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Return to Work After Brain Injury Jeffrey S. Kreutzer, Ph.D. Virginia Commonwealth University Medical Center.

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Presentation on theme: "Return to Work After Brain Injury Jeffrey S. Kreutzer, Ph.D. Virginia Commonwealth University Medical Center."— Presentation transcript:

1 Return to Work After Brain Injury Jeffrey S. Kreutzer, Ph.D. Virginia Commonwealth University Medical Center

2 Pre- and Postinjury Work Status of Patients Working Postinjury Brooks, Glasgow

3 Proportion of Employed Patients at Varying Times Postinjury Brooks, Glasgow Months Postinjury

4 Return to Work and Job Stability after TBI A TBI Model System Multicenter Analysis J. Kreutzer, J. Marwitz, W. Walker,et al. Virginia Commonwealth University Medical Center Job Stability after TBI

5 Job Stability after TBI Primary Outcome Measure Job Stability – operational definition  Stably Employed - employed at all three follow-up intervals (n=44)  Unstably Employed - employed at 1 or 2 of 3 follow-up intervals (n=35)  Unemployed - unemployed at all 3 follow-up intervals (n=50)

6 Employment and Productivity Status Job Stability after TBI

7 Employment and Productivity Status Job Stability after TBI

8 TBIMS Employment Rates 1996 and 2002 Comparisons

9 Perception of Problems Impeding Return to Work  no transportation  bad temper  no motivation  can’t walk or climb stairs  depression  poor vision  trouble using limbs  can’t speak properly  can't understand speech  memory problems  seizures  medical illness  thinking problems n=443

10 Perceived Employment Impediments

11 Key Point Successful Return to Work holistic approaches work best

12 Neurobehavioral Problems Most Commonly Reported 5 - 10 Years Postinjury 1. Bored 2. Moves slowly 3. Frustrated 4. Difficulty lifting 5. Writes slowly 6. Reads slowly 7. Poor concentration 8. Trouble making decisions 9. Tired 10. Thinks slowly 11. Loses train of thought 12. Easily distracted 13. Impatient 14. Loses balance 15. Misunderstood by others Witol, Sander, Seel, & Kreutzer

13 Neurobehavioral Problems Most Commonly Reported More Than 10 Years Postinjury 1. Frustrated 2. Forgets reading 3. Impatient 4. Misunderstood 5. Bored 6. Loses train of thought 7. Reads slowly 8. Writes slowly 9. Moves slowly 10. Tired 11. Thinks slowly 12. Thinking of the right word 13. Restless 14. Trouble making decisions 15. Trouble following directions 16. Learns slowly Witol, Sander, Seel, & Kreutzer

14 Most Commonly Reported Mood Problems * Symptom 5- 10 yrs10+ yrs bored2.57 2.28 frustrated2.40 2.44 impatient2.20 2.33 misunderstood2.14 2.33 *among 15 most commonly reported n=97

15 Most Commonly Reported Slowness Problems * *among 15 most commonly reported Symptom5-10 yrs 10+ yrs moving2.542.22 writing2.302.24 reading2.342.27 thinking2.272.19 learning 2.11

16 Employee Evaluation Supervision Issues Rating 1. Performs routine tasks with little oralways no guidance 2. Requires little supervision toalways complete complex tasks 3. Willingly accepts and carries outalways assignments Position Title: Executive Secretary I

17 Employee Evaluation Time Utilization Issues Rating 1. Able to work effectively againstalways tight deadlines 2. Performs effectively in pressuredalways and tense situations 3. Uses time in an efficient and always productive manner 4. Uses the organization’s resources always effectively to meet deadlines Position Title: Executive Secretary I

18 Employee Evaluation Time Utilization Issues Rating 5. Sets priorities and revises workalways plans to meet deadlines 6. Works overtime to make certainalways that deadlines are met 7. Punctualalways 8. Coordinates time away from the always office in accordance with guidelines Possible Ratings: Always, Usually, Rarely

19 Employee Evaluation Knowledge and Creativity Rating 1. Demonstrates thorough knowledgealways and applies to assignments 2. Maintains conscientious effortusually to enhance knowledge 3. Provides and applies creative usually solutions to assignments Position Title: Executive Secretary I

20 Employee Evaluation Performance Quality Issues Rating 1. Thorough and accurate inusually completing assignments 2. Attentive to detailusually 3. Maintains acceptable production usually rate without sacrificing quality 4. Reliablealways Possible Ratings: Always, Usually, Rarely

