Returning to Work after Brain Returning to Work after Brain InjuryInjury

James F. Malec, PhDJames F. Malec, PhD

Professor, Professor, Mayo Clinic and Medical School

Rochester, MN

CollaboratorsCollaborators

Lisa Degiorgio, MS,CRCLisa Degiorgio, MS,CRC

Anne M. Moessner, RN, MSNAnne M. Moessner, RN, MSN

Angela L. H. Buffington, MS, CRCAngela L. H. Buffington, MS, CRC

Benchmarks for Return to Benchmarks for Return to WorkWork

After Moderate-Severe Brain InjuryAfter Moderate-Severe Brain Injury

Without intervention:Without intervention:– less than 40% employedless than 40% employed

With intensive day treatment:With intensive day treatment:– 75% to 85% employed75% to 85% employed– 50% in community-based independent 50% in community-based independent

workwork

Project Admission CriteriaProject Admission Criteria

Age 18 to 65Age 18 to 65 Minnesota residentMinnesota resident Admitted to hospital following brain injuryAdmitted to hospital following brain injury Neuropsychological evidence of brain injuryNeuropsychological evidence of brain injury No active psychiatric or substance abuse No active psychiatric or substance abuse

disorder accounting for impairmentsdisorder accounting for impairments Not in residential placementNot in residential placement Consent to participateConsent to participate

Vocational Services SampleVocational Services Sample

61% Male; 39% Female61% Male; 39% Female Age: Age:

– Mean Mean = 37.4 yrs= 37.4 yrs

– Median = 38 yrsMedian = 38 yrs

Preinjury education:Preinjury education:– <12 yrs = 22%<12 yrs = 22%

– 12 to 15 yrs = 61%12 to 15 yrs = 61%

– > 16 yrs = 17%> 16 yrs = 17%

Preinjury vocational Preinjury vocational status:status:– UnemployedUnemployed = 9%= 9%– SupportedSupported = 6%= 6%– TransitionalTransitional = 16%= 16%– IndependentIndependent = 69%= 69%

Current living status:Current living status:– 24-hr supervision = 1%24-hr supervision = 1%– Partial supervision= 22%Partial supervision= 22%– IndependentIndependent = =

77%77%

Vocational Services SampleVocational Services Sample Type of injury:Type of injury:

– TBITBI = 64%= 64%– CVACVA = 26%= 26%– OtherOther = 10%= 10%

Initial injury severity:Initial injury severity:– MildMild = 21%= 21%– Moderate Moderate = 7%= 7%– SevereSevere = =

56%56%– UnknownUnknown = 16%= 16%

Time since injury:Time since injury:– Mean = 65.5 mosMean = 65.5 mos– Median = 12.7 mosMedian = 12.7 mos

Non-brain injuriesNon-brain injuries

present in:present in:– 67% of TBI sample67% of TBI sample

Vocational Referral NetworkVocational Referral NetworkNurse Case Coordinator

(Acutely injured pts)

Vocational Case

Coordinator

Acute Medical & Rehabilitation Services

Outpatient

Rehabilitation

Services

(Chronic pts)

Community

Based Services

(Chronic pts)

Vocational Referral SourcesVocational Referral Sources

36% Outpatient rehabilitation 36% Outpatient rehabilitation evaluationsevaluations

25% Nurse Case Coordinator25% Nurse Case Coordinator 26% Other medical-center staff26% Other medical-center staff 13% Community agencies13% Community agencies

Other Services ReceivedOther Services Received

39% Comprehensive day rehabilitation39% Comprehensive day rehabilitation 33% Community Reintegration 33% Community Reintegration

Outpatient Group (3 hrs/wk)Outpatient Group (3 hrs/wk) 56% MN Rehabilitation Services Branch56% MN Rehabilitation Services Branch 26% Other community based vocational 26% Other community based vocational

services (e.g., evaluation, job search, services (e.g., evaluation, job search, job coach)job coach)

Primary Emphases of ProjectPrimary Emphases of Project

Early medical, rehabilitative, and Early medical, rehabilitative, and vocational interventionvocational intervention

Integration of medical center and Integration of medical center and community servicescommunity services

Work trialsWork trials Temporary or long-term supported Temporary or long-term supported

employmentemployment Employer education about brain injuryEmployer education about brain injury

Key Elements Key Elements of Vocational Case Coordinator Modelof Vocational Case Coordinator Model

Focus on early vocational intervention

Identify residual impairments that may interfere with vocational re-integration and refer for appropriate medical rehabilitation services

Integrate vocational goals with rehabilitation therapy goals

Develop comprehensive return-to-work plans that address issues ranging from number of hours worked to the work environment to compensation techniques

Improve community agency linkages to develop a team approach

Provide a smooth transition from medical to community based services

Key Elements Key Elements of Vocational Case Coordinator Modelof Vocational Case Coordinator Model

