returning to work after brain injury james f. malec, phd professor, professor, mayo clinic and...
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Returning to Work after Brain Returning to Work after Brain InjuryInjury
James F. Malec, PhDJames F. Malec, PhD
Professor, Professor, Mayo Clinic and Medical School
Rochester, MN
CollaboratorsCollaborators
Lisa Degiorgio, MS,CRCLisa Degiorgio, MS,CRC
Anne M. Moessner, RN, MSNAnne M. Moessner, RN, MSN
Angela L. H. Buffington, MS, CRCAngela L. H. Buffington, MS, CRC
Benchmarks for Return to Benchmarks for Return to WorkWork
After Moderate-Severe Brain InjuryAfter Moderate-Severe Brain Injury
Without intervention:Without intervention:– less than 40% employedless than 40% employed
With intensive day treatment:With intensive day treatment:– 75% to 85% employed75% to 85% employed– 50% in community-based independent 50% in community-based independent
workwork
Project Admission CriteriaProject Admission Criteria
Age 18 to 65Age 18 to 65 Minnesota residentMinnesota resident Admitted to hospital following brain injuryAdmitted to hospital following brain injury Neuropsychological evidence of brain injuryNeuropsychological evidence of brain injury No active psychiatric or substance abuse No active psychiatric or substance abuse
disorder accounting for impairmentsdisorder accounting for impairments Not in residential placementNot in residential placement Consent to participateConsent to participate
Vocational Services SampleVocational Services Sample
61% Male; 39% Female61% Male; 39% Female Age: Age:
– Mean Mean = 37.4 yrs= 37.4 yrs
– Median = 38 yrsMedian = 38 yrs
Preinjury education:Preinjury education:– <12 yrs = 22%<12 yrs = 22%
– 12 to 15 yrs = 61%12 to 15 yrs = 61%
– > 16 yrs = 17%> 16 yrs = 17%
Preinjury vocational Preinjury vocational status:status:– UnemployedUnemployed = 9%= 9%– SupportedSupported = 6%= 6%– TransitionalTransitional = 16%= 16%– IndependentIndependent = 69%= 69%
Current living status:Current living status:– 24-hr supervision = 1%24-hr supervision = 1%– Partial supervision= 22%Partial supervision= 22%– IndependentIndependent = =
77%77%
Vocational Services SampleVocational Services Sample Type of injury:Type of injury:
– TBITBI = 64%= 64%– CVACVA = 26%= 26%– OtherOther = 10%= 10%
Initial injury severity:Initial injury severity:– MildMild = 21%= 21%– Moderate Moderate = 7%= 7%– SevereSevere = =
56%56%– UnknownUnknown = 16%= 16%
Time since injury:Time since injury:– Mean = 65.5 mosMean = 65.5 mos– Median = 12.7 mosMedian = 12.7 mos
Non-brain injuriesNon-brain injuries
present in:present in:– 67% of TBI sample67% of TBI sample
Vocational Referral NetworkVocational Referral NetworkNurse Case Coordinator
(Acutely injured pts)
Vocational Case
Coordinator
Acute Medical & Rehabilitation Services
Outpatient
Rehabilitation
Services
(Chronic pts)
Community
Based Services
(Chronic pts)
Vocational Referral SourcesVocational Referral Sources
36% Outpatient rehabilitation 36% Outpatient rehabilitation evaluationsevaluations
25% Nurse Case Coordinator25% Nurse Case Coordinator 26% Other medical-center staff26% Other medical-center staff 13% Community agencies13% Community agencies
Other Services ReceivedOther Services Received
39% Comprehensive day rehabilitation39% Comprehensive day rehabilitation 33% Community Reintegration 33% Community Reintegration
Outpatient Group (3 hrs/wk)Outpatient Group (3 hrs/wk) 56% MN Rehabilitation Services Branch56% MN Rehabilitation Services Branch 26% Other community based vocational 26% Other community based vocational
services (e.g., evaluation, job search, services (e.g., evaluation, job search, job coach)job coach)
Primary Emphases of ProjectPrimary Emphases of Project
Early medical, rehabilitative, and Early medical, rehabilitative, and vocational interventionvocational intervention
Integration of medical center and Integration of medical center and community servicescommunity services
Work trialsWork trials Temporary or long-term supported Temporary or long-term supported
employmentemployment Employer education about brain injuryEmployer education about brain injury
Key Elements Key Elements of Vocational Case Coordinator Modelof 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
Key Elements Key Elements of Vocational Case Coordinator Modelof Vocational Case Coordinator Model
Use on-the-job evaluations to gather the best information about a person’s 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
Vocational Service ModelsVocational Service Models Specialized Specialized
– Provides early Provides early interventionintervention
– Bridges gap between Bridges gap between hospital and communityhospital and community
– On-the-job evaluationsOn-the-job evaluations
