Psychiatric Rehabilitation Journal 2014, Vol. 37, No. 2, 110 –112
In the public domain http://dx.doi.org/10.1037/prj0000079
Individual Placement and Support (IPS) in Physical Rehabilitation and Medicine: The VA Spinal Cord Injury Experience Lisa Ottomanelli
Scott D. Barnett
Veterans Health Administration, Tampa, Florida, and University of South Florida
Veterans Health Administration, Tampa, Florida
Rich Toscano Veterans Health Administration, Washington, DC 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. Keywords: employment, supported, rehabilitation, vocational, spinal cord injuries
care and approximately 450 newly injured veterans and activeduty service members receive rehabilitation annually. Comprehensive care by interdisciplinary teams emphasizes wellness and prevention of complications to maintain the health and independence of persons with spinal cord injury (Department of Veterans Affairs Office of Public Affairs Media Relations, 2009). Even with advances in modern medicine and rehabilitation to restore health and function among persons with spinal cord injuries, the rates of returning to work remain extremely low (Ottomanelli & Lind, 2009). Individual Placement and Support (IPS) is a standardized and effective method for assisting persons with mental disabilities to find competitive employment through integrating vocational services into clinical care (Bond, Drake, & Becker, 2008). In 2004, through its Compensated Work Therapy (CWT) program, the VA launched a large-scale rollout of IPS, referred to as evidence-based supported employed (SE), for veterans with serious mental illness (Resnick & Rosenheck, 2007). Veterans with spinal cord injury, however, either were referred outside the VA to state systems for vocational rehabilitation or could use their benefits to pursue education. In 2005, the VA funded a trial of SE for veterans with spinal cord injury to address this gap in services. The Spinal Cord Injury Vocational Integration Program (SCI-VIP) tested whether integrated SE services in VA spinal cord injury centers was more effective than traditional vocational rehabilitation (Ottomanelli, Goetz, et al., 2009). SCI-VIP was the first trial of IPS in the field of physical medicine and rehabilitation (PM&R) and, to date, the only trial of employment services for persons with spinal cord injury. This report briefly summarizes findings from the SCI-VIP trial (for a full report of primary outcomes see Ottomanelli et al., 2012)
A spinal cord injury is a catastrophic injury that results in paralysis of lower limbs (paraplegia) or all four limbs (tetraplegia) and is associated with multiple secondary medical conditions such as pressure ulcers, pain, spasticity, bowel and bladder problems, and depression. The Veterans Health Administration (VHA) is the largest provider of spinal cord injury care with 24 spinal cord injury centers and 134 spinal cord injury primary care clinic teams. Forty-two thousand veterans with spinal cord injury are eligible for
Lisa Ottomanelli, PhD, Research Psychologist, HSR&D/RR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans’ Hospital, Tampa, Florida, and Associate Professor of Rehabilitation and Mental Health Counseling, University of South Florida; Scott D. Barnett, PhD, MSPH, Statistician, HSR&D/RR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans’ Hospital; Rich Toscano, MEd, National Program Evaluation Specialist, Office of Mental Health Operations, Veterans Health Administration, Washington, DC. Rich Toscano is now a National Employment Monitor at VA Research & Development, Tuscaloosa VA Medical Center, Tuscaloosa, AL. Supported by the Rehabilitation Research and Development Service, Office of Research and Development, Veterans Health Administration (VA RR&D grant no. B3773R). Contents of this article do not represent the view of the Department of Veterans Affairs or the United States Government. Portions of this work were presented at the 121st Annual Convention of the American Psychological Association in Honolulu, Hawaii, July 31–August 4, 2013 and at the 40th Anniversary Scientific Meeting. American Spinal Injury Association, Chicago, Illinois, May 6 – 8, 2013. Correspondence concerning this article should be addressed to Lisa Ottomanelli, PhD, HSR&D/RR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans Hospital, 8900 Grand Oak Circle (151R), Tampa, FL 33637. E-mail: lisa [email protected] 110
IPS AND SCI IN THE VA
and discusses adaptations of the model to a medically complex population.
