Implementation of supported employment for homeless veterans with psychiatric or addiction disorders: Two-Year outcomes

Authors: 
Rosenthal, D. A., Dalton, J. A. & Gervey, R.
Year Published: 
2007
Publication: 
Psychiatric Services
Volume: 
58
Number: 
3
Pages: 
325-333
Publisher: 
American Psychiatric Association
Background: 

Experimental studies have robustly demonstrated the effectiveness of the Individualized Placement and Support (IPS) model of supported employment services for people with severe mental illness, and several studies of real-world implementation have shown significant cross-sectional correlations between employment success and fidelity to the IPS model. Experiences with IPS programs have stimulated broad efforts to disseminate evidence-based practices. Although multiple dissemination efforts are underway, analyses on the benefits of efforts to disseminate IPS have been on cross-sectional and site-level data, rather than on longitudinal information on individual clients. To implement IPS in health care systems with limited previous experience, sustained and individualized training programs may be needed to realize potential client benefits. Few studies have demonstrated that IPS, or other evidence-based practices for that matter, can both be implemented in a system that lacks prior experience with the model and yield outcomes for comparable cohorts that are superior, over several years, to those of a comparison group for which this intervention was not available.

Purpose: 

This study examined a low-intensity training approach for implementing the individual placement and support (IPS) model at nine Department of Veterans Affairs (VA) programs and compared client outcomes before (phase 1) and after (phase 2) the program was implemented (phase 1).

Setting: 

The setting included 9 Veterans Administration Programs for Homeless Veterans.

Sample: 

A total of 308 veterans were recruited during phase 1, starting in January 2001, when IPS was still unavailable anywhere in the VA. An additional 321 veterans were recruited in phase 2, starting in July 2001, after the IPS employment specialist had been hired and trained, and were invited to participate in IPS for at least two years. Follow-up data collection continued through March 2005.

Data Collection: 

Participants in phase 1 were compared with participants in phase 2 on baseline characteristics by using chi square tests and t tests. All available participants were included in all analyses whether or not they were currently participating in IPS. Mixed models were then used to compare outcomes between the phases over the two-year follow-up period, controlling for baseline differences, using the MIXED procedure of SAS, with the alpha set at <.05.

Intervention: 

Training began with a one-day, on-site, face-to-face orientation for both employment specialists and other VA mental health staff that was led by a social worker with experience training IPS specialists and conducting IPS fidelity ratings. For the duration of the project regular teleconferences continued providing weekly individual case reviews for the first three months, monthly individual case review conferences, and monthly conference calls with all nine employment specialists jointly. A review of ratings of model fidelity at six, 12, and 18 months after program implementation was also performed with a modified version of the IPS fidelity scale. Training was provided by a social worker with extensive experience disseminating the IPS model in other research projects. He was assisted by a VA occupational therapist with experience in supported employment. Monthly conference calls were also held with administrators responsible for program implementation at each site.

Control: 

Phase 1 control group did not receive IPS services. Comparison was made with Phase 2 group who did receive IPS services.

Findings: 

Measures of both client-level service delivery and site-level fidelity to IPS suggest that implementation was successful at most, but not all, sites. Overall, compared with veterans in the phase 1 group, those in the phase 2 group had a better long-term work history at the time of program entry. When the analyses controlled for baseline differences, the mean number of competitive employment days per month over the two-year follow-up period was 15% higher for veterans in phase 2 (8.4 days compared with 7.3 days; p<.001) and the mean number of days housed during follow-up was also higher in phase 2 (34.1 days compared with 29.8 days; p=.04), but there were no differences for other outcome measures. (Psychiatric Services 58:325—333, 2007)

Conclusions: 

A sustained training program can be used to implement IPS in systems that have had little past experience with this approach. This effort was associated with improved employment outcomes and more rapid housing placement.

URL: 
http://www.nchv.org/images/uploads/Implementation_of_Supported_Employment_for_Homeless_Veterans_With_Psychiatric_or_Addiction_Disorders-Two-Year_Outcomes.pdf
Disabilities: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Impact of public support payments, intensive psychiatric community care, and program fidelity on employment outcomes for people with severe mental illness

Authors: 
Rinaldi, M., Mcneil, K., Firn, M., Koletsi, M., Perkins, R., & Singh, S. P.
Year Published: 
2003
Publication: 
The Journal of Nervous and Mental Disease
Volume: 
191
Number: 
3
Pages: 
139-144
Publisher: 
Lippincott, Williams and Wilkens
Background: 

Supported employment is an evidenced based practice that assists individuals with mental illness with gaining and maintaining employment. One of the major barriers to work are disability payments offered by the Social Security Administration and the Veterans Administration. A few studies have shown that the amount of public income is negatively associated with employment, involvement with vocational rehabilitation services and income received from employment. There are no studies related to to the impact of disability benefits on employment of those individuals who receive intensive case management services.