– Integrates vocational Integrates vocational and rehabilitation goalsand rehabilitation goals
– Places and trainsPlaces and trains
TraditionalTraditional– Waits for person to Waits for person to
applyapply– No involvement in No involvement in
medical rehabilitationmedical rehabilitation– Interest and aptitude Interest and aptitude
testing, work samplestesting, work samples– Focuses only on Focuses only on
vocational goalsvocational goals– Trains and placesTrains and places
Vocational Service ModelsVocational Service Models
SpecializedSpecialized– Employer and co-Employer and co-
worker educationworker education– Addresses psychosocial Addresses psychosocial
and functional issues and functional issues before job placementbefore job placement
– Team approachTeam approach– Sequence of short-term Sequence of short-term
goalsgoals– Supported risk takingSupported risk taking
TraditionalTraditional– No educational No educational
outreachoutreach– Addresses psychosocial Addresses psychosocial
and functional issues and functional issues after they ariseafter they arise
– One counselor per One counselor per clientclient
– One long-term One long-term vocational goalvocational goal
– High risk for failureHigh risk for failure
Vocational OutcomesVocational Outcomes
And Outcome PredictorsAnd Outcome Predictors
Vocational Independence Vocational Independence ScaleScale
Competitive: Competitive: Community-based work (at least Community-based work (at least 15 hours per week) without external supports15 hours per week) without external supports
Transitional:Transitional: Community-based work (at least Community-based work (at least 15 hours per week) with temporary supports, 15 hours per week) with temporary supports, such as, job coach, reduced hours OR such as, job coach, reduced hours OR enrollment in an educational or training enrollment in an educational or training programprogram
Supported:Supported: Community-based work with Community-based work with permanent supports or less than 15 hours per permanent supports or less than 15 hours per week OR volunteer workweek OR volunteer work
Sheltered:Sheltered: Work in a sheltered workshop Work in a sheltered workshop UnemployedUnemployed
Vocational Independence Vocational Independence Scale at Placement and 1 Yr Scale at Placement and 1 Yr
Follow-upFollow-up
10%10% 9%
25%
46%
13%6%
9%
19%
53%
0%
10%
20%
30%
40%
50%
60%
Initial Placement(n=114)
One Yr Follow-up(n=101)
Not placed/unemployedSheltered
Supported
Transitional
Independent
Vocational Outcome Vocational Outcome PredictorsPredictors
After Brain InjuryAfter Brain Injury
Severity of initial injurySeverity of initial injury Time since injuryTime since injury Impairment/disabilityImpairment/disability Impaired self-awarenessImpaired self-awareness Preinjury vocational statusPreinjury vocational status Preinjury educational statusPreinjury educational status
Mayo-Portland Adaptability Mayo-Portland Adaptability InventoryInventory
MobilityMobility Use of handsUse of hands VisionVision Motor speechMotor speech CommunicationCommunication MemoryMemory Attention/concentrationAttention/concentration Novel problem solvingNovel problem solving Visuospatial abilitiesVisuospatial abilities Fund of information Fund of information Irritability/aggressionIrritability/aggression
DepressionDepression ResidenceResidence Self caresSelf cares Work/schoolWork/school Leisure activitiesLeisure activities DrivingDriving Family/significant Family/significant
relationshipsrelationships Social contactSocial contact Appropriate social Appropriate social
interactioninteraction IndifferenceIndifference InitiationInitiation
Stepwise Logistic Regression: Stepwise Logistic Regression:
VIS at PlacementVIS at Placement
Time Since Injury (ΧTime Since Injury (Χ2 2 = 9.70, p <.01)= 9.70, p <.01) Rasch Staff MPAI (ΧRasch Staff MPAI (Χ2 2 = 8.30, p <.01)= 8.30, p <.01)
Stepwise Logistic Regression: Stepwise Logistic Regression:
VIS at 1 Year Follow-upVIS at 1 Year Follow-up
VIS at placement (ΧVIS at placement (Χ2 2 = 53.30, p = 53.30, p <.0001)<.0001)
Stepwise Linear Regression: Stepwise Linear Regression: Time to PlacementTime to Placement
Rasch Staff MPAI (RRasch Staff MPAI (R22 = .16) = .16) Preinjury education (RPreinjury education (R22 = .03) = .03)
Vocational Outcome Vocational Outcome SummarySummary
81% in community-based employment at 1 81% in community-based employment at 1 year follow-upyear follow-up
53% in independent employment at 1 year53% in independent employment at 1 year 39% of those placed returned to previous 39% of those placed returned to previous
employmentemployment 58% of total placements made within 6 58% of total placements made within 6