21 Employee Evaluation Performance Quality Issues Rating 5. Answers calls promptly and takesalways accurate messages 6. Demonstrates good follow-throughalways on assignments 7. Adapts and copes well with always changing situations 8. Written communication is organized, always grammatical, and accurate Position Title: Executive Secretary I

22 Rating 1. Active in providing phone coveragealways to the team 2. Offers assistance to team membersalways and supports “team concept” 3. Resolves conflict in a professionalusually manner Performance Evaluation Professionalism Position Title: Executive Secretary I

23 Key Point Successful Return to Work Recognize that employee evaluations often emphasize performance speed

24 Key Point Successful Return to Work Some jobs and work environments are more disability-friendly than others

25 Vocational Demands and Outcome Success in higher status occupations is more difficult because of lower error tolerances Key Point

26 Vocational Tasks for Persons with Severe Disabilities  Typing & word processing  Computer data entry  Photocopying  Phone answering  Collating & stapling  Mail preparation  Filing  Packaging & unpacking  Pricing  Delivery  Light assembly  Light cleaning  Microfilming  Food preparation

27 Experience tells us that people with even the most severe disabilities can succeed at working -  The personal qualities of successful workers are well known.  Personal qualities are different than work skills.  You have the ability to change the kind of person you are, and to succeed at work. How so?

28 “Am I Ready To Work ?” Test True or False?  I know my strengths and limitations.  I have clear goals and focus on making things better.  I keep trying even when things seem difficult.  I try to learn from my mistakes.

29 “Am I Ready To Work ?” Test True or False?  I am willing to admit when I make a mistake.  I am willing to ask for help.  When people ask if I need help, I respond politely.  When people talk, I make sure to listen.

30 “Am I Ready To Work ?” Test True or False?  When I’m not sure how to do something, I ask.  I look for the positive in other people and situations.  I’m polite and respectful to others.  I can learn a lot from other people.  I’m thankful when people offer me constructive feedback.

31 “Am I Ready To Work ?” Test True or False?  I do my best to be patient with myself, my goals, and other people.  I pay attention to how I’m feeling.  I work hard to control my discouragement and anger.  I think about other people’s feeling.

32 “Am I Ready To Work ?” Test True or False?  I can clearly see the benefits of work.  Outside of work, I try to do things that are good for me.  I choose to spend time with people who can help me reach my goals.

33 “Am I Ready To Work ?” Test True or False?  I am an important and responsible member of my treatment team.  I communicate my feelings, needs, concerns, and ideas.  I understand that success at work means more than just doing my job.

34 Vocational Planning and Counseling Jeffrey S. Kreutzer, Ph.D., ABPP VCU Health System

35 Case Planning Issues Ü Should I choose to help this person find and keep a job? Ü What goals and time frames are practical? Ü What do I need to be concerned about or sensitive to?

36 Client Factors Character, Personality, Intellect, Skills, and Health Ü Work ethic, attitude, desire for success Ü Stamina, sleep, pain, and health Ü Transportation independence Ü Stress and frustration tolerance Ü Control of sexual and aggressive impulses Ü Ability to accept diminished skills and potential

37 Client Factors Character, Personality, Intellect, Skills, and Health Ü Interpersonal and negotiation skills Ü Responsiveness to feedback Ü Neuropsychological functioning Ü Adaptability Ü Loyalty to employer

38 Client Factors Situational Ü Immediate and long-term financial needs Ü Expense of working Ü Accumulated benefits and other pressures to remain Ü Consistency between career plans, hopes, and available options Ü Retirement plans

39 Work Responsibilities and Environmental Factors Ü Dangers Ü Cost of making mistakes Ü Job complexity and demand on workers Ü Flexibility in scheduling and assigning responsibilities Ü Organizational stability Ü Noise, distractions, and ambience

40 Colleague and Supervisor Factors ÜPresence and level of supervision ÜMorale ÜAttitude toward people with disabilities and willingness to be supportive ÜEmployee evaluation and feedback system ÜCompetitiveness ÜTolerance of individual differences

41 Community Factors ÜDemand for workers ÜAccessibility ÜPresence and types of local businesses ÜAvailability of medical and rehabilitation resources ÜCost of living and average wages

42 Return to Work Assessment Jeffrey S. Kreutzer, Ph.D., ABPP VCU Health System

43 Assessment Components Interview or Questionnaire Format  conditions for return to work  responsibilities  schedule  safety issues  work environment  relationship with your supervisor  goals and job security

44 Conditions for Return to Work  Has your doctor or employer set any conditions for your return to work?  If yes, describe conditions…….  How long do you feel that you need before you can return to work part-time?  How long do you feel that you need before you can return to work full-time?

