Transcript Click here to the Strategies for Success
Strategies for Success: Returning To Work After Brain Injury
BANCROFT Brain Injury Services Heads-Up Webinar Series By Lorraine Myro, MSW, LSW Clinical Director, Bancroft Brain Injury Services, New Jersey
Our Mission
.
Bancroft provides opportunities to children and adults with diverse challenges to maximize their potential.
Our Vision
A community where every individual has a voice, a purpose and a rightful place in society. 2
Our Core Values
R
esponsible
E
mpathetic
S
upportive
P
assionate
E
mpowered
C
ommitted
T
rustworthy
R E S P E C T
3
Re-Cap of May Webinar:
Finding the Perfect Job
Reviewed the significance of volunteer and employment positions as related to quality of life Identified Community resources and services available to support the vocational process Identified challenges encountered when helping individuals with acquired brain injuries find their “Perfect Job” Explored how to utilize brain injury outcome measures (the MPAI-4) as an effective assessment tool to determine job compatibility
Today’s Objectives
Identify what percentage of individuals with TBI are returning to work, as well as the limitations of the research Identify limiting and facilitating factors for returning to work Identify what employers need from us to engage in successful partnerships Identify key elements that support successful return to work programming
People who are employed report . . .
Better sense of well-being
Better health status
Greater social integration within the community
Less health service usage
More social contacts
Overall better quality of life
Van Helzen, Van Bennekom, Edelaar, Sluiter, & Frings Dresen, 2009
Factors affecting return to work rates (RTW)
o Invisibility of injury o Economic conditions o
Specific employer hiring strategies
o
Employer attitudes
o
Continuing symptoms
o
Life changes
o
Lack of information provision, advice and guidance re: RTW
Van Helzen, Van Bennekom, Edelaar, Sluiter, & Frings Dresen, 2009; Hernandez, Chen, Araten-Bergman, Levy, Kramer, Rimmerman, 2012
7
Limitations of research
Reviews published 2007 - 2011 Challenges with the studies o Definition of “return to work” o • • Same job, other job, studies, homemaker FT/PT Length of RTW employment to be considered “successful RTW” Distinguishing ABI vs. TBI Range of measures (6 months, 1 year, 2 years) Severity of injury Contradictory findings
Return to work rates
10 studies, international
TYPE OF INJURY
MILD (6 weeks – 9 months)
RATE
12 – 87.5% MIXED (> 1 year) 45 – 66% SEVERE (> 1 year) 18 – 37 % Shames, Treger, Ring & Giaquinto, 2007
Influence of race/ethnicity on RTW post ABI
Race/ethnicity independently predicts employment outcomes after ABI Example: African Americans twice as likely as whites to be nonproductive 1 year postinjury Minorities, as a group, more likely than whites to not be competitively employed at 1 year postinjury Wehman, Gentry, West, Arango-Lasprilla, 2009
RTW Predictive Factors
Length of stay ADL functioning Injury severity Self-awareness Motivation Shames, Treger, Ring, & Giaquinto, 2007; Van Helzen, Van Bennekom, Edelaar, Sluiter, & Frings-Dresen, 2009
Qualitative Predictive Factors
Patient’s positive valuation of work Flexible and supportive workplace Higher scores on neuropsychological screenings Subscale for Affect discriminated o Ability to express an affect with the voice o Interpret facial emotional expressions o Ability to control emotional impulses o Ability to comprehend and express response to humor Hofgren, Esbjornsson, & Sunnerhagen, 2010
Most prevalent barrier for RTW
Inappropriate behavior Behavioral outbursts Lack of tact Disinhibition Shames, Treger, Ring & Giaquinto, 2007
RTW Barriers Continued
Self-report Tiredness/fatigue Lack of support from colleagues, supervisors Recovery time took too long Unable to drive Physical consequences (vision, hearing, balance, pain) Cognitive consequences (aphasia, concentration) Van Velzen, Van Bennekom, Van Dormolen, Sluiter, & Frings-Dresen, 2011
RTW Facilitating Factors
Self-report Motivation* Strong will* Support from colleagues and bosses Goodness of fit for job task Humor* Functional use of upper extremities* Van Velzen, Van Bennekom, Van Dormolen, Sluiter, & Frings-Dresen, 2011
15
Clinical Implications for Successful Program Planning
Research identifies complex interactions between Pre-morbid characteristics Injury factors Post-injury impairments Personal and environmental factors
16
Programming for Success
Commitment from Administrative team Business Advisory Council Support/partnership with vocational rehabilitation professionals Supported Employment/Customized Employment Inter-disciplinary team model Vocational Grand Rounds Utilization of strengths-based practices Personal Futures Planning
o o
Commitment from Administrative Team: Business Advisory Council
Committee of local business representatives who come together to identify avenues for helping those with TBI get back into the work force. Purpose = network Zuger, Brown, O'Neill, Stack, Amitai, 2002
Why a Business Advisory Council?