Purpose: 

The purpose of this study was to explore the relationship between income from public support, participation in Intensive Psychiatric Community Care and employment among veterans with severe mental illness.

Sample: 

The sample included 520 veterans with severe mental illness who were randomly assigned to either IPCC or standard care. Prior to entering the study the majority or 87.5% were receiving at least one form of public payment. The average amount was nine hundred and fifty five dollars.
At the 12 month follow up interview, most of the sample 91.2%) were classified as non workers. There were few differences on baseline and demographic and mental health status. There was a significant difference between workers and non-workers on the amount of public income received in the month prior to baseline assessment, with non workers receiving more money.

Data Collection: 

Demographic and mental health status were obtained through participant interviews at baseline and one year out. Symptom severity was measured using the Brief Psychiatric Rating Scale. Alcohol and drug use were examined using scores from the Addiction Severity Index. Functional status was assessed using the Global Assessment Scale. Fidelity to the IPCC Model was measured using the Dartmouth Assertive Community Treatment scale. A liberal measure was used to determine employment. In the data analysis, only composite scores were examined. Bivariate analyses were used to examine differences between demographic and mental health status variables. Multivariate logistic regression was used to look at the contribution of the independent variable.

Intervention: 

The intervention was Intensive Psychiatric Community Care (IPCC).

Control: 

The control condition was standard care.

Findings: 

Public support levels were inversely related to employment. Symptom severity did not appear to be an independent barrier to work.

Conclusions: 

Previous analyses of this study did not look at infrequent outcomes like employment. However, there is value in doing so as the results revealed the impact of assertive case management on employment outcomes.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/12637839
Disabilities: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Methods of a multisite randomized clinical trial of supported employment amount veterans with spinal cord injury

Authors: 
Ownsworth, T., & McKenna, K.
Year Published: 
2009
Publication: 
Journal of Rehabilitation Research & Development
Volume: 
46
Number: 
7
Pages: 
919-930
Publisher: 
Department of Veterans Affairs
Background: 

Baseline data revealed that 65% of the study sample of veterans with spinal cord injury (SCI) who were seeking employment had never been employed postinjury. Nearly half (41%) of this group had received some type of prior vocational rehabilitation. This rate is consistent with veterans with SCI reported for samples in the community of individuals with SCI.

Purpose: 

This article compares evidence-based supported employment (SE) with conventional vocational rehabilitation for veterans with SCI. The researchers hypothesis was that evidence-based supported employment when compared with conventional vocational rehabilitation will significantly improve competitive employment outcomes. The secondary hypothesis was that evidence-based supported employment for veterans with SCI would be more cost-effective than standard care.

Setting: 

The study took place at multiple competitive employment sites versus standard vocational rehabilitation care at various Department of Veterans Affairs medical SCI centers.

Sample: 

Veterans with spinal cord injury consisting of 95% males with an average age of 48.3 years. More than half of the subjects were white, 35.3% African American, 5% Hispanic.

Data Collection: 

All subjects were followed for 12 months with face-to-face interviews every three months to collect data on primary employment variables and secondary outcomes measured. After this initial 12 months, the follow-up period was extended to 24 months at all sites including telephone interviews every three months. MANCOVAs were used to determine treatment group differences over time on the outcome variables (employment index, perceived barriers to employment, level of disability, quality of life, depression, and sustaining care needs), controlling for specified covariates. This included study site, sex, and age.

Competitive employment was as a primary outcome measure and measured every three months. Competitive employment is "community jobs that pay at least minimum wage (directly by the employer to the employee) that any person can apply for, including full-time and part-time jobs." General rehabilitation outcomes were measured at baseline and 3-month follow-up interviews. Standardized measures used included 1) Alcohol Use Disorders Identification test, 2)The Craig Handicap Assessment and Reporting Technique (CHART), 3) VR-36 that measures health-related quality of life in veterans, and 4) The Quick Inventory of Depressive Symptomatology Self-Report.

