Vocational Treatment Components in TBI Model Systems of Care

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Vocational Treatment Components in TBI Model
Systems of Care

• Tessa Hart, PhD
• Moss Rehabilitation Research Institute
• Moss TBI Model System
• Philadelphia PA

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TBIMS Collaborators

• NY Marcel Dijkers, PhD
• WA Bob Fraser, PhD
• NJ Charlotte Trott, PhD Keith Cicerone, PhD
• CO Cindy Dahlberg, MA, CCC-SLP Eileen
  McLaughlin
• NC Flora Hammond, MD Mark Hirsch, PhD John
  Humphreys
• MS Mark Sherer, PhD Joyce Leverenz
• MN Jim Malec, PhD Tom Bergquist, PhD
• OH Jennifer Bogner, PhD
• PA John Whyte, MD, PhD

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Overview

• Two-phase project on vocational treatment within
  the TBI Model Systems
• What motivated this project?
• What are we trying to find out?
• What have we found out? (Phase 2 isnt done yet,
  so dont have complete results)

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Background Motivation

• Vocational project was developed by group of
  investigators in 8 TBI Model Systems Treatment
  Special Interest Group
• Why a Treatment SIG? Isnt the Model System
  program all about treatment?
• Well..

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Person characteristics Impairments Functional
limitations
Rehab Inc. We improve lives
??
Improved functioning Better quality of life
(Slide stolen from M. Dijkers PhD)
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At the State of the Art (and Science)

• Rehabilitation has been called a Black Box, into
  which we cannot see.
• or a Russian Doll full of nested layers of
  hopelessly complicated ingredients
• Our SIG was determined to do some unpacking!

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Why Vocational Treatments?

• Work is an important goal to many persons with
  TBI
• TBI affects people in prime working years
• Work is strongly related to quality of life
• Rates of finding or returning to work after TBI
  are poor
• 1/3 or less in most studies
• does not change much over time
• Vocational services are key components of many
  post-acute programs for TBI
• but little evidence for the effectiveness of
  specific services
• no standard ways to define them

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Objectives of Vocational Treatment Project

• Phase 1 Unpack the Black Box. What is vocational
  rehabilitation?
• what are the treatment components?
• how do they vary across TBIMS programs?
• Phase 2 What components are most effective?
• how are components selected for different people?
• how are components related to outcomes?

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Phase 1 What Is Vocational Rehabilitation?

• We listed and defined every type of vocational
  service we could think of, find in the
  literature, get from VR, etc.
• focus groups of clinicians involved in our
  vocational programs also provided input
• Developed survey (semi-structured interview) to
  ask each of the 16 TBIMS centers
• which services (treatment components) they offer,
  at what frequency/ intensity
• other program characteristics (maturity,
  staffing, funding, philosophy)

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Example Treatment Components and Definitions

• Vocational Counseling/ Education Treatments
  focused on giving the client vocational knowledge
  and information, helping client solve practical
  problems, and/ or changing client attitudes, as
  these issues affect vocational goals. Refers to
  formally scheduled, recurring sessions.

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Example Treatment Components and Definitions

• Job Development and Job Seeking. Treatments
  focused on planning and managing the search
  process, including identifying appropriate job
  leads and job openings, preparing and
  distributing resumes, written applications and
  cover letters interviewing for jobs following
  up after interviews etc.

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Example Treatment Components and Definitions

• Job Coaching. Treatment involving a staff member
  accompanying the client to his/her work place or
  working with the client off site, with a focus on
  job training, trouble-shooting and
  problem-solving, development and application of
  strategies on-the-job. May also include
  intervention or education with employer and
  co-workers, workplace modifications (physical or
  scheduling modifications), or other interventions
  as needed to assist the client in performing a
  job in which he/ she has been (provisionally)
  placed.

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Results of Phase 1

• Enormous diversity among TBIMS vocational
  services from none to very comprehensive
• 3 overall models
• Medical Rehabilitation mostly acute treatment
  done by medical rehab staff, few services after
  job placement such as job coaching
• Supported Employment few or no rehab services
  before placement emphasize coaching and
  follow-along services
• Combo/ Case Management both medical rehab and
  supported work elements , with an emphasis on
  case management to coordinate individual programs

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(No Transcript)
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So What?

• What difference does it make whether people get
  mixture X or mixture Y of vocational treatments?
• i.e., how are vocational treatments related to
  outcomes? What are the most important or powerful
  treatments? 2 ways to answer
• results of controlled studies (of which there are
  none)
• expert opinion e.g., survey respondents

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What Are the Most Important Vocational
Interventions?

• Phase 1 survey respondents cited interventions
  AFTER job placement (job coaching, counseling,
  etc.) as make it or break it interventions for
  vocational success for people with TBI
• Phase 2 was designed to look at post-placement
  services in more detail
• who gets them?
• of what do they consist?
• what are their outcomes?

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Phase 2 Vocational Services Following Job
Placement

• We enrolled 65 clients who were placed on jobs
  and then got treatment such as job coaching at 5
  TBIMS centers (PA, CO, NJ, WA, MS)
• Measured all 3 categories of variables

Person Variables
Outcomes
Treatments!
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Phase 2 Measurement

• Person Variables Demographics, work history,
  injury severity, cognitive status, emotional
  status, drug/ alcohol use, etc.
• Outcomes (3 and 6 mo after placement)
• Are they still working?
• How much are they making?
• How satisfied are they with the job?

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Treatment Measurement

• Content(s) of treatment daily for 6 months
• cognitive/ compensatory strategy training
  (included reviewing how to do the job itself)
• behavioral/ emotional adjustment (included
  feedback on behavior with co-workers, emotional
  reactions)
• supervisor/ employer training/ education
• worksite accommodations (including adjustments in
  schedule)
• life skills training (transportation, finances)
• case management/ advocacy
• family/ SO intervention
• Locations Worksite, clinic, other community,
  phone
• Total amount of time per day of service

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Questions for Phase 2 Data

• What kinds of treatments are given to people with
  TBI after job placement?
• Majority of forms indicate focus on cognitive/
  compensatory strategy training
• Emotional function, supervisor training, worksite
  accommodation also very common
• Most treatment was at worksite or clinic,
  followed closely by on the phone
• There may be potential for developing phone or
  other distance treatment models to save

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Questions for Phase 2 Data

• How much treatment did people get over the 6
  months (130 possible work days)?
• About 8 got 1 day or session of treatment
• 75 got 15 days/ sessions or less
• 8 got 30 days/ sessions or more (highest 75)

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Lots of Remaining Questions

• How are types and amounts of treatment selected
  for different clients?
• For example, do people with worse cognitive
  deficits get more treatments targeted to
  cognitive compensatory strategies?
• What about if the job is a new one vs. one to
  which the client is returning?
• Or do centers provide a standard package for all
  or most clients regardless of person variables?

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The Ultimate Questions

• How are these treatments related to outcomes?
• Do people who get more treatment have better
  outcomes other things being equal?
• Do people who get more treatments at the worksite
  do better than those who get more treatments in
  the clinic?
• Etc., etc., etc

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Thank You!

• Contact me at thart_at_einstein.edu
• For results of Phase 1 see
• Hart, Dijkers, Fraser, Cicerone, Bogner, Whyte,
  Malec, Waldron Vocational services for
  traumatic brain injury Treatment definitions and
  diversity within Model Systems of Care, Journal
  of Head Trauma Rehabilitation 21(6)467-482, 2006