Lisa Ottomanelli

Effectiveness of Supported Employment for Veterans With Spinal Cord Injuries: Results From a Randomized Multisite Study

OBJECTIVE To examine whether supported employment (SE) is more effective than treatment as usual (TAU) in returning veterans to competitive employment after spinal cord injury (SCI). DESIGN Prospective, randomized, controlled, multisite trial of SE versus TAU for vocational issues with 12 months of follow-up data. SETTING SCI centers in the Veterans Health Administration. PARTICIPANTS Subjects (N=201) were enrolled and completed baseline interviews. In interventional sites, subjects were randomly assigned to the SE condition (n=81) or the TAU condition (treatment as usual-interventional site [TAU-IS], n=76). In observational sites where the SE program was not available, 44 subjects were enrolled in a nonrandomized TAU condition (treatment as usual-observational site [TAU-OS]). INTERVENTIONS The intervention consisted of an SE vocational rehabilitation program called the Spinal Cord Injury Vocational Integration Program, which adhered as closely as possible to principles of SE as developed and described in the individual placement and support model of SE for persons with mental illness. MAIN OUTCOME MEASURES The primary study outcome measurement was competitive employment in the community. RESULTS Subjects in the SE group were 2.5 times more likely than the TAU-IS group and 11.4 times more likely than the TAU-OS group to obtain competitive employment. CONCLUSIONS To the best of our knowledge, this is the first and only controlled study of a specific vocational rehabilitation program to report improved employment outcomes for persons with SCI. SE, a well-prescribed method of integrated vocational care, was superior to usual practices in improving employment outcomes for veterans with SCI.

Methods of a multisite randomized clinical trial of supported employment among veterans with spinal cord injury

This article compares the methods of a randomized multisite clinical trial of evidence-based supported employment with conventional vocational rehabilitation among veterans with spinal cord injury (SCI). The primary hypothesis is that, compared with conventional vocational rehabilitation (i.e., standard care), evidence-based supported employment will significantly improve competitive employment outcomes and general rehabilitation outcomes. The secondary hypothesis is that evidence-based supported employment in SCI will be more cost-effective than standard care. The current article describes the clinical trial and presents baseline data. The present sample includes 301 veterans with SCI, which includes paraplegia (50%), high tetraplegia (32%), and low tetraplegia (18%). Baseline data indicate that 65% of this sample of employment-seeking veterans with SCI had never been employed postinjury, despite the fact that nearly half (41%) had received some type of prior vocational rehabilitation. These rates of unemployment for veterans with SCI are consistent with the rates reported for community samples of persons with SCI. Forthcoming outcome data will provide much needed insights into the best practices for helping these veterans restore vocational goals and improve overall quality of life.

Activity and participation after spinal cord injury: State-of-the-art report

The importance of activities and community participation for persons with spinal cord injury (SCI) has been recognized for decades and yet theoretical and empirical advances have been limited. This report summarizes the recommendations for researchers on the topic of measuring activity and participation among persons with SCI formulated by the Spinal Cord Injury workgroup at the State-of-the-Art Conference on Outcome Measures in Rehabilitation held in January 2010. Activity and participation were defined as independent constructs ideally measured in reference to personal values and environmental influences. Measures of activity, participation, and factors influencing activity and participation are reviewed and critiqued. Gaps in available measures are described, measures in development are discussed, and suggestions for future research are made.

Effectiveness of Supported Employment for Veterans With Spinal Cord Injury: 2-Year Results

OBJECTIVE To examine if supported employment (SE) remains more effective than treatment as usual (TAU) in returning veterans to competitive employment after spinal cord injury (SCI) at 2-year follow-up. DESIGN Prospective, randomized, controlled, multisite trial of SE versus TAU with 24 months of follow-up. SETTING SCI centers. PARTICIPANTS Subjects (N=201) were enrolled and completed baseline interviews. At interventional sites, subjects were randomized to SE (n=81) or TAU (n=76). At observational sites, 44 subjects were enrolled in a nonrandomized TAU condition. INTERVENTION The intervention was a SE program called the SCI Vocational Integration Program, which followed the principles of the individual placement and support model of SE for persons with mental illness. MAIN OUTCOME MEASURES Competitive employment in the community within 2 years. RESULTS For the entire 2-year follow-up period, SE subjects were significantly more likely to achieve employment (30.8%; 95% confidence interval [CI], 21.8-41.6) than either the TAU subjects at the intervention sites (10.5%; 95% CI, 5.2-19.7; P<.001) or the TAU subjects at the observational sites (2.3%; 95% CI, 0.0-12.9; P<.002). Most subjects who obtained competitive employment did so in year 1, and the average time to first employment was about 17 weeks. CONCLUSIONS SE was better than usual practices in improving employment outcomes for veterans with SCI across a 2-year follow-up period. Although SE continued to be superior to traditional practices over the entire study, the first year of participation in SE may represent a critical window for achieving employment after SCI.

