1. Returning to Work after Brain Injury James F. Malec, PhD Professor, Professor, Mayo Clinic and Medical School Rochester, MN

2. Collaborators Lisa Degiorgio, MS,CRC Anne M. Moessner, RN, MSN Angela L. H. Buffington, MS, CRC

3. Benchmarks for Return to Work After Moderate-Severe Brain Injury n Without intervention: –less than 40% employed n With intensive day treatment: –75% to 85% employed –50% in community-based independent work

4. Project Admission Criteria n Age 18 to 65 n Minnesota resident n Admitted to hospital following brain injury n Neuropsychological evidence of brain injury n No active psychiatric or substance abuse disorder accounting for impairments n Not in residential placement n Consent to participate

5. Vocational Services Sample n 61% Male; 39% Female n Age: –Mean = 37.4 yrs –Median = 38 yrs n Preinjury education: –<12 yrs = 22% –12 to 15 yrs = 61% –> 16 yrs = 17% n Preinjury vocational status: –Unemployed= 9% –Supported= 6% –Transitional= 16% –Independent= 69% n Current living status: –24-hr supervision = 1% –Partial supervision= 22% –Independent = 77%

6. Vocational Services Sample n Type of injury: –TBI= 64% –CVA= 26% –Other= 10% n Initial injury severity: –Mild = 21% –Moderate = 7% –Severe = 56% –Unknown= 16% n Time since injury: –Mean = 65.5 mos –Median = 12.7 mos n Non-brain injuries present in: –67% of TBI sample

7. Vocational Referral Network Nurse Case Coordinator (Acutely injured pts) Vocational Case Coordinator Acute Medical & Rehabilitation Services Outpatient Rehabilitation Services (Chronic pts) Community Based Services (Chronic pts)

8. Vocational Referral Sources n 36% Outpatient rehabilitation evaluations n 25% Nurse Case Coordinator n 26% Other medical-center staff n 13% Community agencies

9. Other Services Received n 39% Comprehensive day rehabilitation n 33% Community Reintegration Outpatient Group (3 hrs/wk) n 56% MN Rehabilitation Services Branch n 26% Other community based vocational services (e.g., evaluation, job search, job coach)

10. Primary Emphases of Project n Early medical, rehabilitative, and vocational intervention n Integration of medical center and community services n Work trials n Temporary or long-term supported employment n Employer education about brain injury

11. Key Elements of Vocational Case Coordinator Model n n Focus on early vocational intervention n n Identify residual impairments that may interfere with vocational re-integration and refer for appropriate medical rehabilitation services n n Integrate vocational goals with rehabilitation therapy goals n Develop comprehensive return-to-work plans that address issues ranging from number of hours worked to the work environment to compensation techniques n Improve community agency linkages to develop a team approach n Provide a smooth transition from medical to community based services

12. Key Elements of Vocational Case Coordinator Model n n Use on-the-job evaluations to gather the best information about a person’s work skills n n Provide appropriate support during work evaluations and after placement including job coaching and work trials n n Provide reasonable work accommodations before the client starts the job n Provide BI education to employers, coworkers, community service providers n Clearly identify a BI resource person for the client and employer n Provide regular, frequent follow-up after placement

13. Vocational Service Models n Specialized –Provides early intervention –Bridges gap between hospital and community –On-the-job evaluations –Integrates vocational and rehabilitation goals –Places and trains n Traditional –Waits for person to apply –No involvement in medical rehabilitation –Interest and aptitude testing, work samples –Focuses only on vocational goals –Trains and places

14. Vocational Service Models n Specialized –Employer and co- worker education –Addresses psychosocial and functional issues before job placement –Team approach –Sequence of short-term goals –Supported risk taking n Traditional –No educational outreach –Addresses psychosocial and functional issues after they arise –One counselor per client –One long-term vocational goal –High risk for failure

15. Vocational Outcomes And Outcome Predictors

16. Vocational Independence Scale n Competitive: Community-based work (at least 15 hours per week) without external supports n Transitional: Community-based work (at least 15 hours per week) with temporary supports, such as, job coach, reduced hours OR enrollment in an educational or training program n Supported: Community-based work with permanent supports or less than 15 hours per week OR volunteer work n Sheltered: Work in a sheltered workshop n Unemployed

17. Vocational Independence Scale at Placement and 1 Yr Follow-up

18. Vocational Outcome Predictors After Brain Injury n Severity of initial injury n Time since injury n Impairment/disability n Impaired self-awareness n Preinjury vocational status n Preinjury educational status

19. Mayo-Portland Adaptability Inventory n Mobility n Use of hands n Vision n Motor speech n Communication n Memory n Attention/concentration n Novel problem solving n Visuospatial abilities n Fund of information n Irritability/aggression n Depression n Residence n Self cares n Work/school n Leisure activities n Driving n Family/significant relationships n Social contact n Appropriate social interaction n Indifference n Initiation

20. Stepwise Logistic Regression: VIS at Placement n Time Since Injury (Χ 2 = 9.70, p <.01) n Rasch Staff MPAI (Χ 2 = 8.30, p <.01)

21. Stepwise Logistic Regression: VIS at 1 Year Follow-up n VIS at placement (Χ 2 = 53.30, p <.0001)

22. Stepwise Linear Regression: Time to Placement n Rasch Staff MPAI (R 2 =.16) n Preinjury education (R 2 =.03)

23. Vocational Outcome Summary n 81% in community-based employment at 1 year follow-up n 53% in independent employment at 1 year n 39% of those placed returned to previous employment n 58% of total placements made within 6 months of initiation of services n 92% within 1 year

24. Comprehensive vs. Limited Intervention

25. Comprehensive Postacute Brain Injury Rehabilitation n A cognitive and behavioral approach n Interdisciplinary team n Emphasis on self-awareness, adjustment, compensation and social skills n Low staff-to-patient ratio n Family involvement n Vocational and independent living trials n Systematic outcome assessment

26. Mayo Comprehensive Program Patient Characteristics n Limited self-awareness of disabilities n Cognitive impairments: e.g., concentration, memory, generalization, problem-solving, initiation, reasoning, planning n Poor communication and social skills n Limited emotional/behavioral self-control n Unemployed or failing in employment n Not a danger to self or others

27. Mayo Comprehensive Program Groups Daily n Orientation n Cognitive n Social Awareness n Communication n Life Skills Weekly n Health Education n Vocational Monthly n Patient/Family Group

28. Mayo Comprehensive Program Vocational Independence

29. Community-Based Employment by Time Since Injury

30. Limited Intervention n Vocational Services only n Additional outpatient cognitive rehabilitation n Adjustment counseling n Other outpatient rehabilitation therapies n Community Integration Outpatient Group

31. Probability of Community-Based Employment

32. Conclusions n A medical-center based Vocational Case Coordinator who coordinates service delivery maximizes vocational outcomes for persons after brain injury n Early intervention optimizes outcomes and optimizes the success of limited intervention n Successful vocational placement can be accomplished within 1 year

33. Conclusions n Overall disability and time since injury are the best predictors of vocational placement after brain injury rehabilitation n The best predictor of long-term vocational outcome is initial placement n Return to previous employment is a viable option for many persons after brain injury

34. Conclusions n Comprehensive rehabilitation is often required by more persons with greater disability or chronicity and results in a more extended time to placement n However, comprehensive intervention can be successful with the majority of persons served regardless of chronicity or severity