Demographic variables were also collected such as age, sec, race/ethnicity, employment history, previous levels of income, educational background, legal history, lifetime employment history, vocational services history, duration of SCI, level of SCE, and type of family structure.

Intervention: 

The Spinal Cord Injury Vocational Integration Program uses the principles of evidence-based supported employment. The program integrates vocational services into the SCI continuum of healthcare. The SE principles include 1) integrated treatment, 2) rapid engagement, 3)competitive employment, 4) belief that success is possible regardless of severity or type of disability, 5) ongoing support, 6) veteran preferences, 7) community-based services, and 8)personalized benefits counseling. The investigators spent 4 to 6 months recruiting and hiring staff to provide the evidence-based SE services. All vocational rehabilitation counselors (VRCs) have master's degrees and are certified rehabilitation counselors. Training consisted of 3-day workshop taught by VA faculty. VRCs received ongoing instruction and coaching by a co-investigator who has more than 30 years experience in vocational rehabilitation (VR).

Control: 

The study design was a randomized clinical trial that consisted of an experimental group and a comparison group. Interventional-site subjects were randomized to either the experimental group or the comparison group. Observational sites were selected based on similarity to the intervention site facilities with regards to subjects, communities, and VAMC culture. The observational sites were included because the researchers were considered that veterans and staff at the four intervention sites might be vicariously influenced by veterans and staff involved with the implementation study.

Findings: 

The findings of this study were preliminary. The final enrollment count for the study was 301 subjects. At the time of this publication, 93 participants had reached study completion. Some of the challenges faced included exhausting the study pool earlier than expected, staff turnover, and slow process of culture change within the centers.

Conclusions: 

This article discussed the methods of an ongoing randomized clinical trial of VR approaches among veterans with SCI. Strengths of the study design include repeated measures to evaluate employment across time, inclusion of benefits-counseling, and ongoing fidelity monitoring of the treatment conditions. Before the study, the researchers concluded that there was a lack of attention to identifying or addressing vocational issues in the treatment setting. A culture change occurred such that providers began to introduce and explore the topic. In this study, the recruitment relied on clinical providers' willingness to broaden their definition of rehabilitation to include vocational issues. The preliminary baseline data from this sample showed that the majority (72%) had never been employed postinjury.

URL: 
http://www.rehab.research.va.gov/jour/09/46/7/Ottomanelli.html
NIDILRR Funded: 
Peer Reviewed: 
Yes

Review of critical factors related to employment after spinal cord injury: Implications for research and vocational services

Authors: 
Ottomanelli, L., Goetz, L. L., Suris, A., McGeough, C., Sinnott, P. L., Toscano, R., Barnett, S. D., Cipher, D. J., Lind, L. M., Dixon, T. M., Holmes, S. A., Kerrigan, A. J., & Thomas, F. P.
Year Published: 
2009
Publication: 
The Journal of Spinal Cord Medicine
Volume: 
32
Number: 
5
Pages: 
503-531
Publisher: 
American Paraplegia Society
Background: 

Unemployment is a serious problem for individuals with spinal cord injury (SCI). According to the authors, unemployment for the population of SCI individuals is ten times greater than the general population. In addition, return to preinjury jobs has been reported as very low for this group of individuals.

Purpose: 

The purpose of this study was to provide a comprehensive summary of the literature regarding predictors of employment, the benefits, and barriers.

Setting: 

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

Sample: 

The sample consisted of 60 articles that reported on employment rate of individuals with spinal cord injury.

Data Collection: 

Authors identified 579 articles and reviewed to determine presence of reported employment rates. Of these, 60 articles were found to include employment rates for individuals with SCI. These articles were reviewed to identify critical factors related to employment after spinal cord injury.

Intervention: 

The intervention was evidence-based supported employment and traditional vocational rehabilitation.

Control: 

There were no comparison or control conditions.

Findings: 

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

Conclusions: 

Characteristics associated with employment include demographic variables, injury-related factors, employment history, psychosocial issues and disability benefit status. Evidence-based supported employment practices seem to be the most applicable model for assisting individuals with SCI in restoring meaningful employment. Control studies are needed to test this conclusion.