45 Responsibilities  What is your job title? Do you have a written job description? If yes, please provide a copy.  Is driving required for you to perform your job? Will transportation be an issue if you return to work? How will you get to work?  Describe job responsibilities and indicate most important.

46 Responsibilities  Do you have contact with customers? If yes, please describe.  Do you have contact with other workers? If yes, please describe.  Do you supervise other workers? If yes, please describe?  What equipment do you use on your job? Describe any training or qualifications to use equipment.

47 Schedule  How many hour per week are you required to work?  Are you required to work overtime?  Would you be allowed to work part-time?  Are you required to work swing-shifts?  How much flexibility would you be allowed in your schedule to accommodate breaks, doctors appointments, not feeling well?

48 Safety Concerns  Is your job dangerous? If yes, how?  Do you use dangerous equipment on the job? If yes, describe.  Do other employees use dangerous equipment? If yes, describe.  Have you or others been injury at work? If yes, please explain (e.g., how often).

49 Work Environment  Are there other people in the workplace who have had serious injuries and return to work? If yes, how have they been treated?  Do you have concerns about how you would be received by co-workers if you returned to your previous position? If yes, explain.

50 Relationship with Your Supervisor  How frequently have you had contact with your supervisor since your injury?  What does your supervisor know about the injury?  What was your relationship with your supervisor like before the injury?

51 Relationship with Your Supervisor  What feedback has your supervisor given you since your injury?  Has your supervisor offered to change your responsibilities or position so that you can do your job? If yes, how?

52 Goals and Job Security  What do you see as your biggest challenges in return to work?  Describe your career goals and whether they have changed since the injury.  Do you feel that you will have a secure job if you return to work? If not, why not?

53 The Potential Family Role They can...  facilitate  ignore  impede  sabotage The process of...  job development  job matching  placement  maintenance

54 Family members often need help understanding the demands of a job... I know he can’t remember what day it is Still, why couldn’t he run a nuclear plant?

55 Employment Can Increase Family Members’ Stress Levels  need for transportation assistance  caretaker’s resumption of former work responsibilities  redistribution of injured person’s responsibilities  daily apprehensions about client’s failures or termination

56 Employment Interference by Family Members  Communicating and emphasizing personal fears about failure  Over-protectiveness - calling employer, following patient, questioning  Telling client he’s too good for the job  Demanding better performance  Failing to acknowledge client’s gains and hardships

57 Skepticism about the value of intervention often increases as a function of time post-injury Gain an understanding of the family’s  past experiences with rehabilitation professionals  personal expectations for the process and outcome of intervention

58 Leave the family out... When intervention fails and when  the personal problems of family members exceed their potential contribution or  family members clearly indicate a desire to sabotage

59 Employment Enhancement by Family Members  Acknowledging and emphasizing client’s efforts and successes  Encouraging communication  Promoting in-home generalization of cognitive and behavioral interventions  Encouraging abstinence from alcohol

60 Employment Enhancement by Family Members  Acknowledging personal impact of employment process  Understanding interactions between client, family, and personal goals  Moderating feedback and offers of assistance  Aiding participation in alcohol-free social and recreational opportunities

61 Building Family Trust  Set realistic goals and expectations  Acknowledge potential benefits and limits of intervention  Maintain ongoing communication  Follow through with agreements A written program description and contract helps establish and document agreements

62 Supported Employment Methods and Models Jeffrey S. Kreutzer, Ph.D., ABPP Virginia Commonwealth University Medical Center

63 Attributes of Employment Models  employees’ level and type of disability  nature of supervision and support resources  work responsibilities for workers and supervisors  level of compensation and benefits  workers’ relationship to host company  number of work sites  level of community integration and visibility

64 Supported Employment Models  enclave  mobile work crew  small business  sheltered workshop  co-worker training  center based training  individualized supported employment

65 Enclave Characteristics  Structure - special training group, 3 - 8 persons working in community based industry  Supervision - permanent, full-time, on site  Incentives - pay and benefits based on productivity; commensurate with other workers  Workers - paid by host or support company  Supervisor - paid by support company

66 Enclave Advantages  intensive supervision allows hiring persons with very severe disabilities  employee improvement and supervisor fading not required  greater likelihood of co-worker stability and support  supervisor can oversee more than one worker  potential for good pay and benefits especially when host is larger company

