Vocational rehabilitation: models, evidence and guidelines ...

Vocational rehabilitation: models, evidence

and guidelines to support

the development of a

service for a neurological

population’

16th December 2019

Sarah Porter

Occupational Therapist

Guidance to shape practice

Vocational Rehabilitation: models, evidence and guidelines to support the development of a service for a

neurological population

St George’s University Hospitals NHS Foundation Trust

• Vocational Rehabilitation Standards of Practice, VRA, 2013

• British Society of Rehabilitation Medicine. Vocational assessment and

rehabilitation for people with long-term neurological conditions:

recommendations for best practice. London, British Society of

Rehabilitation Medicine, 2010

• The National Service Framework for Long term Conditions, 2005

• Vocational assessment and rehabilitation after acquired brain injury –

Interagency guidelines, 2004

• British Society of Rehabilitation Medicine. Vocational rehabilitation - the

way forward (2nd Edition): report of a working party (Chair: Frank AO).

London, British Society of Rehabilitation Medicine, 2003

NICE Guidelines

Vocational Rehabilitation: models, evidence and guidelines to support the development of a service for a neurological

population


• Stoke in Adults 2016

Quality Statement 5 Return to Work

• Head Injury 2014

Quality Statement 7 Community Rehabilitation service for

people with traumatic brain injury -

vocational

Legal considerations


population


• Health and Safety at Work Act 1974

• Employment Rights Act 1996

• Human Rights Act 1998

• Data Protection Act 1998

• Disability Rights Commission Act 1999

• Employment Act 2008

• Equality Act 2010

• The Welfare Reform Act 2012

How it all began for me…….

From 52 referrals a year to 228

• Pilot study in 2003 for two years

• 3 part time members of staff

• Plan to offer more than regular OT intervention

• Outcomes

Now

• 228 referrals in 2018

• 1 full time and 8 part time members of staff

• Running 3 groups a year alongside individual sessions and bespoke

groups

• Outcomes Vocational Rehabilitation: models, evidence and guidelines to support the development of a service for a



Research into practice

Using evidence to develop a programme

• Are methodological variations clouding the

RTW rates?

(van Dongen et al, 2017, Wei et al, 2016)

• What type of intervention is successful?

(Saltchev et al, 2013, Ownsworth et al, 2004, Kendall et al, 2006)

• Specialist knowledge of VR and TBI more

likely to improve opportunity for RTW in TBI

(Powell et al, 2002, Ponsford et al, 2006)




Models of Vocational Rehabilitation

Unlikely that one treatment model is optimal for patients with varied patterns of deficits

and strengths involving the evolution of different types of programmes (Hart et al, 2010)

• Two systematic reviews (Fadyl et al,2009 , Hart et al, 2006)

• Literature review (Tyerman et al, 2012)

• Resource Facilitation (Trexler , L and Parrot, D. 2018)


population


ABI programmes with added or integrated vocational

components

• Vocational rehabilitation elements added to out patient brain injury

rehabilitation

• 3 phases

• Remedial intervention

• Guided voluntary occupational trials

• Assistance finding suitable work placements




Vocational Rehabilitation models adapted for Brain

Injury

• Adapting existing vocational rehabilitation models

• Primary VR model adapted is supported placement model with four

phases

• Job placement

• Job site training and advocacy

• On-going assessment

• Job retention and follow along




Care coordination/resource for facilitation models

• Core feature being case coordination, facilitating the vocational

rehabilitation process in liaison with other rehabilitation, vocational and

community services




Consumer directed approach

• People with ABI have a major role in running the programme

• Clubhouse model

• Consumer directed, community based day programme operated by and

for its members

• Members often been considered unsuitable or been unsuccessful in past

job placements

Vocational Rehabilitation: models, evidence and guidelines to support the development of a service for

a neurological population


Considerations when developing a service

Conceptual model of vocational rehabilitation (Hayward et al, 2019)

• Key findings:

1. Need for nationally agreed funding

2. Extended VR MDT

3. Job seeking pathway

4. Shared understanding of VR interventions

5. Shared standards for data collection and outcome measurement

6. Provision of timely VR services

7. Integration of VR services within the local community


population



Predicting a RTW after brain injury




Longer

hospital

duration

Employment

status pre

diagnosis Reduced

functional ability

on discharge

Self

Awareness Psychological

factors

Over 40 at

time of

diagnosis

Support of

significant

others

Motivation


Barriers to RTW




No established route to paid RTW,

expectations of immediate RTW,

transportation, fatigue and cognition (Beaulieu, 2019) ,, 2019)

