Veterans

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)

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

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.

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.

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.

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.

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).

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.

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.