Returning to Work after Brain Injury

1
Returning to Work after Brain Injury

• James F. Malec, PhD
• Professor, Mayo Clinic and Medical School
• Rochester, MN

2
Collaborators

• Lisa Degiorgio, MS,CRC
• Anne M. Moessner, RN, MSN
• Angela L. H. Buffington, MS, CRC

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Benchmarks for Return to WorkAfter
Moderate-Severe Brain Injury

• Without intervention
• less than 40 employed
• With intensive day treatment
• 75 to 85 employed
• 50 in community-based independent work

4
Project Admission Criteria

• Age 18 to 65
• Minnesota resident
• Admitted to hospital following brain injury
• Neuropsychological evidence of brain injury
• No active psychiatric or substance abuse disorder
  accounting for impairments
• Not in residential placement
• Consent to participate

5
Vocational Services Sample

• 61 Male 39 Female
• Age
• Mean 37.4 yrs
• Median 38 yrs
• Preinjury education
• lt12 yrs 22
• 12 to 15 yrs 61
• gt 16 yrs 17

• Preinjury vocational status
• Unemployed 9
• Supported 6
• Transitional 16
• Independent 69
• Current living status
• 24-hr supervision 1
• Partial supervision 22
• Independent 77

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Vocational Services Sample

• Type of injury
• TBI 64
• CVA 26
• Other 10
• Initial injury severity
• Mild 21
• Moderate 7
• Severe 56
• Unknown 16

• Time since injury
• Mean 65.5 mos
• Median 12.7 mos
• Non-brain injuries
• present in
• 67 of TBI sample

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Vocational Referral Network
Nurse Case Coordinator (Acutely injured pts)
Outpatient Rehabilitation Services (Chronic pts)
Vocational Case Coordinator
Acute Medical Rehabilitation Services
Community Based Services (Chronic pts)
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Vocational Referral Sources

• 36 Outpatient rehabilitation evaluations
• 25 Nurse Case Coordinator
• 26 Other medical-center staff
• 13 Community agencies

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Other Services Received

• 39 Comprehensive day rehabilitation
• 33 Community Reintegration Outpatient Group (3
  hrs/wk)
• 56 MN Rehabilitation Services Branch
• 26 Other community based vocational services
  (e.g., evaluation, job search, job coach)

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Primary Emphases of Project

• Early medical, rehabilitative, and vocational
  intervention
• Integration of medical center and community
  services
• Work trials
• Temporary or long-term supported employment
• Employer education about brain injury

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Key Elements of Vocational Case Coordinator Model

• Focus on early vocational intervention
• Identify residual impairments that may interfere
  with vocational re-integration and refer for
  appropriate medical rehabilitation services
• Integrate vocational goals with rehabilitation
  therapy goals

• Develop comprehensive return-to-work plans that
  address issues ranging from number of hours
  worked to the work environment to compensation
  techniques
• Improve community agency linkages to develop a
  team approach
• Provide a smooth transition from medical to
  community based services

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Key Elements of Vocational Case Coordinator Model

• Use on-the-job evaluations to gather the best
  information about a persons work skills
• Provide appropriate support during work
  evaluations and after placement including job
  coaching and work trials
• Provide reasonable work accommodations before the
  client starts the job

• Provide BI education to employers, coworkers,
  community service providers
• Clearly identify a BI resource person for the
  client and employer
• Provide regular, frequent follow-up after
  placement

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Vocational Service Models

• Specialized
• Provides early intervention
• Bridges gap between hospital and community
• On-the-job evaluations
• Integrates vocational and rehabilitation goals
• Places and trains

• Traditional
• Waits for person to apply
• No involvement in medical rehabilitation
• Interest and aptitude testing, work samples
• Focuses only on vocational goals
• Trains and places

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Vocational Service Models

• Specialized
• Employer and co-worker education
• Addresses psychosocial and functional issues
  before job placement
• Team approach
• Sequence of short-term goals
• Supported risk taking

