Article Details

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Citation:  Malec, J. F., Buffington, A. L. H., Moessner, A. M., & Degiorgio, L. (2000). A medical/vocational case coordination system for persons with brain injury: An evaluation of employment outcomes. Archives of Physical Medicine and Rehabilitation, 81 (8), 1007-1015.
Title:  A medical/vocational case coordination system for persons with brain injury: An evaluation of employment outcomes
Authors:  Malec, J. F., Buffington, A. L. H., Moessner, A. M., & Degiorgio, L.
Year:  2000
Journal/Publication:  Archives of Physical Medicine and Rehabilitation
Publisher:  Elsevier
Full text:   
Peer-reviewed?  Yes
NIDILRR-funded?  Yes
Research design:  Quasi-experimental

Structured abstract:

Background:  The present study tested a Medical/Vocational Case Coordination System (MVCCS) designed for persons with brain injury. The MVCSS, which was based on knowledge gained from the research literature and from clinical experience in medical and vocational rehabilitation for persons with BI, emphasize early intervention and coordinated service delivery through integrated medical center–based and community-based services. Early intervention was emphasized to reduce the time between injury and community reintegration and to reduce the associated psychosocial complications that may result from lack of early intervention. The MVCCS was expected to maximize participants’ vocational and independent living outcomes and to minimize the use of medical and community resources. The researchers review of previous research supported the belief that an intervention system for improving vocational outcomes of persons with BI must include these features: (1) early case identification and coordination, (2) appropriate medical and vocational rehabilitation interventions, (3) work trials, and (4) temporary or long-term supported employment in appropriate cases. To be viable, the system must significantly improve on the benchmark of 60% unemployment with results at least equivalent to those of earlier intervention studies; that is, approximately 75% of participants in community-based employment: approximately 50% working without long-term supports and approximately 25% in long-term, community-based, supported employment or in educational or training programs. They studied vocational outcomes of the MVCCS over a 4-year period.
Purpose:  To evaluate initial placement and 1-year employment outcomes of a Medical/Vocational Case Coordination System (MVCCS) for persons with brain injury (BI) that provides: (1) early case identification and coordination, (2) appropriate medical and vocational rehabilitation interventions, (3) work trials, and (4) supported employment interventions including job coaching. The study design evaluated 2 hypotheses. The first hypothesis was that vocational outcomes will meet or exceed those reported previously, that is, (1) 75% of participants in community- based independent or supported community-based employment or education/training programs (Vocational Independence Scale [VIS] levels 3 to 5); and (2) 50% of participants in independent community-based employment (VIS level 5). The second hypothesis was that vocational outcomes will be related to (1) severity of injury, (2) severity of impairment/disability, (3) ISA, (4) time since injury, (5) presence of additional non-brain injuries, and (6) preinjury educational/vocational status.
Setting:  The setting was a large urban medical center.
Study sample:  One hundred fourteen Minnesota residents with traumatic or other acquired brain injury between the ages of 18 and 65 years. The majority (or 64%) had TBI followed by CVA (26%) and other (10%). The largest portion (36%) of the sample was referred for vocational services through outpatient rehabilitation evaluations. Severity of injury was classified only in TBI cases, based on results of available initial Glasgow Coma Scale (GCS) score and duration of loss of consciousness (LOC) at the time of injury; 56% were classified as severe TBI. Among all participants N=114, the majority (61%) were male. Mean age was 37.4. Preinjury education was less than 12 (22 %); 12 to 15 years (61%) and greater than 16 years (17%). Sixty nine percent were working prior to injury and 77% had an independent living status. The mean time since injury for the group was 65.5 months with a median of 12.7 months.
Intervention:  The MVCCS interfaced a medical center–based BI Nurse Case Coordinator (NCC) with a medical-center based BI Vocational Case Coordinator (VCC) who served as a liaison to community-based services. This interface provided: (1) early identification by the NCC of individuals needing medical services, medical rehabilitation, vocational rehabilitation, and social services; (2) late identification of other persons with chronic impairments after BI and their service needs by either the NCC or the VCC; (3) personal vocational counseling, consumer advocacy, and on-site consultation to other vocational services provided by the VCC; (4) access to community-based vocational services through the VCC that included: vocational evaluations, supported work trials, long-term community- based supported employment, job coaching, job development, and job placement; (5) access to other community based services that support employment, such as independent living services, community-based social services and mental health services, and traumatic brain injury (TBI) waivered services, including behavioral aide services; and (6) access to medical center services that enhance vocational re-entry for persons with BI, such as a CI day rehabilitation program; a 3-hour weekly community reintegration group; individual cognitive rehabilitation; medical rehabilitation services such as standard rehabilitation therapies, work hardening, and physical work assessments; neuropsychologic and psychiatric services, including psychotherapy, family therapy, behavioral medicine, and substance abuse treatment; and other medical diagnostic and therapeutic services, including physiatric and behavioral neurology services. In the day-to-day operation of the MVCCS, the NCC, working with emergency room staff, identified all brain-injured persons admitted to the hospital each working day and served as case coordinator for these cases. She reviewed the medical record, met with the patient, recommended additional services to the primary medical service, obtained consent, and entered participants into the clinical database. The NCC followed the patient after dismissal from acute care. If the patient left from acute care to home, she followed up by telephone within 1 month to identify potential BI sequelae and service needs and to assist in scheduling required services. If the patient left acute service to the rehabilitation unit, the NCC turned medical case coordination over to the rehabilitation social worker. In all cases referred, the VCC met with study participants and obtained consent for study participation, provided all appropriate vocational evaluations and counseling, completed the Staff MPAI with input from other involved rehabilitation staff, obtained the Survivor MPAI, and referred appropriate participants to community-based vocational services. The VCC followed up on each participant 1 year after the person was placed or left the project.
