Supporting Employment for Adults With Acquired Brain Injury

A Conceptual Model

 

Vikki L. Vandiver, DrPH; Jan Johnson, MS; Carol Christofero-Snider, MS

Employment, or return-to-work, is a common goal for adults who have experienced brain injury. Unfortunately, many individuals suffer significant psychosocial, cognitive, and physical deficits as a result of the injury that negatively affect their ability to seek or maintain employment. Research, points to the importance of addressing these deficits using a supportive vocational rehabilitation team approach that focuses on assessing a wide range of cognitive, physical, and functional variables. The purpose of this article is to describe the Brain Injury Assessment Model (MAM) for use as a vocational assessment tool for clients diagnosed with acquired brain injury and who are seeking employment or are returning to work. Key words: acquired brain injury, brain injury assessment model, Job coach/developer, return to work, vocational rehabilitation.

PERSONS who experience brain injury are one of several populations living with a lifelong impairment. Data show that only 20 years ago, 50% of all people diagnosed with brain injury died. Now that proportion has been reduced to 22%. In the United States, the occurrence of brain injury has been estimated to be as high as 1,500,000 per year and is the leading cause of death and disability in individuals under the age of 35, the age group most at risk for brain injury is 16- to 25-year-olds. Thus, the majority of those affected are in the prime years of their initial vocational productivity.

National statistics suggest that vocational placements for brain-injured individuals can vary widely with return-to-work rates ranging from a low of 20% to a high of 66%. In Oregon, the most recent statewide statistics (2000-2001) show that 33% Oregonians were hospitalized for a traumatic brain injury and of these, 1140 found their way to vocational rehabilitation services for assistance with employment or return to work. The purpose of this paper is to describe The Brain Injury Assessment Model (BIAM) for use as a vocational assessment tool for clients who have been diagnosed with an "acquired brain injury" and are attempting to return to work or seek employment. We will define acquired brain injury as compromised brain function resulting from a specific event (eg, stroke, accident) that is not associated with injury at birth.

SCOPE OF PROBLEM

As clients, family members, and rehabilitation counselors attest, failure to regain pre-injury work abilities is a devastating consequence of brain injury. Like non-disabled and other disability groups, most brain-injured clients see employment as a means to community reintegration, self-worth, and independence. Individuals with brain injury often have extensive deficiencies in executive functioning and memory, which results in impaired organization and reasoning, decreased motivation, increased dependency and interpersonal skills deficits—all of which have serious effects on the client's ability for successful employment. Family members experience not only the loss of income, but the loss of the relationship as known before the injury. Vocational counselors have found that whether or when a person returns to work is influenced by the severity of brain injury (eg, mild to severe or traumatic), coexisting injuries to other parts of the body, and neuropsychological impairment at 1-month post injury. Similarly, adverse factors that hampered return to work and resulted in extended periods of unemployment, in spite of even mild injury, included older age, low educational level, and severe injury to other parts of the body. Without a thorough understanding of the needs, strengths, or deficits of brain-injured clients, vocational counselors may not always refer clients to the appropriate resources for assessment or employment.

Two challenges faced by rehabilitation workers are trying to predict "real world" (or in vivo) performance for people with brain injury who are seeking employment and using ecologically valid functional disability measures. Typically, vocational rehabilitation counselors have used neuropsychological assessments as a means of predicting vocational functioning. Critics of this approach note that this singular structured approach is not adequate to address the wide range of functional deficits and environmental needs of brain injured clients. LeBlanc and colleagues argue for the use of the Situational Vocational Evaluation (also referred to as the Situational Assessment) as an adjunct to neuropsychological assessments in making real world predictions for employment potential. The Situational Assessment involves clients performing a variety of simulated vocational tasks in environments that approximate actual work settings.

