Supported Employment for Veterans With Traumatic Brain Injury: Patient Perspectives

Associations Between Traumatic Brain Injury and Severity of Tinnitus-Related Functional Impairment Among US Military Veterans: A National, Population-Based Study

OBJECTIVE

To describe associations between a history of traumatic brain injury (TBI) and the severity of tinnitus-related functional impairment among a national, stratified random sample of veterans diagnosed with tinnitus by the Department of Veterans Affairs (VA) healthcare system.

SETTING

A multimodal (mailed and internet) survey administered in 2018. Participants: VA healthcare-using veterans diagnosed with tinnitus; veterans with comorbid TBI diagnosis were oversampled.

DESIGN

A population-based survey.

MAIN MEASURES

TBI history was assessed using International Classification of Diseases (ICD) diagnosis codes in veterans' VA electronic health records. The severity of participants' overall tinnitus-related functional impairment was measured using the Tinnitus Functional Index. Population prevalence and 95% confidence intervals (CIs) were estimated using inverse probability weights accounting for sample stratification and survey nonresponse. Veterans' relative risk ratios of very severe or moderate/severe tinnitus-related functional impairment, versus none/mild impairment, were estimated by TBI history using bivariable and multivariable multinomial logistic regression.

RESULTS

The population prevalence of TBI was 5.6% (95% CI: 4.8-6.4) among veterans diagnosed with tinnitus. Veterans with a TBI diagnosis, compared with those without a TBI diagnosis, had 3.6 times greater likelihood of rating their tinnitus-related impairment as very severe (95% CI: 2.1-6.3), and 1.5 times greater likelihood of rating their impairment as moderate/severe (95% CI: 1.0-2.4), versus none/mild.

CONCLUSIONS

These findings suggest an important role of TBI in the severity of tinnitus-related functional impairment among veterans. This knowledge can help inform the integration of tinnitus management services into the care received by veterans with TBI.

Prevalence and Correlates of VA-Purchased Community Care Use Among Post-9/11-Era Veterans With Traumatic Brain Injury

OBJECTIVE

Post-9/11-era veterans with traumatic brain injury (TBI) have greater health-related complexity than veterans overall, and may require coordinated care from TBI specialists such as those within the Department of Veterans Affairs (VA) healthcare system. With passage of the Choice and MISSION Acts, more veterans are using VA-purchased care delivered by community providers who may lack TBI training. We explored prevalence and correlates of VA-purchased care use among post-9/11 veterans with TBI.

SETTING

Nationwide VA-purchased care from 2016 through 2019.

PARTICIPANTS

Post-9/11-era veterans with clinician-confirmed TBI based on VA's Comprehensive TBI Evaluation (N = 65 144).

DESIGN

This was a retrospective, observational study.

MAIN MEASURES

Proportions of veterans who used VA-purchased care and both VA-purchased and VA-delivered outpatient care, overall and by study year. We employed multivariable logistic regression to assess associations between veterans' sociodemographic, military history, and clinical characteristics and their likelihood of using VA-purchased care from 2016 through 2019.

RESULTS

Overall, 51% of veterans with TBI used VA-purchased care during the study period. Nearly all who used VA-purchased care (99%) also used VA-delivered outpatient care. Veterans' sociodemographic, military, and clinical characteristics were associated with their likelihood of using VA-purchased care. Notably, in adjusted analyses, veterans with moderate/severe TBI (vs mild), those with higher health risk scores, and those diagnosed with posttraumatic stress disorder, depression, anxiety, substance use disorders, or pain-related conditions had increased odds of using VA-purchased care. Additionally, those flagged as high risk for suicide also had higher odds of VA-purchased care use.

CONCLUSIONS

Veterans with TBI with greater health-related complexity were more likely to use VA-purchased care than their less complex counterparts. The risks of potential care fragmentation across providers versus the benefits of increased access to care are unknown. Research is needed to examine health and functional outcomes among these veterans.