Table 1 Demographic Characteristics at Baseline (n ⫽ 157)
SCI-VIP Results SCI-VIP was a prospective, multisite, randomized trial of SE compared with standard vocational rehabilitation in veterans with spinal cord injury at six VA spinal cord injury centers over 12 months. Site selection was based on spinal cord injury program strength and compensated work therapy services, leadership commitment and support for implementation, presence of a qualified site investigator, and geographic region. Veterans with spinal cord injury (n ⫽ 157) were randomly assigned to either SE (n ⫽ 81) or treatment as usual (n ⫽ 76 treatment as usual [TAU]) and were followed for 12 months. The SE intervention was delivered by vocational rehabilitation counselors trained in both SE and spinal cord injury medical issues and integrated into the spinal cord injury center interdisciplinary care teams. Treatment as usual involved referrals to traditional vocational rehabilitation outside of and apart from VA spinal cord injury health care. All subjects had at least one visit with a vocational provider, with SE subjects participating in 3.5 visits on average and TAU subjects participating in 1.3 visits on average. The study examined competitive employment outcomes and impact on health-related quality of life, handicap, and functional independence. Subjects were 50.2 ⫾ 9.4 years of age (average), were primarily men (95.5%, n ⫽ 150) and Caucasian (44.5%, n ⫽ 70), had an average of 13.3 ⫾ 2.3 years of education, and had their spinal cord injury for an average of 11.5 ⫾ 11.4 years. Nearly half the sample had paraplegia (47.1%, n ⫽ 74) and the remainder had tetraplegia (50.7%, n ⫽ 102). Medical record review revealed depression and substance abuse were the most frequent mental health comorbidities, and 28.0% (n ⫽ 44) had ⱖ 1 of six medical problems (e.g., diabetes or hypertension) common in similar populations (see Table 1). SE participants were significantly more likely to achieve competitive employment (25.9%; 95% CI [17.6, 36.5]) than TAU participants (10.5%; 95% CI [3.6, 17.4]; p ⬍ .008) (Ottomanelli et al., 2012). Competitive employment rate was 2.5 times higher with SE than with TAU (see Figure 1). Participants obtaining competitive employment reported significantly higher scores on Craig Handicap and Reporting Technique (CHART) measures of social integration, mobility, and occupation. (Ottomanelli, Barnett, & Goetz, 2013).
Discussion This was the first study to demonstrate the effective use of IPS in a spinal cord injury population in the VA health care system. IPS delivered as part of spinal cord injury health care was more effective in restoring employment outcomes for veterans with spinal cord injury than were referrals for vocational services apart from the veterans’ spinal cord injury health care. Employment was associated with higher social participation, access to the community, and time spent in productive roles. When IPS was integrated into medical rehabilitative care, veterans with spinal cord injury received more than twice as many vocational service visits than when veterans were referred to outside agencies and/or providers. These data resonate with earlier reports raising concerns about the
111
Age, years Education, years Race White African American Hispanic Other Marital status Married VA benefits Average time since injury, years No supplemental security Income/social security disability insurance Level of spinal cord injury Tetraplegia Paraplegia Medical comorbidities ⱖ 1 Mental health comorbidities Depression Bipolar disorder Substance abuse Anxiety disorder
SE (n ⫽ 81)
TAU (n ⫽ 76)
48.7 ⫾ 9.8 13.1 ⫾ 2.3
49.8 ⫾ 9.8 13.5 ⫾ 1.9
37 (45.7) 29 (35.8) 5 (6.2) 10 (12.3)
33 (43.4) 37 (48.7) 1 (1.3) 5 (6.6)
30 (37.0) 50 (61.7) 10.7 ⫾ 11.3
15 (19.7) 43 (56.6) 12.4 ⫾ 11.6
55 (67.9)
56 (73.7)
38 (46.9) 43 (53.1) 22 (27.2)
45 (59.2) 31 (40.8) 22 (29.0)
28 (34.6) 1 (1.2) 23 (28.4) 1 (1.2)
26 (34.2) 0 (0.0) 24 (31.6) 3 (3.9)
Note. Values are mean ⫾ standard deviation (SD) or n (%). SE ⫽ supported employment; TAU ⫽ treatment as usual. Adapted from Ottomanelli et al., 2012.