URL: 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2792457/
Populations: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Traumatic brain injury and employment outcomes: Integration of the working alliance model

Authors: 
Kitchiner, N. J.
Year Published: 
2008
Publication: 
Work
Volume: 
31
Number: 
3
Pages: 
309-317
Publisher: 
IOS Press
Background: 

Polytrauma includes a complex constellation of symptoms that may involve an array of interrelated cognitive, physical, and psychological symptoms. According to the United States Veteran Health Administration, polytrauma is an injury to the brain in addition to other body parts or systems resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability. Although problems post traumatic brain injury (TBI) can be challenging many of these individuals remain employable. Rehabilitation specialists assisting persons with TBI with return to work need to understand treatment protocols that could enhance the relationship with the individuals and thereby enhance their employment outcomes.

Purpose: 

This paper provided a brief review of the return to work literature and presented Bordin's working alliance model. A case example was used to illustrate the model.

Setting: 

The setting for the study was an In/Outpatient Rehabilitation Center.

Sample: 

The paper presents one case study.

Data Collection: 

The case study provides a brief overview of the meetings between the client and his rehabilitation counselor.

Intervention: 

The intervention was the Working Alliance Model of Rehabilitation. Some limited research has highlighted the working alliance model‚ benefit in working with participants for whom issues of inclusion, empowerment, and promotion of autonomy have become central to the definition of a healthy counseling relationship. One of the main benefits of the model is its dynamic, collaborative orientation. In essence, the sense of ownership a participant gains given the model‚ central tenet of shared power and decision making within the professional relationship provides a solid rationale for using this model in rehabilitation settings.

Control: 

No comparison condition.

Findings: 

A treatment and rehabilitation program was developed for the individual with TBI using the Work Alliance model. This included: obtaining a neuropsychological evaluation, transitioning level of care to a day treatment program, continuing to work with his rehabilitation counselor using the Work Alliance model to construct realistic return to work plan and refer him to case manager to monitor his behavioral and psychological needs.

Conclusions: 

The model may be able to strengthen the relationship between a person with TBI and a rehabilitation specialist.

URL: 
http://content.iospress.com/articles/work/wor00785
Populations: 
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

Vocational rehabilitation of participants with severe substance use disorders in a VA Veterans Industries Program

Authors: 
Walker, W. C., Marwitz, J. H, Kreutzer, J. S., Hart, T., & Novack, T. A.
Year Published: 
2004
Publication: 
Substance Use and Misuse
Volume: 
39
Number: 
13
Pages: 
2513-2523
Publisher: 
Marcel Dekker
Background: 

The VA Veterans Industries programs have been established across the country to provide a therapeutic gateway to gainful employment for veterans who have physical and mental disabilities or addictive disorders. Eighty percent of patients referred to vocational rehabilitation programs have a history of severe substance use disorders. Despite the interest in the vocational rehabilitation of substance users (Hawkins and Catalano, 1985), little empirical evidence exists about which specific vocational rehabilitation services promote successful employment outcomes.

Purpose: 

The purpose of this study was to evaluate the effectiveness of the Veterans Industries program, a component of the Addictions Partial Hospitalization Program (APHP) at the Houston Veterans Affairs Medical Center (VAMC). Outcome rates are reported including employment, abstinence, and housing support.

Setting: 

The study was conducted at the Houston, TX VAMC within the APHP, an addiction treatment program.

Sample: 

The study sample consisted of 80 veterans who were out-patients of the APHP and who were referred for vocational rehabilitation. The mean age of patients was 45 (range 29–59). Participants were predominantly male (98%) and African-American (62%). Most (68%) were Vietnam era veterans. At enrollment, 100% were unemployed, 73% were homeless, and 15% were receiving a disability pension.

Data Collection: 

Data were collected at intake for age, education, military history, training, employment history, earnings, disability, disability compensation, substance use, and living situation. Employment data were collected following program exit and at three-month follow-up.

Intervention: 

Veterans Industries is a therapeutic work-for-pay program in which the VA contracts with private industry and federal agencies for work to be performed by veterans. These Compensated Work Therapy (CWT) programs have been established since the 1950s. The majority of veterans are involved in outpatient substance user programs and live in VA domiciliaries or supportive housing in the community. In addition to therapeutic work, veterans receive job readiness training group, assistance with job placement, and referral to the state vocational rehabilitation service for assistance with supportive housing in a drug-free environment.

Control: 

The study used a pre/post intervention design, without a control or comparison group.