Further research by Kowalske and colleagues encourages rehabilitation workers to work in an interdisciplinary team and to include specialized assessments that focus not only on specific strengths and weaknesses of the individual, but also on extant environmental factors (eg, degree of structure or distractions that either reinforce or hinder performance). By relating this information to employment considerations, rehabilitation counselors can determine what efforts and resources should be held for later vocational interventions or for appropriate non-vocational supports. The main point is that many clients with brain injury who are seeking employment, whether return to work or supported employment, may need a full range of assessments. These assessments would include environmental, functional, situational, neuropsychological, cognitive, physical, occupational and vocational clients also need ongoing involvement of a continuous team of rehabilitation professionals, employers, and family. The Brain Injury Assessment Model is one such attempt to organize a network of rehabilitation providers who can coordinate multiple vocational assessments and interventions.

THE BRAIN INJURY ASSESSMENT MODEL

 

Background

The Brain Injury Assessment Model (BIAM) is an approach to vocational rehabilitation that was first implemented in 1996 by a community-based rehabilitation agency (Community Rehabilitation Services of Oregon [CRSO]) located in central Oregon. The agency employs a team of rehabilitation specialists consisting of a speech pathologist and certified vocational counselor, a physical therapist, two occupational therapists, and three neuropsychologists. Vocational referrals come primarily from physiatrists, neurologists, worker compensation insurance companies, area hospitals, and Oregon Vocational Rehabilitation Services area offices. Once a referral is made, the case is reviewed by the team and a case coordinator (ie, vocational consultant/job developer) will take final responsibility for the client. The agency is funded through medicaid insurance, worker's compensation insurance, and service dollars provided by state vocational rehabilitation services. Between 1996 and 1999, the agency provided services to 63 individuals diagnosed with mild brain injury, of which 53 of these clients were placed into competitive employment. Follow-up data for these clients found that "return to work" success rates at 3 months were 84%, which is in sharp contrast to national statistics that vary between 20% and 66%.

Theoretical framework

The therapeutic strategies involved in the BIAM are derived from two theoretical approaches; Cognitive Rehabilitation (CR) and Social Learning Theory (SET). Specifically, CR is based on scientific theories of brain functioning, cognitive neuropsychology, speech therapy techniques, and neuropsychological assessment findings. Coelho and colleagues describe CR as a "system of interventions designed to increase daily functional abilities by improving or augmenting deficits in processing and interpreting information and or by modifying the environment " (p 8). SLT is a behavioral theory in which observational learning is emphasized and in vivo (real world) experiences are encouraged. SLT is guided by the principle of reciprocal determinism, which refers to the three-way interaction among behavior (eg, following through with work tasks), external environment (eg, job setting), and internal events or cognitions (eg, sense of self-efficacy or competence). In other words, the environment affects behavior through the mediation of cognition, and the individual's behavior and cognition, in turn, affect the environment.

Both theories have probative value for counselors working with brain-injured clients whose altered cognitions directly affect the quality and experiences in the work environment. Vocational counselors, along with job coaches, use the principles of CR and SLT in their work with brain-injured clients by teaching and then modeling prosocial behaviors for clients who are about to enter the Job Search stage of employment. For example, before a placement occurs, a vocational counselor or job coach will rehearse a job interview with a client using a role-play exercise in which the client can practice answering questions. Once on the job (ie, new work environment), the client and job coach practice the job tasks in vivo and in a repeated fashion. By using the principles of CR and SLT, vocational counselors or job coaches and clients work together to assist the client in developing new cognitive skills while helping moderate problematic behaviors.

OVERVIEW

The BIAM is specifically designed to assess the needs of adults with brain injury prior to work placement or return to work. The model consists of nine distinct steps (see Figure 1) that involve a multisystemic approach to assessment and intervention. While the time frame for completion of the steps will vary with each client as will the availability of appropriate community jobs, the average length of time from intake to case closure is approximately 9 months (eg, 6 months for assessment, interventions, and job search; 3 months follow-along at job site). Most services (eg, neuropsychologist and job coach) and resources (eg, day timers and memory aids) are paid for by funding through vocational rehabilitation services or worker's compensation insurance companies. In most cases, the referral source contracts with a private provider (eg, vocational counselor or job developer) to implement the steps for the BIAM.