The Impact of Tinnitus Severity on Work Functioning among U.S. Military Veterans with Tinnitus

Tinnitus is highly prevalent among military Veterans. Severe tinnitus can be associated with negative impacts on daily life. Veterans with severe tinnitus may also have greater difficulties in functional roles, including work. However, few studies have explicitly explored this relationship. Traumatic brain injury (TBI), also prevalent among Veterans, is associated with tinnitus and can additionally impair work functioning. This quantitative investigation used a population-based survey to assess the relationship between tinnitus severity, measured using the Tinnitus Functional Index (TFI), and the impact of tinnitus on work, measured using a composite score from the Tinnitus History Questionnaire, among a stratified random sample of VA healthcare-using Veterans diagnosed with tinnitus, with and without comorbid TBI. Analyses were weighted to account for sampling design and Veteran non-response; multiple imputation was used to account for missing data. Results indicated that for every 1-point increase in TFI score, there was an average 8% increase in the odds of reporting a high level of impact on work functioning (OR: 1.08; 95% CI: 1.06, 1.11). Veterans with a comorbid TBI diagnosis, compared with those without, were more likely to have high tinnitus-related impact on work functioning (OR: 2.69, 95% CI: 1.85, 3.91), but the relationship between tinnitus severity and the impact of tinnitus on work functioning did not differ by TBI status. These data can help researchers and clinicians understand complex symptoms experienced by Veterans with tinnitus, with and without TBI, supporting the improved provision of clinical services to these patients.

Evaluation of clinical outcomes and employment status in veterans with dual diagnosis of traumatic brain injury and spinal cord injury

PURPOSE

To examine clinical outcomes and employment status in Veterans with and without a dual diagnosis of traumatic brain injury (TBI) and spinal cord injury (SCI).

METHODS

This cross-sectional study examined a national sample of Veterans enrolled in the VA Million Veteran Program who completed the Comprehensive TBI Evaluation (CTBIE) as part of the Veterans Health Administration's TBI Screening and Evaluation Program. Veterans (N = 12,985) were classified into the following TBI/SCI groups using CTBIE data: those with a dual diagnosis of TBI and SCI (TBI+/SCI+); those with a history of TBI but no SCI (TBI+/SCI-); and those with no history of TBI or SCI (TBI-/SCI-; i.e., the control group). CTBIE-derived outcomes included neurobehavioral symptoms, comorbid psychiatric symptoms, pain and pain interference, and employment status.

RESULTS

Chi-square analyses showed significant associations between TBI/SCI group and all clinical outcomes evaluated (all p's < .001; V = 0.07-0.11). In general, the TBI+/SCI+ and TBI +/SCI- groups endorsed comparable levels of neurobehavioral symptoms, psychiatric symptoms, and pain, but significantly greater rates of symptoms and pain relative to the TBI-/SCI- group. Effect sizes for all pairwise comparisons were small (φ = 0.01-0.11). Finally, there was no significant association between TBI/SCI group and employment status (p = .170; V = 0.02), with all three groups showing relatively comparable rates of unemployment.

CONCLUSIONS

Regardless of SCI status, Veterans with TBI history endorsed poorer clinical outcomes than Veterans without TBI and SCI. However, rates of unemployment were similarly high across all three groups. Findings suggest that any Veteran completing the CTBIE may be at risk for poor clinical and employment outcomes.

Characterizing Sex Differences in Clinical and Functional Outcomes Among Military Veterans with a Comprehensive Traumatic Brain Injury Evaluation (CTBIE): A Million Veteran Program (MVP) Study

Using a diverse sample of military Veterans enrolled in the VA's Million Veteran Program (N=14,378; n=1,361 females [9.5%]; all previously deployed), we examined sex differences on the Comprehensive Traumatic Brain Injury Evaluation (CTBIE), a structured traumatic brain injury (TBI) interview routinely administered within the VA. Confirmed TBI diagnoses were more frequent among males than females (65% vs. 58%). Additionally, when compared to females, a greater proportion of males with CTBIE-confirmed TBI histories experienced blast-related injuries and were employed. In contrast, a greater proportion of females reported experiencing falls, sustaining a TBI since deployment, and having more severe neurobehavioral symptoms (particularly affective-related symptoms). Results indicate that males and females experience differential clinical and functional outcomes in the aftermath of military TBI. Findings underscore the need to increase female representation in TBI research to increase understanding of sex-specific experiences with TBI and to improve the clinical care targeted to this vulnerable population.