Invisible impairments, consequences of

stroke, additional personal and family

comorbidities (Phillips et al, 2019)

Wolfson vocational rehabilitation programme

model





Client group and what to offer




• Establish a rigid criteria you are happy to stick to

• Plan your service around the potential referral

numbers

• Staffing

• Outcome measures

• Developing links

• Does the client have a job to go back to

• Have a plan to incorporate growth

• Plan to have an MDT

• Who are they for, what do you want to measure?

• Local opportunities

Developing links

Resources




Encourages employers to become more

confident about employing disabled people

by:

Breaking down the barriers and

challenging negative attitudes towards

employing disabled people;

Through increasing awareness of the

business benefits of employing disabled

people; and

Through building a better understanding of

the support available to employers as they

recruit and retain disabled employees.


Client group and what to offer




• Does the client have a job to go back to

• Have a plan to incorporate growth

• Plan to have an MDT

• Who are they for, what do you want to measure?

• Local opportunities

• Simulation activities to reflect the workplace

• Set this up from the beginning

• Establish a rigid criteria you are happy to stick to

• Plan your service around the potential referral

numbers

• Staffing

• Outcome measures

• Developing links

• Resources

• Database, audit and research

Developing a service

Practicalities




What we thought What we learnt

• All of the patients will want to get back to work

• Early intervention is key

• Employers will do everything they can to support

their member of staff

• No they don’t

• Everyone and their circumstances are different

• Employers will do everything they can to ensure

the plan works best for the company

Providing information to managers

Resources




The AHP health and

work report is

appropriate for physical

and mental health work

related issues

Inform on practical

modifications that may

help an individual to

remain or return to work


Practicalities







• Employers will do everything they can to support

their member of staff

• Patients will want to discuss their diagnosis and

difficulties with their manager

• Reasonable adjustments will be easy to identify

and negotiate

• No they don’t


• Employers will do everything they can to ensure

the plan works best for the company

• Not in every case

• No they aren’t

Equality Act and Reasonable Adjustments

• You’re disabled under the Equality Act 2010 if you have a physical or

mental impairment that has a ‘substantial’ and ‘long-term’ negative effect

on your ability to do normal daily activities.

• Employers must make reasonable adjustments to make sure disabled

workers aren’t seriously disadvantaged when doing their jobs.





Practicalities







• Employers will do everything they can to support their

member of staff

• Patients will want to discuss their diagnosis and

difficulties with their manager

• Reasonable adjustments will be easy to identify and

negotiate

• The power of the group

• We won’t have a waiting list

• No they don’t


• Employers will do everything they can to ensure the

plan works best for the company

• Not in every case

• No they aren’t

• Far better than anything we can say at times!

• Think flexibility within rigidity

Approaching the more difficult situations

Trying to be supportive




RTW WITH A

DEGENERATIVE

CONDITION

RUNNING

GROUPS

SUPPORTING

MEDICAL

RETIREMENT

THE WORK

VISIT

What do the clients want?

For consideration when developing a vocational programme

• Four key themes:

1. Meaning of work

2. Process of return to work and reconciling new identities

3. Opportunities to try versus risks of failure

4. Significance of supports

• Vocational evaluation should include:

1. Assessment of the meaning clients ascribe to work following TBI

2. Post injury goals

3. Clients perceptions of work competency

4. Work readiness

5. Anticipated challenges with return to work

6. Available supports (Stergiou-Kita et al, 2011)




Patient thoughts on vocational rehabilitation




Thank you


www.stgeorges.nhs.uk

@StGeorgesTrust

References




• Van Dongen, C. et al. (2017) Short-term and long term outcomes of a vocational rehabilitation program for

patients with acquired brain injury in the Netherlands. Journal of Occupational Rehabilitation . (28) 523-530

• Wei, X-J, et al (2016) Outcomes of return to work after stroke rehabilitation: s systematic review. British Journal

of Occupational Therapy2016, Vol. 79(5) 299–308

• Holmes, J. et al (2016) Development and evaluation of an early specialised traumatic brain injury rehabilitation

training package. British Journal of Occupational Therapy. 2016, Vol. 79(11) 693–702

• Phillips, J. et al (2019) Return to work after stroke-Feasibility of a 6 -year follow-up. British Journal of

Occupational Therapy 2019, Vol. 82(1) 27–37.