Factors associated with employment among veterans with spinal cord injury

The purpose of the present study was to investigate predictors of competitive employment after a spinal cord injury (SCI) among veterans. This study retrospectively examined return to work after SCI, types of jobs held, and variables that were associated with return to work. The present sample included 238 veterans receiving healthcare at one of several Veteran Affairs Medical Centers. Data were obtained through subject interviews and chart extraction. Subjects were also administered the Veterans RAND 36-Item Health Survey (VR-36), Quick Inventory for Depressive Symptomatology - Self Report (QIDS-SR), and Craig Handicap Assessment Reporting Technique (CHART). Results revealed that 34.5% of our study sample was employed at some point after SCI. Employed subjects had significantly higher scores on two of the CHART subscales (Mobility and Occupation) than unemployed subjects, but there were no significant differences among subjects on the QIDS or the VR-36. Receipt of social security benefits was a significant disincentive for employment, but receipt of Veterans disability benefits was not. Education, gender, ethnicity, level and severity of injury were not significant predictors of employment status after SCI, after controlling for demographic variables. Clinical implications of these findings may be that vocational rehabilitation interventions that focus on rapid re-entry to the workforce using existing skill sets may maximize post-SCI employment.

Facilitators and Barriers to Employment Among Veterans with Spinal Cord Injury Receiving 12 Months of Evidence-Based Supported Employment Services

BACKGROUND Return to work is associated with positive rehabilitation outcomes for persons with spinal cord injury (SCI); however, more research is needed on vocational support for persons with disabilities seeking employment. OBJECTIVE The association between facilitators and barriers of employment and employment outcome was examined among Veterans with SCI who participated in an evidence-based supported employment (EBSE) program. METHODS Using a mixed-methods, nested case-control design, data on facilitators and barriers to employment were extracted from qualitative interviews and quantitative measures administered in person to 34 Veterans with SCI who completed 12 months of an EBSE program. Participants who did (case) and did not (control) obtain competitive employment were matched on time since SCI. Facilitators and barriers to employment were compared between the groups. RESULTS Self-report measures administered at baseline were examined; there were no statistically significant factors that predicted employment outcomes after 12 months of EBSE program participation. Qualitative interview data revealed program-specific facilitators and Veteran characteristics that were associated with employment outcomes. CONCLUSIONS Qualitative data illustrate how the integration of the vocational rehabilitation specialist on the medical team is helpful for addressing identified disability-specific barriers, including practical matters such as transportation and caregiving schedules, to facilitate employment outcomes.

Ethnography, fidelity, and the evidence that anthropology adds: supplementing the fidelity process in a clinical trial of supported employment.

This discussion considers the role and findings of ethnographic research within a clinical trial of supported employment for veterans with spinal cord injury. Contributing to qualitative evaluation research and to debates over anthropological evidence vis-à-vis clinical trials, we demonstrate how enactors of a randomized controlled trial can simultaneously attend to both the trials evidentiary and procedural requirements and to the lived experiences and needs of patients and clinicians. Three major findings are described: (1) contextual information essential to fidelity efforts within the trial; (2) the role of human interrelationships and idiosyncratic networks in the trials success; and (3) a mapping of the power and authority structures relevant to the staffs ability to perform the protocol. We emphasize strengths of anthropological ethnography in clinical trials that include the provision of complementary, qualitative data, the capture of otherwise unmeasured parts of the trial, and the realization of important information for the translation of the clinical findings into new settings.

Cost-Effectiveness of Supported Employment for Veterans With Spinal Cord Injuries

OBJECTIVE To estimate the cost-effectiveness of a supported employment (SE) intervention that had been previously found effective in veterans with spinal cord injuries (SCIs). DESIGN Cost-effectiveness analysis, using cost and quality-of-life data gathered in a trial of SE for veterans with SCI. SETTING SCI centers in the Veterans Health Administration. PARTICIPANTS Subjects (N=157) who completed a study of SE in 6 SCI centers. Subjects were randomly assigned to the intervention of SE (n=81) or treatment as usual (n=76). INTERVENTION A vocational rehabilitation program of SE for veterans with SCI. MAIN OUTCOME MEASURES Costs and quality-adjusted life years, which were estimated from the Veterans Rand 36-Item Health Survey, extrapolated to Veterans Rand 6 Dimension utilities. RESULTS Average cost for the SE intervention was

Individual placement and support (IPS) in physical rehabilitation and medicine: the VA spinal cord injury experience.

1821. In 1 year of follow-up, estimated total costs, including health care utilization and travel expenses, and average quality-adjusted life years were not significantly different between groups, suggesting the Spinal Cord Injury Vocational Integration Program intervention was not cost-effective compared with usual care. CONCLUSIONS An intensive program of SE for veterans with SCI, which is more effective in achieving competitive employment, is not cost-effective after 1 year of follow-up. Longer follow-up and a larger study sample will be necessary to determine whether SE yields benefits and is cost-effective in the long run for a population with SCI.

Provider-identified barriers and facilitators to implementing a supported employment program in spinal cord injury

TOPIC This report summarizes the first studies on individual placement and support (IPS) in the field of physical medicine and rehabilitation (PM&R) and discusses adaptation of the model. PURPOSE Research related to the implementation and evaluation of the use of IPS in the VA System of Spinal Cord Injury Care is reviewed. Results suggest that IPS was more effective than traditional vocational rehabilitation. With physical disabilities, the model needs adaptation with respect to integration, disclosure, and job development while following the core principles. Special consideration is needed with respect to caseload size and transportation issues. SOURCES USED Published results from the Spinal Cord Injury Vocational Integration Program (SCI-VIP) study and clinical field observations. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE IPS can be successfully adapted to physical medicine and rehabilitation.