What makes this approach different from traditional vocational approaches is the enhanced level of communication among client, family, employer, and vocational professionals and the intensive assessment process at the front end of service delivery. A brief description of each step follows:

Step1

Medical rehabilitation involves assembling a comprehensive team of medical rehabilitation providers (physician, occupational therapist, physical therapist, case management, speech/language pathologist, and psychologist) whose primary goals are to assess the client's medical status and determine how this will relate to the physical and cognitive demands of the workplace. Examples of medical rehabilitation assessments include pain management, visual perception, balance assessment, financial problems, need for prosthetic aids (eg, memory books), and neuropsychological. Treatment can then be directed toward functional goals, such as processing visual information from a computer screen.

Step 2

Vocational assessment involves the efforts of the vocational counselor to assess the physical, psychological, and cognitive demands of the job using a battery of vocational tests (Career Assessment Inventory, Career Orientation Placement, Career Ability Placement Survey, and Job Analysis). The goal is to gather a broad picture of the client's strengths, weaknesses, interests, and aptitude in numerous personal and professional areas.

Step 3

Neuropsychological assessment involves the efforts of a neuropsychologist in assessing the client's cognitive abilities, including attention, concentration and mental tracking, and language use (eg, expressive and receptive modalities and written and oral). Other components are memory (short term visual, auditory, and motor), learning style (visual, auditory, or hands-on), constructional and spatial skills (left/right orientation), and executive functioning (planning, organizing, initiating). The goal is to discern a global picture of the individual’s functioning across several domains and then provide this information to the Rehabilitation team and client for employment planning.

Step 4

Team meeting involves the gathering of the rehabilitation team members, client, and family to review results from vocational and neuro-psychological assessments. These results may be very specific regarding the cognitive and physical requirements of possible volunteer options. The goal is to provide an open forum for communication among the rehabilitation team, client, and family as it relates to the next steps for vocational placement.

Step 5

Situational assessment involves the use of a functional evaluation administered by a job developer at the work site or a vocational counselor by phone. Assessment may even start at the client's home and then move to the community and eventually to a work site. Usually occurring over a 4- to 6-week period, the goals are to give the job developer and counselor an idea of potential job possibilities and to determine the client's strengths and limitations using, various criteria (appearance, punctuality, executive functioning, use of compensatory memory strategies, and daily living and communication, skills).

Step 6

Follow-up team, meeting occurs after the situational assessment and involves a meeting of the client, family, vocational rehabilitation counselor, and job developer/coach Vocational objectives for employment are developed using assessment information and family input. The goal is to discuss the results of the assessment and implications for future employment.

Step 7

Job search involves a series of activities performed by client and job coach/developer, and includes skill development (resume writing, interviewing, role playing), interpersonal development (participation in support group), use of resources (prosthetic memory and attentional aids, daytimers), employment outreach (employer contact, newspaper, employment office, cold calls) and team communication (vocational counselor, family, rehabilitation team, and job developer). The goal is for the client to remain an active participant and in a consistent relationship with a job developer who can teach, lead, and support all post rehabilitation activities listed above.

Step 8

Job placement involves the final stages of coordinating placement arrangements among employer, agency representatives (vocational counselor and job coach), and client. Once the client has been placed, there are 3 goals. From an employer perspective, the goal is for client and job coach to work closely with the employer to learn job duties and discuss strategies for implementing the prosthetic aids the client is using (memory aids, daytimers, physical accommodations). From a job coach perspective, the goal is to discuss physical/cognitive states and plans for follow-along. From the client perspective, the goal is to keep in contact with the support team and employer. For all three, the goal is successful employment.

Step 9

Follow-along usually occurs for 3 months postplacement and involves the efforts of all parties (rehabilitation team, job coach, client, employer, and family members) to stay in contact with each other regarding employment status. The goal is to provide visibility and sup­ port to employer and client during this critical period.

From the Graduate School of Social Work, Portland State University, Portland, OR (Dr Vandiver); Community Rehabilitation Services of Oregon (Johnson) Eugene, OR; RL Snider and Associates, Inc., Vocational and Rehabilitation Case Management Services (Christofero-Snider) Portland, OR.

This project was funded by a federal grant from the Department of Education, Rehabilitation Services Administration/National Vocational Rehabilitation Technical Assistance Center with support from the Department of Human Services - Oregon Vocational Rehabilitation Services Division/Project Employ.