• Hayward, K. et al (2019) Developing vocational rehabilitation services for people with long-term neurological

conditions: Identifying facilitators and barriers to service provision. British Journal of Occupational Therapy

• 2019, Vol. 82(6) 337–347

• Beaulieu, K. (2019) Lived experiences of return to paid work following a brain injury. British Journal of

Occupational Therapy 0(0) 1–8

• Trexler, LE, Parrott, DR (2018) Models of brain injury vocational rehabilitation: The evidence for resource

facilitation from efficacy to effectiveness. Journal of Vocational Rehabilitation 49 (2018) 195–203

References




• Intercollegiate Stroke Working Party (2012) National clinical guideline for stroke, 4th edition. London: Royal

College of Physicians.

• Taylor, G., Todman,J., Broomfield,N. (2011): Post-stroke emotional adjustment: A modified social cognitive

transition model,Neuropsychological Rehabilitation, DOI:10.1080/09602011.2011.598403

• British Society of Rehabilitation Medicine (2004) Interagency guidelines vocational assessment and

rehabilitation after acquired brain injury. London: BSRM

• Care Quality Commission.(2011) Supporting life after stroke: a review of services for people who have a stroke

and their carers. London: The Care Quality Commission(CQC)

• Department of Health. (2005)The National Service Framework for Long Term Conditions. London: Department

of Health

• Medin, J., Barajas, J., Ekberg, K. Stroke patients’ experiences of return to work. Disability and Rehabilitation,

September 2006; 28 (17): 1051-1060

• Vocational interventions and supports following job placement for persons with traumatic brain injury,Tessa

Hart, Marcel Dijkers, John Whytea, Cynthia Bradenc, Charlotte T. Trott and Robert Fraser ,Journal of

Vocational Rehabilitation 32 (2010) 135–150

References


population


• Equality Act 2010. Available at: http://www.legislation.gov.uk/ukpga/2010/15/contents (Accessed 03.12.13)

• Sinclair, E., Radford,K., Grant, M., Terry,J. Developing Stroke-specific vocational rehabilitation: a soft systems

analysis of current service provision. Disability and Rehabilitation 36;409-417

• Coole,C., Radford,K., Grant, M., Terry, J. Returning to Work After Stroke: Perspectives of Employer

Stakeholders, a Qualitative Study. Journal of Occupational Rehabilitation (2013) 23:406-418 DOI

10.1007/s10926-012-9401-1

• Lawrence,M. Young adults’ experience of stroke: a qualitative review of the literature. British Journal of Nursing,

2010, Vol 19(4) 241-248

• Building capacity for work: a UK framework for vocational rehabilitation (DWP 2004); Vocational Rehabilitation

Conference, London 16 June 2007; Vocational Rehabilitation Task Group.

• An Integrated Review of the Processes and Factors Relevant to Vocational Evaluation Following Traumatic

Brain Injury, Mary Stergiou-Kita, Deirdre R. Dawson, Susan G. Rappolt J Occup Rehabil (2011) 21:374–394

• Vocational rehabilitation following traumatic brain injury: A quantitative synthesis of outcome studies, Elizabeth

Kendall, Heidi Muenchberger and Travis Gee Journal of Vocational Rehabilitation 25 (2006) 149–160 149

• Return to work following traumatic brain injury: Trends and challenges, Jeffery Shames, Iuly Treger, Haim Ring,

Salvatore Giaquinto.Disability and Rehabilitation, September 2007; 29(17): 1387 – 1395

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from the stroke survivor, vocational specialist and employer.Topics in stroke rehabilitation;july-august2011;18(4):325-340

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and self: A thematic synthesis of qualitative studies. Archives of physical medicine and rehabilitation. 2013;94:11171-83

• Baldwin,C. Brusco,N. The effect of vocational rehabilitation on return to work rates post stroke: a systematic review. Topics in

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• NHS Long term plan. 2019

• Improving Lives: The Future of Work, Health and Disability. (DWP/DoH: October2017)

• Good Work: The Taylor Review of Modern Working Practices. (DoBE&IS:July 2017)

References


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