Use on-the-job evaluations to gather the best information about a person’s work skills

Provide appropriate support during work evaluations and after placement including job coaching and work trials

Provide reasonable work accommodations before the client starts the job

Provide BI education to employers, coworkers, community service providers

Clearly identify a BI resource person for the client and employer

Provide regular, frequent follow-up after placement

Vocational Service ModelsVocational Service Models Specialized Specialized

– Provides early Provides early interventionintervention

– Bridges gap between Bridges gap between hospital and communityhospital and community

– On-the-job evaluationsOn-the-job evaluations

– Integrates vocational Integrates vocational and rehabilitation goalsand rehabilitation goals

– Places and trainsPlaces and trains

TraditionalTraditional– Waits for person to Waits for person to

applyapply– No involvement in No involvement in

medical rehabilitationmedical rehabilitation– Interest and aptitude Interest and aptitude

testing, work samplestesting, work samples– Focuses only on Focuses only on

vocational goalsvocational goals– Trains and placesTrains and places

Vocational Service ModelsVocational Service Models

SpecializedSpecialized– Employer and co-Employer and co-

worker educationworker education– Addresses psychosocial Addresses psychosocial

and functional issues and functional issues before job placementbefore job placement

– Team approachTeam approach– Sequence of short-term Sequence of short-term

goalsgoals– Supported risk takingSupported risk taking

TraditionalTraditional– No educational No educational

outreachoutreach– Addresses psychosocial Addresses psychosocial

and functional issues and functional issues after they ariseafter they arise

– One counselor per One counselor per clientclient

– One long-term One long-term vocational goalvocational goal

– High risk for failureHigh risk for failure

Vocational OutcomesVocational Outcomes

And Outcome PredictorsAnd Outcome Predictors

Vocational Independence Vocational Independence ScaleScale

Competitive: Competitive: Community-based work (at least Community-based work (at least 15 hours per week) without external supports15 hours per week) without external supports

Transitional:Transitional: Community-based work (at least Community-based work (at least 15 hours per week) with temporary supports, 15 hours per week) with temporary supports, such as, job coach, reduced hours OR such as, job coach, reduced hours OR enrollment in an educational or training enrollment in an educational or training programprogram

Supported:Supported: Community-based work with Community-based work with permanent supports or less than 15 hours per permanent supports or less than 15 hours per week OR volunteer workweek OR volunteer work

Sheltered:Sheltered: Work in a sheltered workshop Work in a sheltered workshop UnemployedUnemployed

Vocational Independence Vocational Independence Scale at Placement and 1 Yr Scale at Placement and 1 Yr

Follow-upFollow-up

10%10% 9%

25%

46%

13%6%

9%

19%

53%

0%

10%

20%

30%

40%

50%

60%

Initial Placement(n=114)

One Yr Follow-up(n=101)

Not placed/unemployedSheltered

Supported

Transitional

Independent

Vocational Outcome Vocational Outcome PredictorsPredictors

After Brain InjuryAfter Brain Injury

Severity of initial injurySeverity of initial injury Time since injuryTime since injury Impairment/disabilityImpairment/disability Impaired self-awarenessImpaired self-awareness Preinjury vocational statusPreinjury vocational status Preinjury educational statusPreinjury educational status

Mayo-Portland Adaptability Mayo-Portland Adaptability InventoryInventory

MobilityMobility Use of handsUse of hands VisionVision Motor speechMotor speech CommunicationCommunication MemoryMemory Attention/concentrationAttention/concentration Novel problem solvingNovel problem solving Visuospatial abilitiesVisuospatial abilities Fund of information Fund of information Irritability/aggressionIrritability/aggression

DepressionDepression ResidenceResidence Self caresSelf cares Work/schoolWork/school Leisure activitiesLeisure activities DrivingDriving Family/significant Family/significant

relationshipsrelationships Social contactSocial contact Appropriate social Appropriate social

interactioninteraction IndifferenceIndifference InitiationInitiation

Stepwise Logistic Regression: Stepwise Logistic Regression:

VIS at PlacementVIS at Placement

Time Since Injury (ΧTime Since Injury (Χ2 2 = 9.70, p <.01)= 9.70, p <.01) Rasch Staff MPAI (ΧRasch Staff MPAI (Χ2 2 = 8.30, p <.01)= 8.30, p <.01)

Stepwise Logistic Regression: Stepwise Logistic Regression:

VIS at 1 Year Follow-upVIS at 1 Year Follow-up

VIS at placement (ΧVIS at placement (Χ2 2 = 53.30, p = 53.30, p <.0001)<.0001)

Stepwise Linear Regression: Stepwise Linear Regression: Time to PlacementTime to Placement

Rasch Staff MPAI (RRasch Staff MPAI (R22 = .16) = .16) Preinjury education (RPreinjury education (R22 = .03) = .03)