Groundbreaking research by Fraser, et al (2009) explored the hiring intentions and behaviors of nonprofit and for-profit organizations Follow up study identified differences in hiring strategies o o For-profit driven by mission to sell Nonprofit driven by mission to serve For-profit organizations: participants involvement with disability employment committees or networks seemed to foster hiring of individuals with a disability Hernandez, Chen, Araten-Bergman, Levy, Kramer, Rimmerman, 2012
Critical Elements of BAC
Chair person who can attract and motivate members Committee members either are decision makers in their organization or have access to decision makers in local businesses Serve as advisors, advocates, liaisons, and educators Network Events Personal meet and greets Newsletter to the local community Zuger, Brown, O'Neill, Stack, Amitai, 2002
Benefits of a BAC . . .
Networking Educate, break down barriers within the business community Employers can communicate about trends, their needs, make recommendations and referrals Advice about resumes Invite us to their functions, opportunities for company exposure, ambassador for clients Zuger, Brown, O'Neill, Stack, Amitai, 2002
21
Benefits for business professionals on a BAC
. . .
Develop awareness Exposed to cultural and sensitivity training Inspiration Opportunity to “shine”
22
Vocational Rehabilitation Specialists
Comprehensive Evaluations
o
Recommendations based off of evaluations
Situational assessments
Work trials/Job coaching
Problem solve, resources
Therapeutic interventions
Network, advocate, bridge gaps
Most prevalent barrier for RTW
Inappropriate behavior Behavioral outbursts Lack of tact Disinhibition
Strategic interventions
Tailor the environment o o Quiet, structured, routinized Structured, routinized, and loud Opportunity and space to take breaks as needed
24
Examples of strategies/therapeutic interventions
Make building a resume a priority: volunteer and internships demonstrate individual’s strengths and capacities Modify working tasks/ work times to individual’s capabilities Work less hours/have sufficient time to recover Introduce adaptations to improve performance
25
Examples of strategies/therapeutic interventions
Prolonged support for individual and employer Collaborate with inter-disciplinary team Make sure individual has name/# of on-site contact (and back-up contact) each time he/she goes to work Make sure individual has name/# of contact for transportation, when it should arrive and what to do if it doesn’t
Emphasize pre-vocational work
Volunteering o Opportunity to practice work skills Follow a structured schedule Build cognitive and physical stamina Improve upon skills Opportunity to practice accountability Opportunity for evaluation in a safe setting o Add to resume
What do employers look for when hiring
Goodness of fit Compatability/connection Understand what their needs are: business practices, trends, and outcomes their hiring process what their industry calls for from it’s workers how a carved out position can help them
28
What supports do employers need from us?
Language they can understand and relate to, “The individual sustained an injury from a car accident” Education about TBI and individual’s capabilities Commitment from support team to individual’s success Availability to provide on-the-spot support Relationship Reliability of individual and support team
Supported Employment
2009 study identified that “finding evidence that the approach is being utilized on a wide-scale basis by individuals with ABI is difficult” 2012 study indicated that “Individualized placement and the model of supported employment have been established as one of the most supported EBPs” Wehman, Gentry, West, & Arango-Lasprilla, 2009; Drebing, Bell, Campinell, Fraser, Malec, Penk, & Pruitt-Stephens, 2012
What is supported employment?
Individualized and intensive support Provided by vocational rehabilitation professional Identify individual’s abilities and potential work place needs Contact employer to discuss hiring needs, including job seekers abilities, and specific tasks that employers need to have done Wehman, Gentry, West, & Arango-Lasprilla, 2009;
Customized Employment
ODEP explains CE as “individualizing the employment relationship between employees and employers in ways that meet the needs of both” Predicated on a
“negotiation”
between the job seeker (or his/her representative) and the employer; the means of getting the job differs from the traditional approach of applying, interviewing, orienting, and working.
Griffin, Hammis, Geary, & Sullivan, 2008; Griffin & Keeton, 2009
Inter-disciplinary team model
Inter-disciplinary team model Neuropsychologist Speech therapist Occupational therapist Physical therapist Cognitive rehabilitation therapist Employment specialists Vocational Rehabilitation specialists Person being served, significant others Physician
Example of how an IDT model can work . . .
Case Example: AC 38 yo, injured as a child, working at ACME for 10 years Lives in residential rehabilitation program, with full IDT Behaviors: Asking customers for puzzles Uniform chronically dirty Anger outbursts (yelling, cursing, stomping away)
34
Strategies used:
• • • • • Employment Specialist met with management to assure them team was addressing issues; followed up to ensure improvement Bring uniform to Day Program daily, include a clean back-up uniform that is kept on-site Staff pre-set AC of expectations o Change into work clothes right before work o Do not ask customers for puzzles Therapy with neuropsychologist Initial response to interventions: angry outbursts o Calm, consistent implementation of strategies o Eventually outbursts ceased o Problematic behaviors ceased
35
AC’S WORK PREPARATION CHECKLIST
Each day that AC works, staff will review this checklist with him. Both AC and staff will initial the box as they review the item. Our support with this responsibility is critical to AC keeping his job.