Findings: 

Of 80 patients, 72 (90%) successfully completed APHP and received a regular discharge. This means that they completed 4 weeks of partial hospital treatment and graduated to outpatient treatment consisting of group therapy twice a week. Fifty-nine percent of the homeless veterans received supportive housing. All veterans who remained abstinent and continued to participate in work therapy received supportive housing. The average length of service was 3 months. Forty-three of the 80 veterans (54%) obtained competitive employment. The majority of jobs were in entry-level service positions including housekeeping, building maintenance, security, shipping, and receiving. A follow-up conducted 3 months after discharge from Veterans Industries indicated that 60% maintained competitive employment.

Conclusions: 

The study findings support the conclusion that vocational services improve the employment rates of clients leaving treatment. The existence of job counseling, job placement, and job development services in clinics is positively correlated with the difference between admission and discharge employment rates.

URL: 
http://www.tandfonline.com/doi/abs/10.1081/JA-200034695?journalCode=isum20
NIDILRR Funded: 
Peer Reviewed: 
Yes

Employment issues and assistive technology use for persons with spinal cord injury

Authors: 
Hoffman, H., Jackel, D., Glauser, S., & Kupper, Z.
Year Published: 
2006
Publication: 
Journal of Rehabilitation Research & Development
Volume: 
43
Number: 
2
Pages: 
185-198
Publisher: 
United States Department of Veterans Affairs
Background: 

Assistive technology (AT) improves the functional independence of persons with spinal cord injury (SCI/D) and affords them greater opportunity for societal participation and integration. These technologies are designed to circumvent environmental barriers, maximize independence, and increase activity participation among persons with physical disabilities. Logically, the improvements in functional independence, societal participation, and integration attributed to AT should also enhance the employability of persons with SCI/D. However, little is known about the extent of AT in the workplace and the role that AT may play in reducing employment-related barriers and enhancing employment outcomes for persons with SCI/D.

Purpose: 

In this study, the authors examined the associations between assistive technology (AT) cost, underwriting, ownership, use, employment, and employer accommodations for two groups (civilian and veteran) of working age adults (18-64 yr) with spinal cord injury or dysfunction (SCI/D).

Sample: 

The sample included working-age adults (18-64 yr) with SCI/D. The first group of participants, civilians, was identified from the University of Illinois at Urbana-Champaign (UIUC) Disability Resources and Educational Services (DRES) Student Database. At initiation of the study, 170 alumni with SCI/D were in this database and valid addresses and phone numbers were available for 140 of them. The second group of participants, veterans with SCI/D, was identified with the VA Spinal Cord Dysfunction Registry. After identifying all veterans with SCI/D, the authors randomly selected a pool of 400 potential veteran participants from the national VA database maintained by the VA Allocation Resource Center (ARC). Of the 200 veterans, 98 agreed to participate in the survey (49% response rate), and 93 of the 140 UIUC alumni agreed to participate in the survey (66% response rate). Therefore, the overall project response rate was 56 percent (191/340).

Data Collection: 

Prospective and retrospective data were collected from the two groups. The prospective data were collected with a telephone survey. This included the following questions:

1. What AT devices are owned by individuals with SCI/D?
2. How much did these devices cost?
3. For individuals employed at time of survey, did device cost vary by disability severity, employer category, or importance of the device to work?
4. Who underwrites the purchase, maintenance, and replacement costs of the devices owned?
5. Which AT devices are identified as important to work?
6. Are there any unmet AT needs in terms of workplace accommodations, repair, and overall satisfaction?

In addition, the survey included information on disability, demographic, health status, and physical activity information. Descriptive and comparative analyses were conducted for the total sample, for each cohort separately, and by subgroup when sample sizes were large enough. In addition, logistic regression models were created with AT as a predictor of employment and U.S. Social Security Administration (SSA) benefits data for adjustment of potentially confounding factors, such as disability severity, health status, hospitalization, physical activity level, functional status, and comorbid conditions.

Control: 

There were no control or comparison groups.