Vocational Outcome Vocational Outcome SummarySummary

81% in community-based employment at 1 81% in community-based employment at 1 year follow-upyear follow-up

53% in independent employment at 1 year53% in independent employment at 1 year 39% of those placed returned to previous 39% of those placed returned to previous

employmentemployment 58% of total placements made within 6 58% of total placements made within 6

months of initiation of servicesmonths of initiation of services 92% within 1 year92% within 1 year

Comprehensive vs. LimitedComprehensive vs. Limited

InterventionIntervention

Comprehensive Postacute Brain Comprehensive Postacute Brain Injury RehabilitationInjury Rehabilitation

A cognitive and behavioral approachA cognitive and behavioral approach Interdisciplinary teamInterdisciplinary team Emphasis on self-awareness, adjustment, Emphasis on self-awareness, adjustment,

compensation and social skillscompensation and social skills Low staff-to-patient ratioLow staff-to-patient ratio Family involvementFamily involvement Vocational and independent living trialsVocational and independent living trials Systematic outcome assessmentSystematic outcome assessment

Mayo Comprehensive ProgramMayo Comprehensive Program

Patient CharacteristicsPatient Characteristics

Limited self-awareness of disabilitiesLimited self-awareness of disabilities Cognitive impairments: e.g., Cognitive impairments: e.g.,

concentration, memory, generalization, concentration, memory, generalization, problem-solving, initiation, reasoning, problem-solving, initiation, reasoning, planningplanning

Poor communication and social skillsPoor communication and social skills Limited emotional/behavioral self-controlLimited emotional/behavioral self-control Unemployed or failing in employmentUnemployed or failing in employment Not a danger to self or othersNot a danger to self or others

Mayo Comprehensive ProgramMayo Comprehensive Program

GroupsGroups

DailyDaily OrientationOrientation CognitiveCognitive Social AwarenessSocial Awareness CommunicationCommunication Life SkillsLife Skills

WeeklyWeekly Health EducationHealth Education VocationalVocational

MonthlyMonthly Patient/Family Patient/Family

GroupGroup

Mayo Comprehensive ProgramMayo Comprehensive ProgramVocational IndependenceVocational Independence

84%

26%

27%

6% 8% 6%3% 3%

18%

3%

53%

10%

4%

10%

39%

0%10%20%30%40%50%60%70%80%90%

Perc

ent

of G

raduate

s

Unemployed Sheltered Supported Transitional Independent

Pre Post 1-Year

Community-Based Community-Based Employment by Time Since Employment by Time Since

InjuryInjury

0%

10%

20%

30%

40%

50%

60%

70%

80%

Perc

ent

of G

raduate

s

< 1 yr(n=36)

1-2 yrs(n=16)

2-5 yrs(n=17)

5-10 yrs(n=15)

10+ yrs(n=12)

Time Since Injury

Pre Post 1-Yr

Limited InterventionLimited Intervention

Vocational Services onlyVocational Services only Additional outpatient cognitive Additional outpatient cognitive

rehabilitationrehabilitation Adjustment counselingAdjustment counseling Other outpatient rehabilitation therapiesOther outpatient rehabilitation therapies Community Integration Outpatient Community Integration Outpatient

GroupGroup

Probability of Community-Probability of Community-Based EmploymentBased Employment

Staff MPAI Standard ScoreMonthsSinceInjury 300 400 500 600 700

6-12 .98 .94 .81 .53 .24

60 .96 .88 .67 .36 .13

120 .91 .75 .45 .18 .06

CDT .98 .92 .77 .47 .20

ConclusionsConclusions A medical-center based Vocational Case A medical-center based Vocational Case

Coordinator who coordinates service Coordinator who coordinates service delivery maximizes vocational outcomes for delivery maximizes vocational outcomes for persons after brain injurypersons after brain injury

Early intervention optimizes outcomes and Early intervention optimizes outcomes and optimizes the success of limited optimizes the success of limited interventionintervention

Successful vocational placement can be Successful vocational placement can be accomplished within 1 yearaccomplished within 1 year

ConclusionsConclusions Overall disability and time since injury are Overall disability and time since injury are

the best predictors of vocational the best predictors of vocational placement after brain injury rehabilitationplacement after brain injury rehabilitation

The best predictor of long-term vocational The best predictor of long-term vocational outcome is initial placementoutcome is initial placement

Return to previous employment is a viable Return to previous employment is a viable option for many persons after brain injuryoption for many persons after brain injury

ConclusionsConclusions Comprehensive rehabilitation is often Comprehensive rehabilitation is often

required by more persons with greater required by more persons with greater disability or chronicity and results in a disability or chronicity and results in a more extended time to placement more extended time to placement

However, comprehensive intervention However, comprehensive intervention can be successful with the majority of can be successful with the majority of persons served regardless of persons served regardless of chronicity or severitychronicity or severity