access and underutilization of vocational services that is typical in spinal cord injury rehabilitation (Ottomanelli, Bradshaw, & Cipher, 2009; Wehman, Wilson, Parent, Sherron-Targett, & McKinley, 2000). Including IPS as part of spinal cord injury health care could be construed as a means of addressing insufficient access to vocational services and ensuring an adequate level of vocational assistance is provided to impact employment outcomes. Whether other methods of vocational rehabilitation delivered in equivalent amounts would have resulted in comparable or better employment outcomes is unclear from the present data. Nevertheless, increased contact with vocational services focused on finding competitive jobs likely represents a shift from conventional wisdom suggesting that individuals with significant physical disabilities need to spend time in prevocational activities (e.g., independent living and/or work hardening programs) prior to entering the workforce. The data from this study provide initial evidence that when vocational care is connected to medical rehabilitation in a structured and coordinated fashion, as was the case in the SE treatment condition, employment outcomes are improved, as opposed to treatment paradigms where vocational care is delivered separately. For this reason, examining the application of the active elements of IPS as they were delivered in this novel setting is clinically worthwhile. A first step in applying the model to this field was embracing the principle of zero exclusion by actively recruiting veterans with all levels of injury (paraplegia and tetraplegia) and including those with comorbid psychiatric and cognitive issues. This recruitment strategy, along with ongoing education on the value of work and on the principles of the IPS model, communicated to both veterans and providers that work is a viable health care goal. This culture shift paved the way for integration of services where IPS specialists engaged the services of the health care team (e.g., physiatrists, nurses, psychologists, social workers,
112
OTTOMANELLI, BARNETT, AND TOSCANO
occurred outside the VA and the investigators did not have access to non-VA data other than self-report.
Conclusions Due to the medical complexity and comorbid mental health conditions, the expansion of IPS to a spinal cord injury cohort can be construed as the ultimate test of extension of the model to a population with significant physical disability. Although further study is warranted, the thoughtful adaptation of the IPS model to a spinal cord injury population demonstrates a potential for successful implementation to a broad range of persons in physical medicine and rehabilitation populations. Figure 1. Percent of veterans achieving competitive employment over 1 year by type of vocational rehabilitation: supported employment (SE), treatment as usual at a site where SE was available (TAU-IS).
and occupational, physical, and recreation therapists) to actively direct their efforts toward addressing the medical and psychosocial barriers to work. Addressing barriers often involved cotreatment in the community, for example occupational or assistive technology therapists accompanying IPS specialists and veterans to evaluate worksite accommodations. With a visible physical disability, the IPS specialists and veterans did not spend time deciding whether to disclose to employers the disability itself. Instead the emphasis of the IPS specialists was on working with employers to understand how a person with a given set of physical impairments can competently and capably perform a job with appropriate support from the IPS specialist and health care team. Logistical issues such as transportation needed special consideration and lower caseload ratios than those in the mental health field were preferable given the level of medical complexity. Our clinical experience suggests that, although some subtle modifications may be necessary, overall the core IPS principles can be implemented in the field of physical disability to successfully address real and perceived barriers through collaborative care and education of consumers, employers, and health care teams.
Limitations The study sample was recruited from VA spinal cord injury centers in metropolitan areas and may not be generalizable to persons who live in less urban areas where access to transportation and employment opportunities may be more limited. Further, given the largely male population served, findings may not generalize to women. The data collected on the treatment as usual condition did not allow identification of the exact nature of the vocational services that were received outside the purview of the subjects’ VA spinal cord injury care. Despite being a randomized clinical trial, this study was conducted within a real-world field setting. In this context, the intervention condition was delivered within the VA system whereas the treatment as usual condition
References Bond, G. R., Drake, R. E., & Becker, D. R. (2008). An update on randomized controlled trials of evidence-based supported employment. Psychiatric Rehabilitation Journal, 31, 280 –290. doi:10.2975/31.4.2008 .280.290 Department of Veterans Affairs Office of Public Affairs Media Relations. (2009, January). Fact sheet: VA and spinal cord injury. Washington, DC: Department of Veterans Affairs. Retrieved from http://www1.va .gov/opa/publications/factsheets/fs_spinal_cord_injury.pdf Ottomanelli, L., Barnett, S. D., & Goetz, L. L. (2013). A prospective examination of the impact of a supported employment program and employment on health-related quality of life, handicap, and disability among Veterans with SCI. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 22, 2133–2141. doi:10.1007/s11136-013-0353-5 Ottomanelli, L., Bradshaw, L. D., & Cipher, D. (2009). Employment and vocational rehabilitation service use among veterans with spinal cord injury. Journal of Vocational Rehabilitation, 31, 39 – 43. Ottomanelli, L., Goetz, L., McGeough, C., Suris, A., Sippel, J., Sinnott, P., . . . Cipher, D. J. (2009). Methods of a multisite randomized clinical trial of supported employment among veterans with spinal cord injury. Journal of Rehabilitation Research and Development, 46, 919 –930. doi: 10.1682/JRRD.2008.10.0145 Ottomanelli, L., Goetz, L. L., Suris, A., McGeough, C., Sinnott, P. L., Toscano, R., . . . Thomas, F. P. (2012). Effectiveness of supported employment for veterans with spinal cord injuries: Results from a randomized multisite study. Archives of Physical Medicine and Rehabilitation, 93, 740 –747. doi:10.1016/j.apmr.2012.01.002 Ottomanelli, L., & Lind, L. (2009). Review of critical factors related to employment after spinal cord injury: Implications for research and vocational services. The Journal of Spinal Cord Medicine, 32, 503–531. Resnick, S. G., & Rosenheck, R. (2007). Dissemination of supported employment in Department of Veterans Affairs. Journal of Rehabilitation Research and Development, 44, 867– 877. doi:10.1682/JRRD.2007 .02.0043 Wehman, P., Wilson, K., Parent, W., Sherron-Targett, P., & McKinley, W. (2000). Employment satisfaction of individuals with spinal cord injury. American Journal of Physical Medicine & Rehabilitation/Association of Academic Physiatrists, 79, 161–169.