• Traditional
• No educational outreach
• Addresses psychosocial and functional issues
  after they arise
• One counselor per client
• One long-term vocational goal
• High risk for failure

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Vocational Outcomes

• And Outcome Predictors

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Vocational Independence Scale

• Competitive Community-based work (at least 15
  hours per week) without external supports
• Transitional Community-based work (at least 15
  hours per week) with temporary supports, such as,
  job coach, reduced hours OR enrollment in an
  educational or training program
• Supported Community-based work with permanent
  supports or less than 15 hours per week OR
  volunteer work
• Sheltered Work in a sheltered workshop
• Unemployed

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Vocational Independence Scale at Placement and 1
Yr Follow-up
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Vocational Outcome PredictorsAfter Brain Injury

• Severity of initial injury
• Time since injury
• Impairment/disability
• Impaired self-awareness
• Preinjury vocational status
• Preinjury educational status

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Mayo-Portland Adaptability Inventory

• Mobility
• Use of hands
• Vision
• Motor speech
• Communication
• Memory
• Attention/concentration
• Novel problem solving
• Visuospatial abilities
• Fund of information
• Irritability/aggression

• Depression
• Residence
• Self cares
• Work/school
• Leisure activities
• Driving
• Family/significant
• relationships
• Social contact
• Appropriate social interaction
• Indifference
• Initiation

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Stepwise Logistic Regression VIS at Placement

• Time Since Injury (?2 9.70, p lt.01)
• Rasch Staff MPAI (?2 8.30, p lt.01)

21
Stepwise Logistic Regression VIS at 1 Year
Follow-up

• VIS at placement (?2 53.30, p lt.0001)

22
Stepwise Linear Regression Time to Placement

• Rasch Staff MPAI (R2 .16)
• Preinjury education (R2 .03)

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Vocational Outcome Summary

• 81 in community-based employment at 1 year
  follow-up
• 53 in independent employment at 1 year
• 39 of those placed returned to previous
  employment
• 58 of total placements made within 6 months of
  initiation of services
• 92 within 1 year

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Comprehensive vs. Limited

• Intervention

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Comprehensive Postacute Brain Injury
Rehabilitation

• A cognitive and behavioral approach
• Interdisciplinary team
• Emphasis on self-awareness, adjustment,
  compensation and social skills
• Low staff-to-patient ratio
• Family involvement
• Vocational and independent living trials
• Systematic outcome assessment

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Mayo Comprehensive ProgramPatient Characteristics

• Limited self-awareness of disabilities
• Cognitive impairments e.g., concentration,
  memory, generalization, problem-solving,
  initiation, reasoning, planning
• Poor communication and social skills
• Limited emotional/behavioral self-control
• Unemployed or failing in employment
• Not a danger to self or others

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Mayo Comprehensive ProgramGroups

• Daily
• Orientation
• Cognitive
• Social Awareness
• Communication
• Life Skills

• Weekly
• Health Education
• Vocational
• Monthly
• Patient/Family Group

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Mayo Comprehensive ProgramVocational Independence
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Community-Based Employment by Time Since Injury
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Limited Intervention

• Vocational Services only
• Additional outpatient cognitive rehabilitation
• Adjustment counseling
• Other outpatient rehabilitation therapies
• Community Integration Outpatient Group

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Probability of Community-Based Employment
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Conclusions

• A medical-center based Vocational Case
  Coordinator who coordinates service delivery
  maximizes vocational outcomes for persons after
  brain injury
• Early intervention optimizes outcomes and
  optimizes the success of limited intervention
• Successful vocational placement can be
  accomplished within 1 year

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Conclusions

• Overall disability and time since injury are the
  best predictors of vocational placement after
  brain injury rehabilitation
• The best predictor of long-term vocational
  outcome is initial placement
• Return to previous employment is a viable option
  for many persons after brain injury

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Conclusions

• Comprehensive rehabilitation is often required by
  more persons with greater disability or
  chronicity and results in a more extended time to
  placement
• However, comprehensive intervention can be
  successful with the majority of persons served
  regardless of chronicity or severity