"Manoeuvring in uncharted waters - a balancing act": A qualitative exploration of treatment and improvement after mild traumatic brain injury

Background: Individuals who have sustained mild traumatic brain injury (mTBI) with a protracted course of recovery may experience long-lasting somatic, cognitive, and emotional symptoms affecting activities of daily living. There is limited knowledge regarding individuals' lived experiences with treatments and advice provided.Purpose: To explore how individuals with mTBI describe and make sense of their injury, recovery process, and their experiences with various treatment approaches.Methods: Eight participants with mTBI were recruited from the intervention group in an ongoing randomized controlled trial regarding return-to-work. They were interviewed once after treatment delivery using a qualitative hermeneutical approach. Thematic analysis was applied, and findings are discussed in light of a salutogenic theory.Results: Participants expressed uncertainty regarding conflicting advice they received in the early phase of recovery. Three main themes were developed: (1) "Ambiguity and hope"; (2) "Uncertainty concerning activity and rest"; and (3) "To become the person I used to be vs. to become a new version of myself."Conclusion: The findings showed that the participants experienced both uncertainty and hope for further recovery. The recovery process is challenged by the variability of TBI symptoms that affects participation in everyday life, as well as the conflicting advice received by the participants.

Experiences of VA vocational and education training and assistance services: Facilitators and barriers reported by veterans with disabilities

OBJECTIVE

To understand the experiences of veterans with disabilities and caregiving needs who use Department of Veterans Affairs (VA) vocational and education services, including Supported Employment, the Post-9/11 GI Bill, and Vocational Rehabilitation and Employment.

METHOD

We conducted 26 joint semistructured interviews with post-9/11 veterans who had used at least one of three vocational and education services, and their family members who were enrolled in a VA Caregiver Support Program.

RESULTS

VA vocational and education services helped veterans with disabilities transition from the military into civilian life by providing skills and incremental exposure to engaging in everyday life tasks. Veteran motivation, caregiver support, and engaged staff at VA and academic institutions were key drivers of veteran success. Veterans who experienced challenges cited the following barriers: health problems, concerns about benefits loss if they became employed, and VA and academic programs that did not accommodate the needs of nontraditional veteran learners.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

There is a need to bolster VA vocational and educational services for veterans with disabilities in several domains, including modifying the roles of frontline staff and increasing communication between vocational counselors and health care teams to better accommodate the veteran's health-related limitations. Providing a vocational rehabilitation navigator to help veterans identify opportunities within VA and work/educational settings that are a good match for the veteran's goals and abilities could also be beneficial across vocational and educational services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Vocational Rehabilitation in the Veterans Health Administration Polytrauma System of Care: Current Practices, Unique Challenges, and Future Directions

OBJECTIVE/PURPOSE

Veterans and service members (V/SMs) with traumatic brain injury (TBI) and comorbid conditions are treated in the Veterans Health Administration (VHA) Polytrauma System of Care (PSC). These V/SMs comprise a unique population with distinct needs for restoring community reintegration, including participation in meaningful employment. Low employment rates after TBI vary and are influenced by many factors. Employment is a central aspect of the VHA priority of facilitating adjustment, and addressing vocational needs alongside healthcare is critical to community reintegration. The purpose of this article is to outline current practices of addressing vocational rehabilitation in the PSC, discuss the unique challenges in serving Veterans with polytrauma, and outline future directions to improve vocational services and outcomes.

METHODS

Briefly review literature on V/SM with TBI and employment, describe the PSC and VHA vocational programs for V/SM with polytrauma, and synthesize proceedings on vocational rehabilitation from the 2017 VHA "Community Reintegration in the Polytrauma System of Care" meeting.

