Strategies for Success: Returning To Work After Brain Injury

1. 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

2. Our Mission Bancroft provides opportunities to children and adults with diverse challenges to maximize their potential. . Our Core Values Responsible Empathetic Supportive Passionate Empowered Committed Trustworthy R E S P E C T Our Vision A community where every individual has a voice, a purpose and a rightful place in society.

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

4. 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

5. 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

6. Factors affecting return to work rates (RTW) • Invisibility of injury • Economic conditions • Specific employer hiring strategies • Employer attitudes • Continuing symptoms • Life changes • 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 • Definition of “return to work” • 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

8. Return to work rates 10 studies, international Shames, Treger, Ring & Giaquinto, 2007

9. 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

10. 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

11. Qualitative Predictive Factors • Patient’s positive valuation of work • Flexible and supportive workplace • Higher scores on neuropsychological screenings • Subscale for Affect discriminated • Ability to express an affect with the voice • Interpret facial emotional expressions • Ability to control emotional impulses • Ability to comprehend and express response to humor Hofgren, Esbjornsson, & Sunnerhagen, 2010

12. Most prevalent barrier for RTW • Inappropriate behavior • Behavioral outbursts • Lack of tact • Disinhibition Shames, Treger, Ring & Giaquinto, 2007

13. 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

14. 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

17. 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

18. 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 • 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

19. 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

20. 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 • Recommendations based off of evaluations • Situational assessments • Work trials/Job coaching • Problem solve, resources • Therapeutic interventions • Network, advocate, bridge gaps

23. Most prevalent barrier for RTW • Inappropriate behavior • Behavioral outbursts • Lack of tact • Disinhibition Strategic interventions • Tailor the environment • 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

26. Emphasize pre-vocational work Volunteering • 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 • Add to resume

27. 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

29. 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

30. 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;

31. 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

32. 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

33. 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 • Change into work clothes right before work • Do not ask customers for puzzles • Therapy with neuropsychologist • Initial response to interventions: angry outbursts • Calm, consistent implementation of strategies • Eventually outbursts ceased • 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 • Vocational specialist: liaison between AC, team and employer; provided on-site support until issues resolved • Residential program manager  sent clothes in with AC • Day program manager: trained staff on protocol • Staff: pre-set AC daily • Neuropsychologist: source for AC, support with pre-setting

37. 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

38. Benefits of Vocational Grand Rounds • Outreach • Education • Development/strengthening of relationships with community resources Zuger, Brown, O'Neill, Stack, Amitai, 2002

39. Strengths-based Practice: Personal Futures Planning • Person – centered approach to treatment planning • Assumes that vocational goals are defined, achieved, and retained within a broad context • Focus on vision and action plan to address all areas of life that are important to individual • Vision and goals are adapted to fit life with challenges and new reality Zuger, Brown, O'Neill, Stack, Amitai, 2002

40. 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 • Utilize the MPAI to highlight strengths and skill areas • Categorize types of employment, compare with strengths and weaknesses of MPAI • 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

43. MPAI Tool to Assess Job Compatibility

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

46. 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 History, evaluations, situational functioning Persistence, creativity, and commitment Zuger, Brown, O'Neil, Stack, Amitai, 2002

47. 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? 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