Items to Review
__________ Wearing ACME uniform __________ __________ __________ __________ Pants are clean Shirt and Vest are clean Apron is clean and on Review reminders
REMINDERS IN ORDER TO STAY EMPLOYED
WEAR A CLEAN UNIFORM FOR THE FULL SHIFT IF THEY ASK YOU TO WEAR YOUR ACME JACKET WHILE YOU ARE WORKING, BE SURE TO WEAR DO NOT ASK CUSTOMERS FOR ANYTHING BE RESPECTFUL AND POLITE TO YOUR BOSS BE RESPECTFUL AND POLITE TO YOUR CO-WORKERS IF YOUR BOSS ASKS YOU TO DO SOMETHING, BE SUPPORTIVE BY SAYING “YES” AND DOING IT
36
Inter-disciplinary team support
o o Vocational specialist: liaison between AC, team and employer; provided on-site support until issues resolved Residential program manager with AC sent clothes in o Day program manager: trained staff on protocol o Staff: pre-set AC daily o Neuropsychologist: source for AC, support with pre-setting
IDT: Vocational Grand Rounds
Similar to medical model of grand rounds Gathering of professionals involved in vocational rehabilitation that focuses discussion on unique or problematic cases Offer expertise from across the spectrum • • • • • • • Neuropsychologists Vocational specialists Counselors Funder Community business leaders Advocates Individual * Zuger, Brown, O'Neill, Stack, Amitai, 2002
Benefits of Vocational Grand Rounds
•
Outreach
•
Education
•
Development/strengthening of relationships with community resources
Zuger, Brown, O'Neill, Stack, Amitai, 2002
Strengths-based Practice:
o
Personal Futures Planning
Person – centered approach to treatment planning o Assumes that vocational goals are defined, achieved, and retained within a broad context o Focus on vision and action plan to address
all
areas of life that are important to individual o Vision and goals are adapted to fit life with challenges and new reality Zuger, Brown, O'Neill, Stack, Amitai, 2002
In the words of one client,
“Following my accident, society seemed to say to me, ‘Drop out of life, take your medication and maybe we can find you a job in a file room somewhere.’ PFP helped clear the psychosocial logjam that inhibited the flow of my personal development.”
Zuger, Brown, O'Neill, Stack, Amitai, 2002
41
Clinical practice going forward: Using our resources
o o Utilize the MPAI to highlight strengths and skill areas Categorize types of employment, compare with strengths and weaknesses of MPAI o o o Implement principles of customized employment Utilize resources from BAC • • • Implement previously identified strategies Comprehensive assessment Inter-disciplinary treatment Job coaching, supported employment, job mentor
42
MPAI-4 Tool to Assess Job Compatibility
Extrapolate results from MPAI Executive Functioning Memory Attention Social Communication Visuospatial Physical Ability
MPAI Tool to Assess Job Compatibility
Person Served: Job Title: Organization: Hours: LOS: Assessor: Date: 0 None
1 Mild problem but does not
MPAI Scoring Rubric
2 Mild problem; interferes with 3 Moderate problem; interfere with activities; may use assistive device or medication activities 5-24% of the time interferes with activities 25-75% of the time 4 Severe problem; interferes with activities more than 75% of the time
Executive Functioning Functional Area/Correlating MPAI Rating
PS Rating
11. Novel problem-solving 20. Impaired self-awareness 22. Initiation
3 3 3 2 2 2 Job With Aid?
Y/N Y/N
Y
/N
Total
9 6
44 MPAI-4 Tool to assess job compatibility
45
Treatment Plan
Long term goal: Employment Short term goal: Reduce MPAI rating for self awareness from 3 to a 2 Interventions: • • Cognitive therapy Speech therapy • • • • • Individual psychology sessions Group psychology sessions Situational assessment at potential work site Monthly team meetings to monitor progress Job coaching at each work sessions
Critical elements of successful RTW
Network, network, and then network some more!
Commitment from all members of the team, including administrative team Defined roles and expectations of anyone involved Thorough and accurate understanding of individuals injury, strengths, interests and impairments o History, evaluations, situational functioning Persistence, creativity, and commitment Zuger, Brown, O'Neil, Stack, Amitai, 2002
Considerations to improve RTW outcomes
RTW possibility and process should be discussed with family and team early in postacute recovery Embrace RTW principle: everyone is employable when provided with the right opportunities and supports; RTW is a process rather than event Increase use of supported employment Consider alternative forms of employment: tele-work, self employment, independent contracting work Expand efforts to help raise awareness of the centrality of employment outcomes : RTW should be a primary outcome for rehabilitative services Wehman, Gentry, West, & Arango-Lasprilla, 2009; Debring, Bell, Campinell, Fraser, Malec, Penk & Pruitt Stephens, 2012
48 • • • • •
Further research on this topic . . .
What types of jobs are people “returning to”?
Has the practice of customized employment impacted RTW rates? Has the utilization of Business Advisory Councils impacted RTW rates?
Has the use of assistive technology impacted RTW rates? Why do minorities have lower RTW rates than whites?
49
Questions?
“… no matter how broken or deformed the body of a human being may be, within that body is a personality, and it is our business to liberate that body from its prison – to remove the obstructions that prevent the assertion of expression of the individuality”
Margaret Bancroft The Collected Works of Margaret Bancroft, 1915