Received November 4, 2013 Revision received April 3, 2014 Accepted April 15, 2014 䡲
In the public domain http://dx.doi.org/10.1037/prj0000079
Individual Placement and Support (IPS) in Physical Rehabilitation and Medicine: The VA Spinal Cord Injury Experience Lisa Ottomanelli
Scott D. Barnett
Veterans Health Administration, Tampa, Florida, and University of South Florida
Veterans Health Administration, Tampa, Florida
Rich Toscano Veterans Health Administration, Washington, DC 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. Keywords: employment, supported, rehabilitation, vocational, spinal cord injuries
care and approximately 450 newly injured veterans and activeduty service members receive rehabilitation annually. Comprehensive care by interdisciplinary teams emphasizes wellness and prevention of complications to maintain the health and independence of persons with spinal cord injury (Department of Veterans Affairs Office of Public Affairs Media Relations, 2009). Even with advances in modern medicine and rehabilitation to restore health and function among persons with spinal cord injuries, the rates of returning to work remain extremely low (Ottomanelli & Lind, 2009). Individual Placement and Support (IPS) is a standardized and effective method for assisting persons with mental disabilities to find competitive employment through integrating vocational services into clinical care (Bond, Drake, & Becker, 2008). In 2004, through its Compensated Work Therapy (CWT) program, the VA launched a large-scale rollout of IPS, referred to as evidence-based supported employed (SE), for veterans with serious mental illness (Resnick & Rosenheck, 2007). Veterans with spinal cord injury, however, either were referred outside the VA to state systems for vocational rehabilitation or could use their benefits to pursue education. In 2005, the VA funded a trial of SE for veterans with spinal cord injury to address this gap in services. The Spinal Cord Injury Vocational Integration Program (SCI-VIP) tested whether integrated SE services in VA spinal cord injury centers was more effective than traditional vocational rehabilitation (Ottomanelli, Goetz, et al., 2009). SCI-VIP was the first trial of IPS in the field of physical medicine and rehabilitation (PM&R) and, to date, the only trial of employment services for persons with spinal cord injury. This report briefly summarizes findings from the SCI-VIP trial (for a full report of primary outcomes see Ottomanelli et al., 2012)
A spinal cord injury is a catastrophic injury that results in paralysis of lower limbs (paraplegia) or all four limbs (tetraplegia) and is associated with multiple secondary medical conditions such as pressure ulcers, pain, spasticity, bowel and bladder problems, and depression. The Veterans Health Administration (VHA) is the largest provider of spinal cord injury care with 24 spinal cord injury centers and 134 spinal cord injury primary care clinic teams. Forty-two thousand veterans with spinal cord injury are eligible for
Lisa Ottomanelli, PhD, Research Psychologist, HSR&D/RR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans’ Hospital, Tampa, Florida, and Associate Professor of Rehabilitation and Mental Health Counseling, University of South Florida; Scott D. Barnett, PhD, MSPH, Statistician, HSR&D/RR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans’ Hospital; Rich Toscano, MEd, National Program Evaluation Specialist, Office of Mental Health Operations, Veterans Health Administration, Washington, DC. Rich Toscano is now a National Employment Monitor at VA Research & Development, Tuscaloosa VA Medical Center, Tuscaloosa, AL. Supported by the Rehabilitation Research and Development Service, Office of Research and Development, Veterans Health Administration (VA RR&D grant no. B3773R). Contents of this article do not represent the view of the Department of Veterans Affairs or the United States Government. Portions of this work were presented at the 121st Annual Convention of the American Psychological Association in Honolulu, Hawaii, July 31–August 4, 2013 and at the 40th Anniversary Scientific Meeting. American Spinal Injury Association, Chicago, Illinois, May 6 – 8, 2013. Correspondence concerning this article should be addressed to Lisa Ottomanelli, PhD, HSR&D/RR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans Hospital, 8900 Grand Oak Circle (151R), Tampa, FL 33637. E-mail: lisa [email protected] 110
IPS AND SCI IN THE VA
and discusses adaptations of the model to a medically complex population.
