1. HOW TO EVALUATE OUTCOMES OF REHABILITATION Matti Tuusa Training and Information Manager Rehabilitation Foundation, Pakarituvantie 4-5 Po Box 39, 00411 Helsinki, Finland tel: 358 9 53041, gsm 358 40 8332632 e-mail: matti.tuusa@kuntoutussaatio.fi www.kuntoutussaatio.fi www.kuntoutussaatio.fi

2. Rehabilitation Foundation2 Aims of Rehabilitation Society level to ensure a qualified, competent and able work force in the society maintenance and promotion of work ability maintenance and promotion of functional ability social integration, participation, employment reduce health and welfare costs affect early retirement costs

3. Rehabilitation Foundation3 Aims of Rehabilitation Systems and processes level introduce effective service models and fluent service processes for various target groups improve co-operation and mutual dialogue in client service processes Individual level re-employment, work retention empowerment independet living, autonomy personal well-being, quality of life

4. Rehabilitation Foundation4 Interest in the outcomes and effectiveness of rehabilitation The question of benefits and outcome of rehabilitation has received increasing interest during the past decade as rehabilitation activities have enlargened and diversified Evaluation aspect is included in service development and it has become an everyday routine in administration. What is achieved through rehabilitation? Are the measures implemented proper in this certain situation? Is it done in an effective way? What are the actual effects and changes on the life situations of the clients? Are the outcomes results of rehabilitation or due to some other social, structural,situational or individual phenomena?

5. Rehabilitation Foundation5 Interest in the outcomes and effectiveness of rehabilitation The Finnish Government´s Rehabilitation Report submitted to the Parliament in 2002: The growth of the real costs of rehabilitation increased by 9% during the five years review period, The growth of costs has continued with the same rate -> where the money is spent, what kind of outcomes has been achieved with this expenditure, is the expenditure being allocated effectively? Biggest recipient group of rehabilitation: persons with musculoskeletal disorders The proportion of persons with mental health problems had biggest increase Service priority in: ageing workers, long term unemployed persons, children and young people

6. Rehabilitation Foundation6 Interest in the outcomes and effectiveness of rehabilitation Scientific review in the Finnish Government´s Rehabilitation Report in 2002: Scientific evidence of the favourable effects of rehabilition is strongest in the rehabilitation of: –Persons suffering from prolonged low back pain, –Acute rehabilitation of stroke patients –Hospital rehabilitation of older persons who have lost their functional capacity due to acute illness or accident

7. Rehabilitation Foundation7 Interest in the outcomes and effectiveness of rehabilitation The Finnish Government´s Rehabilitation Report. Recommendations to develop rehabilitation (1): Improve the position of the client, develop cooperation of rehabilitation actors Develop the effectiveness of rehabilitation Strengthen the medical rehabilitation of the municipal primary and specialized health care

8. Rehabilitation Foundation8 Interest in the outcomes and effectiveness of rehabilitation Recommendations to develop rehabilitation (2) Priorities Maintenance of the work ability of the employed (postpone retirement age with 2-3 years) Improve the employment of persons with disabilities and long-term unemployed Develop rehabilitation of persons with mental health problems, and persons with substance abuse problems Effective new rehabilitation models for the elderly

9. Rehabilitation Foundation9 Interest in the outcomes and effectiveness of rehabilitation Macro level evaluation example 1: Functioning of the Rehabilitation of the Earnings-Related pensions Scheme –New legislation and practices in 2004 –Evaluation conducted by mail survey, document and register data ( Rehabilitation Foundation, Pensions Security Centre) Macro level evaluation example 2: Evaluation of the Employment Service Centres (STAKES). Process evaluation, developmental evaluation. –39 employment service centres established all around the country combining the services of employment authorities, social welfare, health care and social insurance institution

10. Rehabilitation Foundation10 Development Programme for Rehabilitation Research (1) Made by The Finnish Advisory Board for Rehabilitation in 2004 Rehabilitation research and evaluation is based on a multidisciplinary approach and therefore it is necessary to utilize different research paradigms and methodological solutions. Quantity of rehabilitation research in Finland is not large enough to meet the expectations placed on it It is disperced among different brnches of science and different units, which hampers the utilization of the research data

11. Rehabilitation Foundation11 Development Programme for Rehabilitation Research (2) Biggest gap in the Finnish rehabilitation research can be found in research focusing on the systems level: Functioning of the rehabilitation system, especially its target-setting and friction points Good and efficient rehabilitaton practices Effectiveness and outcomes of different rehabilitation services, including economic effects

12. Rehabilitation Foundation12 Development Programme for Rehabilitation Research (3) Strongest development needs: Outcomes of vocational rehabilitation, Rehabilitation aiming at improving working capacity and improving well-being at work Rehabilitation supporting health and well-being of children and adolecents One of the key proposals Development of rehabilitation research web site and database, Rehabilitation Foundation project, Internet service on rehabilitation research and development data ready in 2008

13. Rehabilitation Foundation13 Evaluation: Systems and process level Evidence based practice -approach Strongly appreciated and followed in medical sciences, psychology, education, social work. Stress on randomized clinical trials in medical research but include also case studies. Cochrane Collaboration, Campbell Collaboration: large databases containing evidence based treatment, practices, service models Strong evidence: Case management supporting persons with mental health problems Supported Employment of persons with mental health problems

14. Rehabilitation Foundation14 Systems and process level evaluation Example: Tutka-project (1) The purpose: cut the spiral of social exclusion of people, who are unemployed and who also have social and financial difficulties. Target groups –highly-educated mental health rehabilitees –young adults with inadequate education –young persons with cerebral palsy The aim: empowerment through employment The way to achieve this goal: combine case management with the method of supported employment

15. Rehabilitation Foundation15 Systems and process level evaluation Example: Tutka-project (2) Supported employment, Employment -> Training -> Support Work capacity and potential is best revealed by doing real work tasks Normal, paid job at a normal workplace, assisted by the personal support from the job coach Vocational rehabilitation, in which the job coach offers his/her support both to the employee as well as the employer The job coach will continue to give support as long as it is necessary. The support can be gradually diminished as the employee integrates in the workplace

16. Rehabilitation Foundation16 Systems and process level evaluation Example: Tutka-project (3) 1.) What kind of results were achieved during the project? - expected/unexpected results - good/ unwanted results 2.) Mechanisms - which factors helped to achieve the good results? - which factors prevented the good results? 3.) Context - which circumstances were the good results possible to be achieved in?

17. Rehabilitation Foundation17 Systems and process level evaluation Example: Tutka-project (4) Outcomes of the project Process evaluation, developmental evaluation –developing and testing a new rehabilitation method Comparing the employment results with a group of comparable clients in the employment office At the end of the project 34% of the clients were employed in the open labour market, after one year follow-up 43% at work (compare group 9%)