months of initiation of servicesmonths of initiation of services 92% within 1 year92% within 1 year
Comprehensive vs. LimitedComprehensive vs. Limited
InterventionIntervention
Comprehensive Postacute Brain Comprehensive Postacute Brain Injury RehabilitationInjury Rehabilitation
A cognitive and behavioral approachA cognitive and behavioral approach Interdisciplinary teamInterdisciplinary team Emphasis on self-awareness, adjustment, Emphasis on self-awareness, adjustment,
compensation and social skillscompensation and social skills Low staff-to-patient ratioLow staff-to-patient ratio Family involvementFamily involvement Vocational and independent living trialsVocational and independent living trials Systematic outcome assessmentSystematic outcome assessment
Mayo Comprehensive ProgramMayo Comprehensive Program
Patient CharacteristicsPatient Characteristics
Limited self-awareness of disabilitiesLimited self-awareness of disabilities Cognitive impairments: e.g., Cognitive impairments: e.g.,
concentration, memory, generalization, concentration, memory, generalization, problem-solving, initiation, reasoning, problem-solving, initiation, reasoning, planningplanning
Poor communication and social skillsPoor communication and social skills Limited emotional/behavioral self-controlLimited emotional/behavioral self-control Unemployed or failing in employmentUnemployed or failing in employment Not a danger to self or othersNot a danger to self or others
Mayo Comprehensive ProgramMayo Comprehensive Program
GroupsGroups
DailyDaily OrientationOrientation CognitiveCognitive Social AwarenessSocial Awareness CommunicationCommunication Life SkillsLife Skills
WeeklyWeekly Health EducationHealth Education VocationalVocational
MonthlyMonthly Patient/Family Patient/Family
GroupGroup
Mayo Comprehensive ProgramMayo Comprehensive ProgramVocational IndependenceVocational Independence
84%
26%
27%
6% 8% 6%3% 3%
18%
3%
53%
10%
4%
10%
39%
0%10%20%30%40%50%60%70%80%90%
Perc
ent
of G
raduate
s
Unemployed Sheltered Supported Transitional Independent
Pre Post 1-Year
Community-Based Community-Based Employment by Time Since Employment by Time Since
InjuryInjury
0%
10%
20%
30%
40%
50%
60%
70%
80%
Perc
ent
of G
raduate
s
< 1 yr(n=36)
1-2 yrs(n=16)
2-5 yrs(n=17)
5-10 yrs(n=15)
10+ yrs(n=12)
Time Since Injury
Pre Post 1-Yr
Limited InterventionLimited Intervention
Vocational Services onlyVocational Services only Additional outpatient cognitive Additional outpatient cognitive
rehabilitationrehabilitation Adjustment counselingAdjustment counseling Other outpatient rehabilitation therapiesOther outpatient rehabilitation therapies Community Integration Outpatient Community Integration Outpatient
GroupGroup
Probability of Community-Probability of Community-Based EmploymentBased Employment
Staff MPAI Standard ScoreMonthsSinceInjury 300 400 500 600 700
6-12 .98 .94 .81 .53 .24
60 .96 .88 .67 .36 .13
120 .91 .75 .45 .18 .06
CDT .98 .92 .77 .47 .20
ConclusionsConclusions A medical-center based Vocational Case A medical-center based Vocational Case
Coordinator who coordinates service Coordinator who coordinates service delivery maximizes vocational outcomes for delivery maximizes vocational outcomes for persons after brain injurypersons after brain injury
Early intervention optimizes outcomes and Early intervention optimizes outcomes and optimizes the success of limited optimizes the success of limited interventionintervention
Successful vocational placement can be Successful vocational placement can be accomplished within 1 yearaccomplished within 1 year
ConclusionsConclusions Overall disability and time since injury are Overall disability and time since injury are
the best predictors of vocational the best predictors of vocational placement after brain injury rehabilitationplacement after brain injury rehabilitation
The best predictor of long-term vocational The best predictor of long-term vocational outcome is initial placementoutcome is initial placement
Return to previous employment is a viable Return to previous employment is a viable option for many persons after brain injuryoption for many persons after brain injury
ConclusionsConclusions Comprehensive rehabilitation is often Comprehensive rehabilitation is often
required by more persons with greater required by more persons with greater disability or chronicity and results in a disability or chronicity and results in a more extended time to placement more extended time to placement
However, comprehensive intervention However, comprehensive intervention can be successful with the majority of can be successful with the majority of persons served regardless of persons served regardless of chronicity or severitychronicity or severity