Table 1 Demographic Characteristics at Baseline (n ⫽ 157)
SCI-VIP Results SCI-VIP was a prospective, multisite, randomized trial of SE compared with standard vocational rehabilitation in veterans with spinal cord injury at six VA spinal cord injury centers over 12 months. Site selection was based on spinal cord injury program strength and compensated work therapy services, leadership commitment and support for implementation, presence of a qualified site investigator, and geographic region. Veterans with spinal cord injury (n ⫽ 157) were randomly assigned to either SE (n ⫽ 81) or treatment as usual (n ⫽ 76 treatment as usual [TAU]) and were followed for 12 months. The SE intervention was delivered by vocational rehabilitation counselors trained in both SE and spinal cord injury medical issues and integrated into the spinal cord injury center interdisciplinary care teams. Treatment as usual involved referrals to traditional vocational rehabilitation outside of and apart from VA spinal cord injury health care. All subjects had at least one visit with a vocational provider, with SE subjects participating in 3.5 visits on average and TAU subjects participating in 1.3 visits on average. The study examined competitive employment outcomes and impact on health-related quality of life, handicap, and functional independence. Subjects were 50.2 ⫾ 9.4 years of age (average), were primarily men (95.5%, n ⫽ 150) and Caucasian (44.5%, n ⫽ 70), had an average of 13.3 ⫾ 2.3 years of education, and had their spinal cord injury for an average of 11.5 ⫾ 11.4 years. Nearly half the sample had paraplegia (47.1%, n ⫽ 74) and the remainder had tetraplegia (50.7%, n ⫽ 102). Medical record review revealed depression and substance abuse were the most frequent mental health comorbidities, and 28.0% (n ⫽ 44) had ⱖ 1 of six medical problems (e.g., diabetes or hypertension) common in similar populations (see Table 1). SE participants were significantly more likely to achieve competitive employment (25.9%; 95% CI [17.6, 36.5]) than TAU participants (10.5%; 95% CI [3.6, 17.4]; p ⬍ .008) (Ottomanelli et al., 2012). Competitive employment rate was 2.5 times higher with SE than with TAU (see Figure 1). Participants obtaining competitive employment reported significantly higher scores on Craig Handicap and Reporting Technique (CHART) measures of social integration, mobility, and occupation. (Ottomanelli, Barnett, & Goetz, 2013).
Discussion This was the first study to demonstrate the effective use of IPS in a spinal cord injury population in the VA health care system. IPS delivered as part of spinal cord injury health care was more effective in restoring employment outcomes for veterans with spinal cord injury than were referrals for vocational services apart from the veterans’ spinal cord injury health care. Employment was associated with higher social participation, access to the community, and time spent in productive roles. When IPS was integrated into medical rehabilitative care, veterans with spinal cord injury received more than twice as many vocational service visits than when veterans were referred to outside agencies and/or providers. These data resonate with earlier reports raising concerns about the
111
Age, years Education, years Race White African American Hispanic Other Marital status Married VA benefits Average time since injury, years No supplemental security Income/social security disability insurance Level of spinal cord injury Tetraplegia Paraplegia Medical comorbidities ⱖ 1 Mental health comorbidities Depression Bipolar disorder Substance abuse Anxiety disorder
SE (n ⫽ 81)
TAU (n ⫽ 76)
48.7 ⫾ 9.8 13.1 ⫾ 2.3
49.8 ⫾ 9.8 13.5 ⫾ 1.9
37 (45.7) 29 (35.8) 5 (6.2) 10 (12.3)
33 (43.4) 37 (48.7) 1 (1.3) 5 (6.6)
30 (37.0) 50 (61.7) 10.7 ⫾ 11.3
15 (19.7) 43 (56.6) 12.4 ⫾ 11.6
55 (67.9)
56 (73.7)
38 (46.9) 43 (53.1) 22 (27.2)
45 (59.2) 31 (40.8) 22 (29.0)
28 (34.6) 1 (1.2) 23 (28.4) 1 (1.2)
26 (34.2) 0 (0.0) 24 (31.6) 3 (3.9)
Note. Values are mean ⫾ standard deviation (SD) or n (%). SE ⫽ supported employment; TAU ⫽ treatment as usual. Adapted from Ottomanelli et al., 2012.