Findings: 

The average number of devices identified in the NPPD (mean ± SD = 10.53 ± 9.57) was significantly (p < 0.001) greater than the average number of devices reported by the veterans (mean ± SD = 2.57 ± 2.01) between 1998 and 2002 (Table 5). The most notable discrepancy between the two sources is the number of MMIL devices. A similar pattern was observed with regard to device repair history. Overall, as shown in Table 6, the number of repairs recorded in the NPPD was more than four times greater than the number of repairs self-reported by veterans. From 1998 to 2002, the average cost per device per person across all device categories was mean ± SD = $2,155.20 ± $2,210.90 for the civilians and $2,032.40 ± $2,559.90 for veterans. No significant differences were found between groups for disability severity, cost data for individuals with paraplegia and tetraplegia were combined across the civilian and the veteran groups. As expected, the total average cost per person for all devices was significantly greater for respondents with tetraplegia (mean ± SD = $2,972.29 ± $2463.70) compared with those with paraplegia ($1,621.90 ± $2,011.00), which corresponded to their ownership of more AT devices overall.

The civilians were significantly more likely to be working at the time of interview or to have worked for pay in the past 5 years compared with the veterans (91% and 30%, respectively. At the time of the interview, 73 percent of the civilians reported they were working at a job for pay compared with only 18 percent of the veterans. Further, of those respondents who were not currently employed, 18 percent of the civilians had worked for pay during the 5 years prior to the interview, while only 12 percent of the veterans had done so. The majority of veterans, 70 percent, reported that they had not worked in the 5 years prior to the interview compared with only 8.6 percent of the civilians. Although no significant predictors of employment were found in the logistic models for the civilians, several factors were found that potentially affect employment status for veterans. Specifically, one factor identified in multivariate logistic regression that increased the probability of employment was an education level of bachelor's degree or above (increased odds 15.4).

The civilians who were working at the time of interview or who had worked during the 5 years prior to the interview (n = 86) reported owning 400 different types of devices, 80 percent of which were subsequently identified as important to work. The majority (59%) of all devices identified by the civilians as being important to work were in the Manual Mobility and Independent Living (MMIL) device category. In addition, Powered Mobility and Independent Living (PMIL) devices accounted for 24 percent, Assistive Computer Technology (ACT) devices for 8 percent, and Prosthetics & Orthotics (P&O) devices for 6 percent. The specific devices identified as most important to work by the civilians were motorized wheelchairs, foot/leg braces and prosthetics, arm/hand braces and prosthetics, manual-exercise devices, manual computer input devices, powered environmental control devices, adjustable-height workstations, adaptive telephone equipment, and Augmentative and Alternative Communication Device (AACD).

The veterans who were employed or who reported working during the 5 years preceding the interview (n = 29) reported owning 88 different types of devices, 77 percent of which were characterized as being important to work. The majority of all devices identified by these veterans as important to work were MMIL devices (57%). The AT devices most frequently identified as being important to work by the veterans were manual wheelchairs, manual independent living devices, ambulatory support devices, motorized wheelchairs, and residential control devices. For total devices overall, 91 percent of ambulatory support devices (e.g., crutches, canes, walkers), 83 percent of manual independent living devices (e.g., reachers), 80 percent of residential control devices (e.g., power door operators), 71 percent of manual motor vehicle control devices, 50 percent of environmental control and magnification devices, and 43 percent of arm/hand prosthetics or braces were identified by civilians and veterans as being important to work.

Overall, the average cost of devices reported as important to work was significantly greater than the average cost of devices with little or no work importance (t(373) = 5.60; p < 0.001. AACD was the only device category for which the mean cost of devices reported as not important for work exceeded that of the AACD identified as important to work (t(127) = 2.40; p = 0.02).

Conclusions: 

The results indicate that AT ownership and use relates to and is important for employment success of persons with SCI/D. In terms of the cost of AT, devices identified as important to work were 3.5 times more expensive than other devices. However, research suggests that employers must recognize that these costs represent investments in that they serve to enhance employee retention and productivity. The more frequent use of AT and corresponding increase in AT expenditures by persons with greater disability severity may indicate that these individuals are endeavoring to compensate for functional limitations with AT. Since improved functional status is significantly associated with employment, future research efforts might investigate the extent to which individuals with SCI/D maximize their use of AT to ameliorate the limitations of their conditions and to pursue employment.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/16847785
Populations: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes

A randomized controlled trial of supported employment among veterans with post-traumatic stress disorder

Authors: 
Diclementi, J. D., Ross, M. K., Mallo, C., & Johnson, S.
Year Published: 
2012
Publication: 
Psychiatric Services in Advance
Volume: 
63
Number: 
5
Pages: 
464-470
Publisher: 
American Psychiatric Association
Background: 

Post traumatic stress disorder (PTSD) is a potentially disabling mental illness that can cause occupational dysfunction. Although vocational rehabilitation is often prescribed for patients with PTSD, standard vocational services are far from adequate in helping them obtain and maintain competitive employment.