67  Crew - one or two supervisors, 3- 8 persons with disabilities  Operate from a van, frequent traveling to provide contract services at many different sites  Common services - grounds keeping, landscaping, custodial, painting, farm labor, snow removal  Model works well in rural areas and small communities Mobile Work Crew Characteristics

68  Some workers not fully productive; increasing supervision and public funding needs  Business status typically “not for profit”  Successful marketing and contract negotiation required

69 Mobile Work Crew Advantages  Contracting allows flexibility based on community needs  Community travel stops facilitate integration  Public work allows citizens to see persons with disabilities working productively  Cost efficient after start up because of low overhead

70 Small Business or Entrepreneurial Option Characteristics  Workers - eight or less; having most severe disabilities  Supervision, very close with ongoing behavioral programming  Business type - manufacturing or contractual  Single business may be constituted of several linked sites

71 Small Business or Entrepreneurial Option Characteristics  Business plan addressees marketing, sales, production, documentation, quality control  Social integration by setting site nearby other businesses, restaurants, stores, recreation sites  Cost comparable to day treatment or day rehabilitation program  Compared to sheltered workshop - smaller number of employees with greater disabilities

72 Sheltered Workshop  Workers with severe and varied disabilities  Supervisors - usually more than one  Close supervision includes behavior management  Work type - light assembly, printing and duplication, mailing, clerical  Incentives - pay less than minimum wage based on productivity, few benefits if any

73 Sheltered Workshop  Management - one or more staff may focus entirely on business operations  Single site usually zoned for business or light industry  Common complaints - – workers feel “unproductive” – extreme segregation – limited options for work responsibilities – concerns about poor models for behavior

74 Co-Worker Training Employment Model  Experienced employees become primary providers of on the job training and support  Employment specialists train experienced employees  Employment specialists serve as consultants, mediators, and data collectors

75 Center Based Rehabilitation Referral Extensive Assessment Placement 6 – 12 week follow-up Eliminate Poor Risks Extensive Vocational Training

76 Supported Employment Referral Brief Holistic Assessment Brief Holistic Assessment Follow-along long-term Job Analysis, Matching, Development Placement interdisciplinary rehabilitation counseling and behavioral services case coordination recreational programs social programs substance abuse treatment

77 Disincentives  Loss of disability income  Loss of medical insurance  Fear of stress or failure  Loss of “helpless role”  Lower pay rate and job status

78 Job Analysis  Required cognitive, academic, technical, interpersonal skills  Transportation needs and skills  Stamina and endurance requirements  Health code requirements  Level of independence and available supervision  Environment - noise and safety issues

79 Principles of Shared Responsibility ðInclude persons with brain injury and their families as equal partners ðDevelop services by preparing supports not people ðEstablish and maintain relationships with funding and service agencies ðEfforts toward improved quality of life

80 Job Development  Seek available jobs  Contact past and new potential employers  Observation and analysis of job site  Ongoing communication with client, family, and rehabilitation providers  Job matching employers needs with client’s skills and interests

81 Vocational Tasks for Persons with Severe Disabilities 1 Typing & word processing 1 Computer data entry 1 Photocopying 1 Phone answering 1 Collating & stapling 1 Mail preparation 1 Filing 1 Packaging & unpacking 1 Pricing 1 Delivery 1 Light assembly 1 Light cleaning 1 Microfilming

82 New Employer Contacts ÜJob hotlines ÜHelp wanted ads ÜPersonal contacts ÜGovernment vacancy listings ÜReferrals from other employers ÜCollege career planning and placement offices

83 Research indicates that persons with disabilities are more...  highly motivated  dependable  likely to stay in their positions longer than persons without disabilities Why hire ‘em?

84 On-Site Intervention  Unobtrusive involvement in training work-related skills  Compensatory strategies development  Promoting positive collegial and supervisor relationships  Stress inoculation  Problem solving interactions emphasizing positive feedback  Phase-out with mastery

85 Job Adaptation and Support Methods  use assistive devices  develop or enhance cues  rearrange work environment  change task sequence or eliminate difficult steps  arrange for co-worker to complete task

86 Job Site Enabling  if a work skill or task can be taught - teach it  if it can’t be taught, adapt it  if neither teaching nor adapting are successful, support it

87 Box 980542, Richmond, VA 23298-0542 USA PH 804 828-9055 Jeff Kreutzer jskreutz@vcu.edu Virginia Commonwealth University Medical Center The National Resource Center for Traumatic Brain Injury www.neuro.pmr.vcu.edu


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