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

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Bancroft provides opportunities to children and adults with diverse challenges to maximize their

potential..

Our Core ValuesResponsible Empathetic Supportive Passionate Empowered Committed Trustworthy

R E S P E C T

A community where every individual has a voice, a purpose and a rightful place in society.

Our Vision

Our Mission

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

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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 injuryo Economic conditionso Specific employer hiring strategieso Employer attitudeso Continuing symptomso Life changeso Lack of information provision, advice and

guidance re: RTWVan Helzen, Van Bennekom, Edelaar, Sluiter, & Frings-Dresen, 2009; Hernandez, Chen, Araten-

Bergman, Levy, Kramer, Rimmerman, 2012

Limitations of research Reviews published 2007 - 2011 Challenges with the studies

o Definition of “return to work”• Same job, other job, studies, homemaker• FT/PT

o 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

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Return to work rates 10 studies, international

TYPE OF INJURY RATE

MILD (6 weeks – 9 months) 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 FactorsLength of stay ADL functioning Injury severitySelf-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 voiceo Interpret facial emotional expressionso Ability to control emotional impulseso 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

Clinical Implications for Successful Program Planning

Research identifies complex interactions between Pre-morbid characteristics Injury factors Post-injury impairments Personal and environmental factors

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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

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Commitment from Administrative Team: Business Advisory Council

o Committee of local business representatives who come together to identify avenues for helping those with TBI get back into the work force.

o 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 For-profit driven by mission to sell o 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

Benefits for business professionals on a BAC . . .

Develop awarenessExposed to cultural and sensitivity

trainingInspirationOpportunity to “shine”

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Vocational Rehabilitation Specialists

Comprehensive Evaluationso Recommendations based off of evaluations

Situational assessments Work trials/Job coaching Problem solve, resources Therapeutic interventions Network, advocate, bridge gaps

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Most prevalent barrier for RTW Inappropriate behavior

Behavioral outbursts Lack of tact Disinhibition

Strategic interventions Tailor the environment

o Quiet, structured, routinizedo Structured, routinized, and loud

Opportunity and space to take breaks as needed

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

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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

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Emphasize pre-vocational workVolunteering

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

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

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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 modelInter-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)

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 worko Do not ask customers for puzzles

• Therapy with neuropsychologist• Initial response to interventions: angry outbursts

o Calm, consistent implementation of strategieso Eventually outbursts ceasedo Problematic behaviors ceased

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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 EMPLOYEDWEAR A CLEAN UNIFORM FOR THE FULL SHIFTIF THEY ASK YOU TO WEAR YOUR ACME JACKET WHILE YOU ARE WORKING, BE SURE TO WEARDO NOT ASK CUSTOMERS FOR ANYTHINGBE RESPECTFUL AND POLITE TO YOUR BOSSBE RESPECTFUL AND POLITE TO YOUR CO-WORKERSIF YOUR BOSS ASKS YOU TO DO SOMETHING, BE SUPPORTIVE BY SAYING “YES” AND DOING IT

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Inter-disciplinary team supporto Vocational specialist: liaison between AC, team

and employer; provided on-site support until issues resolved

o Residential program manager sent clothes in with AC

o Day program manager: trained staff on protocolo Staff: pre-set AC daily o Neuropsychologist: source for AC, support with

pre-setting

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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: Personal Futures Planning

o Person – centered approach to treatment planningo Assumes that vocational goals are defined,

achieved, and retained within a broad contexto 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

Clinical practice going forward: Using our resourceso Utilize the MPAI to highlight strengths and skill areaso Categorize types of employment, compare with

strengths and weaknesses of MPAIo Implement principles of customized employment o Utilize resources from BACo Implement previously identified strategies

• Comprehensive assessment• Inter-disciplinary treatment • Job coaching, supported employment, job mentor

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MPAI-4 Tool to Assess Job Compatibility

Extrapolate results from MPAIExecutive FunctioningMemoryAttentionSocial CommunicationVisuospatial Physical Ability

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Person Served:   Date:Job Title:    

Organization:    Hours:    

LOS:    Assessor:    

MPAI Tool to Assess Job Compatibility

Executive Functioning

Functional Area/Correlating MPAI Rating PS Rating Job With Aid?

11. Novel problem-solving  3 2  Y/N

20. Impaired self-awareness  3 2  Y/N

22. Initiation  3 2  Y/N

Total  9  6  

MPAI Scoring Rubric

0 None 1 Mild problem but does not interfere with activities; may use assistive device or medication

2 Mild problem; interferes with activities 5-24% of the time

3 Moderate problem; interferes with activities 25-75% of the time

4 Severe problem; interferes with activities more than 75% of the time

MPAI-4 Tool to assess job compatibility

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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

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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 impairmentso 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

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?

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Questions? Lorraine.myro@bancroft.org

“… 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

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