Purpose: 

This study is the first to examine the outcome of evidence-based supported employment for veterans with PTSD. Study addressed this gap in the field of rehabilitation research.

Setting: 

The setting for the study was the Tuscaloosa Veterans Administration Medical Center.

Sample: 

Veterans were eligible for the study if they had a diagnosis of PTSD, wee aged 19-60, were eligible for the VAMC Vocational Rehabilitation Program, were currently unemployed, were interested in competitive employment, and were planning to remain in a 100 mile radius of the Tuscaloosa VAMC for the 12-month duration.

Data Collection: 

Using intent to treat analyses and two tailed tests with significance set at p less than or equal to .05, researchers compared rates of competitive employment, as well as number of weeks , day and hours worked; gross wages earned from all sources; and gross wages earned from competitive jobs.

Intervention: 

Unemployed veterans with PTSD were randomly assigned to either individual placement and support (IPS) supported employment (N = 42) or a Veterans Health Administration Vocational Rehabilitation Program (VRP) treatment as usual (N = 43). Employment rates and occupational outcomes were followed for 12 months. IPS intervention involved several important features. For example, the IPS specialist was integrated into the clinical mental health or PTSD treatment team, carried out all phases of the vocational services, provided predominantly community based employment, had a caseload of no more than 25 clients, and provided continuous time unlimited follow along supports for vocational services.

Control: 

The VRP followed the standard care in place at the VMC, which included one or more of these components: routine prevocational testing and evaluation for all patients on referral to VRP, vocational rehabilitation therapy and provided a work regimen with monetary incentives, and a transitional work program that included a temporary work experience.

Findings: 

During the 12-month study, 76% of the IPS participants gained competitive employment, compared with 28% of the VRP participants (number needed to treat = 2.07; ?(2) = 19.84, df = 1, p<.001). Veterans assigned to IPS also worked substantially more weeks than those assigned to VRP (42% versus 16% of the eligible weeks, respectively; Mann-Whitney z test p<.001) and earned higher 12-month income (mean ± SD income of $9,264 ± $13,294 for IPS versus $2,601 ± $6,009 for VRP; Mann-Whitney z test p<.001) during the 12-month period.

Conclusions: 

Veterans with PTSD who received IPS were 2.7 times more likely to gain competitive employment than those who received VRP. Because work is central to recovery, these results should assist stakeholders in planning improved services for veterans with PTSD.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/22307881
Disabilities: 
NIDILRR Funded: 
Peer Reviewed: 
Yes

Preliminary assessment of a prototype advanced mobility device in the work environment of veterans with spinal cord injury

Authors: 
Coviello, D. M., Zanis, D. A., & Lynch, K.
Year Published: 
2004
Publication: 
NeuroRehabilitation
Volume: 
19
Number: 
2
Pages: 
161-170
Publisher: 
IOS Press
Background: 

Many environments are not accessible to individuals that use wheelchairs for ambulation.

Purpose: 

The purpose of this study was to collect data on the potential for the Independence 3000 IBOT Transporter to improve employment satisfaction of veterans who use wheelchairs to work.

Setting: 

Various offices made up the setting.

Sample: 

Subjects were recruited from the Washington Office of the Paralyzed Veterans of America. Four male veterans with traumatic spinal cord injury were selected to participate in the study.

Data Collection: 

Observations were made by trained clinicians and participants responded to a survey.

Intervention: 

The intervention was the use of the IBOT in the work setting to hold eye-level discussions with colleagues, climb stairs, ascend steep ramps, and negotiate curbs.

Control: 

There was no control or comparison condition.

Findings: 

Half of the users felt that the IBOT would help them at work and all users felt it should be made available to veterans who use wheelchairs.

Conclusions: 

A larger study should be conducted to determine if the IBOT affects work performance and the ability to return to work.

URL: 
http://www.ncbi.nlm.nih.gov/pubmed/15201475
Disabilities: 
Populations: 
Outcomes: 
NIDILRR Funded: 
Research Design: 
Peer Reviewed: 
Yes