CONCLUSIONS

To advance and expand vocational services the following guidelines were recommended: (1) designing flexible services based on individualized needs, (2) increasing access to vocational services through communication and collaboration, (3) promoting cross-disciplinary education and engagement in vocational care, and (4) systematically tracking employment outcomes.

Factors associated with employment and work perception in combat-exposed veterans

PURPOSE/OBJECTIVE

The purpose of this study was 2-fold: (a) to evaluate whether perception of work ability is associated with employment status in a sample of combat-exposed veterans, and (b) to determine whether the same sets of variables that are associated with employment status are also associated with perception of work ability. Research Method/Design: In this cross-sectional study, veterans (N = 83) underwent a neuropsychological assessment and completed questionnaires assessing demographic characteristics, combat-related experiences, and psychiatric and neurobehavioral/health-related symptoms. Primary outcomes of interest were employment status (unemployed vs. employed) and veterans' perception of whether their ability to work has declined due to an ongoing condition (yes vs. no).

RESULTS

A chi-square analysis revealed a significant relationship between perception of work ability and employment status. Additionally, psychiatric and neurobehavioral/health-related symptoms were associated with employment status and perception of work ability, whereas demographic characteristics (i.e., service-connected disability rating) and combat-related experiences (i.e., mTBI history) were only associated with perception of work ability. Objective cognitive functioning was not associated with employment status or perception of work ability.

CONCLUSIONS/IMPLICATIONS

Although preliminary, results suggest that perception of work ability is an important factor to consider when evaluating employment-related outcomes in veterans. Moreover, results indicate that while there is some overlap among the variables associated with employment status and perception of work ability, additional variables are linked with perception of work ability. Taken together, these findings suggest that perception of one's ability to work and factors that influence it may be particularly important treatment targets in the veteran population. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Aspects of Executive Dysfunction and Racial/Ethnic Minority Status Are Associated With Unemployment Duration in Veterans With a History of Mild-to-Moderate Traumatic Brain Injury

OBJECTIVE

To examine demographic, psychiatric symptom, and neuropsychological performance factors associated with duration of unemployment in Iraq/Afghanistan Veterans with a history of mild-to-moderate traumatic brain injury (TBI).

DESIGN

Cross-sectional, secondary data analysis of baseline measures in a supported employment study.

SETTING

VA medical center.

PARTICIPANTS

Participants (N=50) were veterans with a history of mild-to-moderate TBI who were unemployed, stating a goal of returning to work, and had documented impairment in at least 1 neuropsychological domain. Participants were referred from VA vocational and assessment-based clinics.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Duration of unemployment, neuropsychological, and psychiatric symptom assessments.

RESULTS

Bivariate correlations revealed that longer duration of unemployment was associated with greater posttraumatic stress disorder (P<.10) and depressive (P<.05) symptom severity, worse executive functioning (P<.05), and racial/ethnic minority status (P<.05). A multiple linear regression analysis including these independent variables explained 26.5% of the variance in duration of unemployment. Worse executive functioning, specifically reasoning and set-shifting, and minority status were each associated with longer duration of unemployment in the context of multiple independent variables.

CONCLUSIONS

Our results underscore the importance of objective assessment of cognitive functioning in job-seeking Veterans with TBI histories. It may be useful to target aspects of executive functioning in vocational rehabilitation interventions and to provide additional assistance to Veterans from racial/ethnic minority groups.

Leveraging institutional support for family caregivers to meet the health and vocational needs of persons with disabilities

BACKGROUND

Family caregivers might enhance veteran engagement in health and nonhealth services (i.e., vocational/educational assistance).

PURPOSE

To describe how veterans with disabilities perceive their recovery needs, identify types of social support from caregivers that help veterans engage in Veterans Affairs (VA) health and nonhealth services, and explore participant views of VA institutional support for caregivers to help veterans engage in these services.

METHODS

Joint in-depth qualitative interviews with U.S. veterans and family caregivers (n = 26).

FINDINGS

Caregivers performed social support functions that helped veterans engage in health and vocational/educational services and institutional support from VA enhanced caregivers' capacity.