Control or comparison condition:  There was no comparison condition. Participants served as their own controls.
Data collection and analysis:  Vocational outcome at time of initial placement and at 1-year follow-up was measured using the Vocational Integration Scale. The Mayo-Portland Adaptability Inventory (MPAI), a scale based on the Portland Adaptability Inventory was used for rating the range of physical, cognitive, emotional, and social impairments and disabilities resulting from BI. It was completed by rehabilitation staff, the patient and a significant other. Rating scale (Rasch) analyses of the Staff MPAI based on 305 assessments led to a reduction in the number of items from 30 to 22 by eliminating noncontributing items. An indicator of Impaired self-awareness ISA was item 24 from the Staff MPAI, which rates level of indifference or lack of awareness of deficits. The second indicator of ISA used was the difference between the Rasch-converted score for 22-item Staff MPAI and the Rasch-converted score for the 22-item Survivor MPAI. Preinjury vocational status, the presence of other non-brain injuries, time since injury, and the Rasch-transformed Staff MPAI appeared to have some value in predicting the level of initial vocational placement. At 1-year follow-up, vocational status was predicted by time since injury and Rasch Staff MPAI. The VIS at initial placement also significantly predicted VIS at follow-up (Spearman coefficient 5 .75, n 5 101, p , .0001). The efficiency of services (ie, months to placement) was significantly predicted by preinjury education, injury severity, time since injury, Rasch Staff MPAI, Rasch Survivor MPAI, and the difference between the Rasch Staff MPAI and Rasch Survivor MPAI. To control for experiment-wise error, potential predictor variables were further scrutinized using regression analyses.
Findings:  The MVCCS evaluated in this study appeared to substantially improve employment outcome for persons with BI without interventions. Results were better than projections based on the previous literature—80% of those served were placed in community-based work with 46% in independent community-based employment. Employment outcomes for persons who received vocational services through this project approached or exceeded outcomes reported previously for intensive rehabilitation interventions. Just as importantly, initial vocational placements were maintained at 1-year follow-up. At the follow-up interview, 81% were working in the community and 53% were employed independently without job supports. Although the results were equivalent to those of other rehabilitation programs that are based on ‘‘best practices,’’the authors could not make direct comparisons with those programs because we did not investigate specific interventions. Primary predictors of initial placement in the present study were time since injury and overall impairment/disability as measured by the Staff MPAI. Return to previous work should be considered especially for the more recently injured who have retained ties to their previous employer. Results indicate that more severe impairments and disabilities, as measured by the MPAI, are significant barriers to employment in the general population of persons with BI. However, for persons with TBI, the presence of additional non-brain injuries appears to be a more important factor. The best predictor of employment level at 1-year follow-up was the level of initial placement. ISA (as measured by the difference between Rasch Staff MPAI and Rasch Survivor MPAI) did not contribute to the prediction of either initial placement or job maintenance. This finding is inconsistent with some other studies reporting an association between ISA and long-term employment after BI. The results suggest that ISA may be a barrier to employment that can be overcome through rehabilitation, through education and support for employers, and by discriminating placement of those persons with ISA in work environments that are more tolerant of limitations in self-awareness. Overall level of impairment and disability also appears to be a factor in time required for placement. In some cases, more intensive rehabilitation efforts, such as a CI day rehabilitation program, were required for more severely disabled persons so they could develop cognitive compensation, communication, behavioral self-management, social, and other pre-vocational skills required for eventual placement. Because of the time required for participation in such an intensive rehabilitation program, most individuals who participated in CI day rehabilitation required 6 to 12 months from the time they were admitted to services to their eventual placement. Our data suggest that most placements (92%) can be made within 1 year of admission to services. Preinjury years of education also contributed slightly to prediction of time to placement, with more highly educated individuals being placed more quickly.
Conclusions:  Introducing a VCC into an MVCCS program appears to optimize participants’ vocational outcome after BI, resulting in community-based employment for 81% of persons served with 53% working independently in the community 1 year after placement. Time since injury and overall level of impairment/ disability were the most significant factors in predicting vocational outcomes. Beyond its association with overall level of disability and chronicity, ISA did not contribute to the prediction of initial placement or job maintenance. The best predictor of employment status at 1 year follow-up was the level of initial placement. Persons with greater overall disability required more extended time and more extensive rehabilitation services before job placement.

Disabilities served:  Traumatic brain injury (TBI)
Populations served:  Gender: Female and Male
Race: Black / African American
Race: White / Caucasian
Interventions:  Other
Outcomes:  Employment acquisition
Return to work
Full-time employment
Part-time employment
Increase in hours worked
Increase in tenure