The setting was a large acute rehabilitation hospital, located in the Midwest.

Sample:

The sample size included 23 individuals with brain-injury and their caregivers. To be included in the study those with brain injury had to meet the following criteria: injury in the last 12 months or less, 18 to 60 years of age, ability to speak English, had been employed and/or had been enrolled in school for 2 years prior to the injury, had a goal to return-to-work or school and had a caregiver who was willing to participate in the study.

Data Collection:

Participants were given O-Log and the C-Log, as part of their clinical examination in the acute rehabilitation center prior to enrollment to determine the initial severity of cognitive impairment. Ratings on the Participation Index of the Mayo- Portland Adaptability Inventory (M2PI) were obtained for 11 RF participants and 11 controls before the intervention and at 6-month follow-up.

Intervention:

All participants received standard follow up. Those assigned to the experimental group also received resource facilitation through a facilitator who was charged with assisting them with returning to work.

Control:

Participants were assigned to either a resource facilitation group N=12 or regular follow up control conditions N=11.

Findings:

Resource facilitation can improve work outcomes. Those who received resource facilitation were more engaged in vocational services. It also had a positive impact on participants involvement in community and home activities. Resource facilitation does not appear to affect depression.

Conclusions:

Six months of resource facilitation, provided soon after patient discharge from acute rehabilitation, may have a powerful impact on employment post brain injury and community participation. More research is needed.

URL:

http://journals.lww.com/headtraumarehab/Abstract/2010/11000/Prospective_Randomized_Controlled_Trial_of.6.aspx

Populations:

Outcomes:

Return to work

NIDILRR Funded:

Yes

Research Design:

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:

Number:

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

Populations:

Hispanic or Latino

Black / African American

White / Caucasian

Outcomes:

Return to work

NIDILRR Funded:

Research Design:

Quasi-experimental

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:

Number:

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:

Outcomes:

NIDILRR Funded:

Research Design:

American Indian or Alaska Native

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:

Number:

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

Populations:

Hispanic or Latino

Asian

Black / African American

Native Hawaiian / other Pacific Islander

White / Caucasian

Outcomes:

Traumatic brain injury (TBI)

NIDILRR Funded:

Yes

Research Design:

Observational

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:

Number:

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

Disabilities:

Populations:

Black / African American

White / Caucasian

Outcomes: