Achieving a successful and sustainable return to the workforce after ABI: a client-centred approach

A vocational intervention that enhances return to work after severe acquired brain injury: A pragmatic trial

BACKGROUND

Following a severe acquired brain injury, individuals often have low return to work rates. The Vocational Intervention Program (VIP), a partnership of Brain Injury Rehabilitation Program community rehabilitation centres with external vocational rehabilitation providers in New South Wales, Australia, was developed to facilitate a return to competitive employment for working-age people.

OBJECTIVES

To evaluate the efficacy of the VIP partnership model, this intervention was compared to outcomes from a health-based brain injury vocational rehabilitation centre (H-VR) or community brain injury rehabilitation centres ("treatment as usual"; TAU).

METHODS

A 3-arm non-randomized controlled trial was conducted among the 12 adult rehabilitation centres of the NSW Brain Injury Rehabilitation Program. The VIP arm was delivered by 6 community rehabilitation centres in partnership with 3 external private Vocational Rehabilitation providers. The H-VR arm was delivered by 1 health-based vocational rehabilitation centre and the 5 remaining centres delivered TAU. Competitive employment status ("Yes"/"No") and clinician ratings of disability and participation were collected pre- and post-intervention, and at 3-month follow-up. Multilevel models were conducted to investigate change over time by treatment arm.

RESULTS

In total, 148 individuals with severe brain injury were included in the trial: n = 75 (VIP), n = 33 (H-VR) and n = 40 (TAU). Sixty-five people (of 108, 60%) completed the VR intervention. A significant arm-by-time interaction was found, with higher return to work rates from pre- to post-intervention in VIP and H-VR arms compared to TAU (P = 0.0002). Significant arm-by-time interactions also indicated improved work-related participation and independent living skills from pre- to post-intervention in VIP and H-VR compared to the TAU arm (P < 0.05). These improvements were maintained at 3-month follow-up.

CONCLUSIONS

The VIP improved return to competitive employment at comparable rates to the specialist H-VR. Larger-scale adoption of the VIP model could provide significant improvements in vocational rehabilition sevices to support people in their return to work following severe brain injury.

ANZCTR TRIAL REGISTRY NUMBER

ACTRN12622000769785.

Clinician perspectives of ABI vocational rehabilitation in Queensland

INTRODUCTION

Services to support adults with acquired brain injury (ABI) and return to work goals are varied. In Queensland, Australia, return to work goals may be addressed through private or publicly funded rehabilitation services or through publicly funded employment programs. No set frameworks or processes are in place to guide clinicians in providing vocational rehabilitation to adults with ABI, and the extent to which services address clients' vocational goals and/or provide vocational rehabilitation is unknown.

METHOD

This qualitative study investigated the clinical practice and experiences of allied health rehabilitation clinicians (n = 34) to identify current practice in providing vocational rehabilitation to adults with ABI, including pathways and services; models, frameworks and tools; and recommendations for ideal services. Focus groups and online surveys were conducted, with data analysed via content analysis.

RESULTS

ABI vocational rehabilitation was inconsistently delivered within and across services in Queensland, with differences in access to services, aspects of vocational rehabilitation provided and timeframes for rehabilitation. Five key themes were identified regarding ABI vocational rehabilitation and service delivery in Queensland: Factors influencing ABI and return to work; Service provision; ABI vocational rehabilitation processes (including assessment tools and interventions); Service gaps; and Ideal ABI vocational rehabilitation services.

DISCUSSION

These findings can inform clinical practice and development, and current and future service delivery models for ABI vocational rehabilitation.

Identifying models, processes, and components of vocational rehabilitation following acquired brain injury: a systematic scoping review

PURPOSE

Acquired brain injury (ABI) is a complex injury which impacts engagement with worker roles. Return to work (RTW) rates for individuals with brain injury are low and those who do RTW often report job instability. Vocational rehabilitation (VR) can improve RTW rates and job stability; however, service provision is varied, and no gold standard has been identified.

METHODS

A systematic scoping review of the literature was completed to explore research activity in VR for individuals with ABI to address the following three questions: what models have been identified to underpin VR in ABI? What clinical processes have been identified to guide provision of VR in ABI? What components of VR have been described and/or recommended in the ABI literature?

RESULTS

The number of included articles was 57. From these articles, 16 models, nine process steps, eight components, and four service delivery components were identified that were utilised in provision of ABI VR. Implications for practice are discussed.

CONCLUSIONS

Key processes and components of ABI VR have been identified across a range of models and apply to clients at all phases post-injury. Findings may be used to inform service provision across a range of time points and support clinicians in their delivery of VR to adults with brain injury.Implications for RehabilitationPeople with acquired brain injury (ABI), even severe injury, can be successful with return to work (RTW) when provided appropriate supports.A wide range of models, interventions, and service components have been identified in the literature which can be used to guide clinical and policy development in ABI vocational rehabilitation.Vocational rehabilitation for individuals with brain injury involves a complex interaction of factors, and consideration should be paid to not only the person and their abilities but also job demands and the environment (physical, social, cultural).Vocational rehabilitation services should be accessible and timed to maximise chances of a successful RTW, provided by a coordinated interdisciplinary team and should involve active stakeholder engagement.

What Does It Take to Get Somebody back to Work after Severe Acquired Brain Injury? Service Actions within the Vocational Intervention Program (VIP 2.0)

Little is known about service actions delivered in the complex intervention of vocational rehabilitation (VR) for people with severe acquired brain injury (ABI). Scale-up of the Vocational Intervention Program (VIP) across the 12 Community teams of the NSW Brain Injury Rehabilitation Program provided an opportunity to analyse the intensity and profile of actions delivered in providing VR programs. Seventy-two participants with severe TBI were supported in returning to either pre-injury employment (FastTrack, FT, n = 27) or new employment (NewTrack, NT, n = 50), delivered by two types of VR providers (Disability Employment Service DES; private providers). VR providers documented their service actions in hours and minutes, using the Case Management Taxonomy, adapted to VR. The NT pathway required significantly higher levels of intervention in comparison to FT (25 h, five minutes vs. 35 h, 30 min, p = 0.048, W = 446). Case coordination was the most frequent service action overall (41.7% of total time for FT, 42.3% for NT). DES providers recorded significantly greater amounts of time undertaking engagement, assessment and planning, and emotional/motivational support actions compared to private providers. Overall duration of the programs were a median of 46 weeks (NT) and 36 weeks (FT), respectively. This study helps illuminate the profile of VR interventions for people with severe TBI.

Is a structured work task application for the assessment of work performance in a constructed environment, useful for patients with attention deficits?

BACKGROUND

The purpose of our study was to develop a Structured Work Task application for the Assessment of Work Performance for patients with attention deficits.

MATERIAL AND METHODS

We developed a computer-based registration task titled the Attention-demanding Registration Task. It had a structured administrative procedure with additional scoring regarding time and accuracy, also linked to the original scoring of the Assessment of Work Performance. We evaluated the Attention-demanding Registration Task for content validity. Furthermore, we investigated it concerning sensitivity and specificity in patients with attention deficits due to acquired brain injury (n = 65) against a comparison group of healthy people (n = 47).

RESULTS

Our investigation on content validity using the Assessment of Work Characteristics confirmed that the Attention-demanding Registration Task sets high demands on process skills, especially on energy, temporal organization, and adaptation. The Attention-demanding Registration Task showed high sensitivity and specificity in differing between patients with attention deficits and a healthy working group; nine out of ten participants were placed in the correct group.

CONCLUSIONS

To assess work performance, the use of a Structured Work Task application, the Attention-demanding Registration Task, linked with the Assessment of Work Performance, proved to be sensitive to attention deficits.Implications for rehabilitationA Structured Work Task application for the Assessment of Work Performance was developed for use in people with attention deficits and showing a high degree of sensitivity and specificity.Linking performance time and accuracy to the Assessment of Work Performance scoring and providing a guide for linking task performance to the Assessment of Work Performance skills in addition to the usual observations performed, may increase scoring accuracy.Reference data for a comparison group of healthy subjects are provided.The use of the Attention demanding Registration Task, while using the Assessment of Work Performance within clinical practice ensures a more accurate description of process skills in performance.

A Systematic Scoping Review of Work Interventions for Hospitalised Adults with an Acquired Neurological Impairment

Purpose Addressing return to work early after neurological impairment from stroke or moderate and severe traumatic brain injury may improve likelihood of returning to employment, yet little is known about how best to organize work interventions for delivery in the inpatient hospital setting. The purpose of this scoping review was to identify knowledge gaps and inform program development in hospital-based work interventions. Method We searched MEDLINE, CINAHL, OTSeeker and Embase for English-language articles published from database inception until March 2018. Citations were then manually searched using reference lists of included papers and Google Scholar. Articles were included if they described programs providing return to work intervention within a hospital to adults with newly acquired neurological conditions, such as traumatic brain injury or stroke. After identifying and selecting relevant studies, we charted the data and then synthesized the results. Results Twenty-eight articles explored work intervention in an inpatient hospital setting. Interventions targeted a diagnostically heterogeneous population, mostly including adults who had suffered either a traumatic brain injury or stroke. Most interventions included a structured process for assessment, highlighted the importance of collaboration, and aimed to improve performance of work skills that could be facilitated within a hospital setting only (as opposed to all work skills). Thematic analysis of included studies resulted in four themes: structure, collaboration, clinician training, and belief in future work capacity. Conclusion Return to work intervention appears to be an important component of neurological rehabilitation. While studies to date have identified enablers for the integration of work interventions into the inpatient hospital setting, there is limited description of specific components of programs, and a lack of studies evaluating program effectiveness.

An exploration of alternative methods for assessing return-to-work success following occupational injury

PURPOSE

To explore alternative methods for assessing return-to-work success.

METHOD

This exploratory study employed a prospective design. Participants (N = 150) were all vocational rehabilitation recipients who sustained a work-related injury that resulted in them being off work for at least 6 months, and were unable to return to their pre-injury position. At baseline (B), all were reported to have found post-injury employment. Qualitative features of the participants' post-injury employment were assessed at the time of initial interview (T1), which was conducted a mean of approximately one year following the participants' scheduled workplace re-entry (mean 344 days). Participants' T1 employment characteristics were then compared to their outcomes at the time of follow-up (T2), which was approximately 3 months later (mean 85 days).

RESULTS

Findings indicate that 25% of participants were not in their baseline jobs at the time of last contact; some were in different jobs, however others were not working. At T1 many of those working reported experiencing difficulties. Comparisons revealed significant relationships between problem indicators at T1 and employment outcomes at T2, with significant problem indicators including worries that symptoms might interfere with their ability to continue in the job, difficulties with the job's physical demands and a strong desire to leave their current job. When problem indicators were used in combination, stronger relationships were observed and self-assessed performance contributed to the effect.

CONCLUSIONS

Results add support to the contention that rather than a single event, RTW is an evolving, complex and sometimes nonlinear process. This should be kept in mind when assessing the success of an injured worker's RTW.

Inter-professional clinical practice guideline for vocational evaluation following traumatic brain injury: a systematic and evidence-based approach

INTRODUCTION

This paper introduces an inter-professional clinical practice guideline for vocational evaluation following traumatic brain injury. This guideline aims to explicate the processes and factors relevant to vocational evaluation to assist evaluators (i.e. health care teams, individuals and employers) in collaboratively determining if clients are able to work and to make recommendations for work entry, re-entry or vocational planning.

METHODS

Methods in the Canadian Medical Association's (CMA) Handbook on Clinical Practice Guideline and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were utilized to ensure rigour. Steps in the CMA handbook were followed and included: (1) identifying the guideline's objective and questions; (2) systematic literature review; (3) study selection and quality appraisal; (4) development of clear recommendations by key stakeholders; (5) guideline pilot testing and endorsement.

RESULTS

The resulting guideline includes 17 key recommendations within the seven domains: (1) evaluation purpose and rationale; (2) initial intake process; (3) assessment of the personal domain; (4) assessment of the environment; (5) assessment of occupational/job requirements; (6) analysis and synthesis; (7) evaluation recommendations.

CONCLUSIONS

The guideline may be useful to individually practicing clinicians, health care teams, employers and individuals with TBI. Future research will formally examine the success of the guideline's implementation.

An integrated review of the processes and factors relevant to vocational evaluation following traumatic brain injury

INTRODUCTION

In order to develop the evidence base for a clinical practice guideline (CPG) for vocational evaluation following traumatic brain injury (TBI), we undertook a review to identify the key processes evaluators should follow and the key factors they should consider when completing a vocational evaluation.

METHODS

Processes outlined in the Cochrane Handbook of Systematic Review guided our processes and included: development of review questions, search strategies and selection criteria; quality appraisal; extraction, analysis and data synthesis; drawing conclusions. Four data bases (i.e. Medline; PsychInfo; Embase; The Cochrane Library of Systematic Reviews) were searched for descriptive articles, quantitative and qualitative studies, and nine websites were searched for CPGs (e.g. Scottish Intercollegiate Guideline Network; US National Guideline Clearinghouse; New Zealand Guideline Group). Two reviewers independently appraised methodological quality. Data were extracted into evidence tables which included: study purpose; location; participants; design/method; themes; findings; relevant processes and factors. Directed content analysis was utilized to analyze and synthesize the descriptive process evidence. A constant comparative method was employed to compare study findings in relation to factors associated with successful employment.

RESULTS

Results from process and factors syntheses are integrated into the Evidence-based Framework for Vocational Evaluation Following TBI. This framework identifies seven key processes in a vocational evaluation, including: (1) identification of the evaluation purpose and rationale; (2) intake process; (3) assessment of the person; (4) assessment of the environment; (5) assessment of the occupation/job requirements; (6) analysis and synthesis of assessment results; (7) development of evaluation recommendations. Relevant factors are integrated into each key process.

CONCLUSIONS

This framework outlines the key information evaluators should gather, the domains of the person, environment and occupation they should assess, and elements of rigour they should consider when completing a vocational evaluation and making recommendations for work re-entry following a TBI.

Return to Work after Traumatic Brain Injury: Recording, Measuring and Describing Occupational Therapy Intervention

Low post-injury employment rates indicate that returning to work is difficult following traumatic brain injury (TBI). Occupational therapists assist people with TBI to return to work, but rarely is their intervention described. This has hindered research into vocational rehabilitation.

As no existing tool was identified for recording intervention, a proforma was developed for this study. Using best practice guidelines and a consensus of expert opinion, 15 categories of the vocational rehabilitation process were identified. Time spent on each category was recorded in 10-minute units after each occupational therapy session. The records of 21 participants who received occupational therapy focused on vocational rehabilitation were analysed.

The proforma was quick and simple to use. The analysis showed that assessment, work preparation, employer involvement, education and dealing with issues of immediate concern to participants accounted for almost 85% of face-to-face intervention. It also showed that for every 1 hour of face-to-face contact, an additional 2 hours was required for liaison and travel.

This study showed that there is potential for using a proforma for quantifying and describing occupational therapy. This is the basis for further work to enable meaningful comparisons with other services and use in future studies.

Treatment paths and costs for young adults with acquired brain injury in the United Kingdom

PRIMARY OBJECTIVES

To identify the health and social care services used by young adults aged 18-25 years with acquired brain injury (ABI) and the costs of these supports.

RESEARCH METHODS

A review of existing literature and databases and contact with academics and stakeholders working with people with ABI.

MAIN OUTCOMES AND RESULTS

The likely care pathways of young adults with ABI were mapped over a notional 1-year period after presentation at hospital accident and emergency departments. Most young adults with ABI will use minimal health and social care support following injury but those with subsequent disabilities may cost the health and social care budget in excess of pound47.2 million per year.

CONCLUSION

Lack of available data mean the service use and cost estimates draw from a range of sources. However, the costs may under-estimate the true impact on budgets as incidence rates may be higher than identified and conservative values were selected for unit costs. The model estimates the cost of treatment and support as provided today, but high levels of unmet need remain.

Returning to work after stroke: a review

This review focuses on the experiences and rehabilitation needs of working age, higher functioning stroke survivors in relation to their 'return to work'. It grew out of the poststroke experience of one of the authors and her realization of the inadequacy of services to facilitate return to work and optimal recovery from stroke. The authors' aim is to present a practice-oriented review that can provide information for future practice and research. Returning to work and sustaining employment are considered key aspects of rehabilitation and recovery by younger stroke survivors. From a psychosocial perspective, successful return to work can enhance recovery and life satisfaction by consolidating self-esteem, confidence and social identity. However, even higher functioning stroke survivors with minimal or no obvious physical disability may experience workplace challenges relating to their neurological condition. Appropriate rehabilitation would include specific preparation for return to work, education within the workplace to facilitate return to work, participation by the stroke survivor in all aspects of the management of their return to work, and an ongoing role for a stroke educator/workplace advocate. In conclusion, further research is required in this area to support stroke survivors in returning to and maintaining employment to achieve their poststroke potential. Thirteen recommendations arising from the existing literature and the lived experience of one of the authors are presented at the end of the review.

Approaches to vocational rehabilitation after traumatic brain injury: a review of the evidence

BACKGROUND

Return to work after traumatic brain injury (TBI) is an important outcome but frequently problematic to achieve. Vocational rehabilitation is commonly recommended as a means of facilitating return to work after TBI. However, there are several different approaches to vocational rehabilitation after TBI and little guidance regarding how to identify the best option for a particular context.

OBJECTIVES

To (1) identify approaches most commonly underpinning vocational interventions in TBI and (2) evaluate the evidence for effectiveness, strengths and weaknesses, and application of each approach for the TBI population.

METHODS

Principles of systematic review were used for searching and critiquing articles. Findings are expressed as descriptive synthesis owing to heterogeneity of designs and outcome measures.

RESULTS

Three broad categories of vocational rehabilitation for people with TBI were identified on the basis of models that underpin them-program-based vocational rehabilitation, supported employment, and case coordinated. The characteristics, similarities, differences, and applications of each approach are described, as are their strengths and limitations.

CONCLUSIONS

There is little clear evidence to suggest what should be considered the "best practice" approach to vocational rehabilitation.