DISCUSSION

Caregivers are well positioned to align health and nonhealth services with patient needs to enhance recovery. Staffing a point person for caregivers within the health system is key to help families develop a coordinated plan of treatment and services to improve patient success across health and nonhealth domains. Nurses are well suited to perform this role.

Health Care Utilization and Mental Health Diagnoses Among Veterans With Tinnitus

Purpose Tinnitus is prevalent among military Veterans and may frequently co-occur with mental health disorders. This study examined health care utilization and mental health diagnoses among Veterans with and without tinnitus who receive Department of Veterans Affairs (VA) health care. Method We randomly sampled 10% of VA health care users for a 5-year period between 2011 and 2016. Tinnitus and other diagnoses were identified using International Classification of Diseases diagnosis codes; Veterans assigned 1 or more inpatient codes or 2 or more outpatient codes were considered to have the respective diagnosis. We examined demographics, military service, clinical characteristics, and health care utilization of Veterans with and without tinnitus diagnoses. Bivariable and multivariable logistic regression was used to estimate associations between tinnitus and mental health diagnoses of interest. Results Among 617,534 eligible Veterans, 3.8% met criteria for tinnitus diagnosis. Prevalence of tinnitus was associated with sex, age, race, marital status, and VA service connection status; additionally, hearing loss and traumatic brain injury were frequently codiagnosed with tinnitus. Veterans with tinnitus had higher annual health care utilization than those without. While controlling for potential confounders, tinnitus diagnoses were associated with mental health diagnoses, including anxiety, depression, and substance use disorders. Conclusion Findings suggest that Veterans who are diagnosed with tinnitus have more health care utilization and are more frequently diagnosed with mental health disorders than Veterans who are not diagnosed with tinnitus. This suggests a need for coordinated tinnitus and mental health care services for Veterans in the VA system of care.

Community Reintegration, Participation, and Employment Issues in Veterans and Service Members With Traumatic Brain Injury

Traumatic brain injury (TBI) has been called the signature injury of the post-9/11 wars in Iraq, Afghanistan, and neighboring countries. Although similarities exist between veterans and service members with TBI, levels of severity and different constellations of coexisting comorbid conditions affect them differently. These conditions affect physical, cognitive, and emotional function, which in turn can complicate community reintegration (CR), or the ability to return to family, vocational, and community life. This special supplement of the Archives of Physical Medicine and Rehabilitation consists of articles written by accomplished teams from multiple disciplines, including anthropology, neuropsychology, nursing, occupational therapy, psychology, and rehabilitation sciences. Each article brings a different perspective to bear on what CR means for veterans and service members from examination of predictors and perceptions of veterans and service members and others to measurement studies. Collectively, this group of articles represents current thinking about CR and lays the groundwork for testing interventions to improve CR outcomes for veterans and service members (eg, employment, living situation, family life).

Employment and vocational rehabilitation experiences among veterans with polytrauma/traumatic brain injury history

Evidence suggests that Iraq and Afghanistan war veterans with polytrauma/traumatic brain injury (TBI) history and neurobehavioral symptoms may face difficulties returning to work, yet also encounter barriers to accessing, navigating, and engaging in Department of Veterans Affairs (VA) vocational rehabilitation programs. This study utilized qualitative interviews and focus groups with veterans with documented polytrauma/TBI history to explore veterans' perceived barriers to employment and vocational rehabilitation program participation, as well as to solicit thoughts regarding interest in an evidence-based vocational rehabilitation program, the Individual Placement and Support model of Supported Employment (IPS-SE). Veterans identified physical, emotional, cognitive, and interpersonal barriers to finding and maintaining work that they described as linked with their polytrauma/TBI symptoms and sequelae. Communication and logistical issues were described as the primary barriers to vocational rehabilitation program access, while barriers to program utilization included eligibility characteristics, fear of losing financial benefits, and a military-cultural belief of self-sufficiency that made help-seeking difficult. Finally, veterans endorsed key aspects of IPS-SE, such as staff serving as translators, advocates, and navigators of the job search and maintenance process. Policy recommendations are addressed. (PsycINFO Database Record (c) 2020 APA, all rights reserved).