access and underutilization of vocational services that is typical in spinal cord injury rehabilitation (Ottomanelli, Bradshaw, & Cipher, 2009; Wehman, Wilson, Parent, Sherron-Targett, & McKinley, 2000). Including IPS as part of spinal cord injury health care could be construed as a means of addressing insufficient access to vocational services and ensuring an adequate level of vocational assistance is provided to impact employment outcomes. Whether other methods of vocational rehabilitation delivered in equivalent amounts would have resulted in comparable or better employment outcomes is unclear from the present data. Nevertheless, increased contact with vocational services focused on finding competitive jobs likely represents a shift from conventional wisdom suggesting that individuals with significant physical disabilities need to spend time in prevocational activities (e.g., independent living and/or work hardening programs) prior to entering the workforce. The data from this study provide initial evidence that when vocational care is connected to medical rehabilitation in a structured and coordinated fashion, as was the case in the SE treatment condition, employment outcomes are improved, as opposed to treatment paradigms where vocational care is delivered separately. For this reason, examining the application of the active elements of IPS as they were delivered in this novel setting is clinically worthwhile. A first step in applying the model to this field was embracing the principle of zero exclusion by actively recruiting veterans with all levels of injury (paraplegia and tetraplegia) and including those with comorbid psychiatric and cognitive issues. This recruitment strategy, along with ongoing education on the value of work and on the principles of the IPS model, communicated to both veterans and providers that work is a viable health care goal. This culture shift paved the way for integration of services where IPS specialists engaged the services of the health care team (e.g., physiatrists, nurses, psychologists, social workers,
112
OTTOMANELLI, BARNETT, AND TOSCANO
occurred outside the VA and the investigators did not have access to non-VA data other than self-report.
Conclusions Due to the medical complexity and comorbid mental health conditions, the expansion of IPS to a spinal cord injury cohort can be construed as the ultimate test of extension of the model to a population with significant physical disability. Although further study is warranted, the thoughtful adaptation of the IPS model to a spinal cord injury population demonstrates a potential for successful implementation to a broad range of persons in physical medicine and rehabilitation populations. Figure 1. Percent of veterans achieving competitive employment over 1 year by type of vocational rehabilitation: supported employment (SE), treatment as usual at a site where SE was available (TAU-IS).
and occupational, physical, and recreation therapists) to actively direct their efforts toward addressing the medical and psychosocial barriers to work. Addressing barriers often involved cotreatment in the community, for example occupational or assistive technology therapists accompanying IPS specialists and veterans to evaluate worksite accommodations. With a visible physical disability, the IPS specialists and veterans did not spend time deciding whether to disclose to employers the disability itself. Instead the emphasis of the IPS specialists was on working with employers to understand how a person with a given set of physical impairments can competently and capably perform a job with appropriate support from the IPS specialist and health care team. Logistical issues such as transportation needed special consideration and lower caseload ratios than those in the mental health field were preferable given the level of medical complexity. Our clinical experience suggests that, although some subtle modifications may be necessary, overall the core IPS principles can be implemented in the field of physical disability to successfully address real and perceived barriers through collaborative care and education of consumers, employers, and health care teams.
Limitations The study sample was recruited from VA spinal cord injury centers in metropolitan areas and may not be generalizable to persons who live in less urban areas where access to transportation and employment opportunities may be more limited. Further, given the largely male population served, findings may not generalize to women. The data collected on the treatment as usual condition did not allow identification of the exact nature of the vocational services that were received outside the purview of the subjects’ VA spinal cord injury care. Despite being a randomized clinical trial, this study was conducted within a real-world field setting. In this context, the intervention condition was delivered within the VA system whereas the treatment as usual condition
References Bond, G. R., Drake, R. E., & Becker, D. R. (2008). An update on randomized controlled trials of evidence-based supported employment. Psychiatric Rehabilitation Journal, 31, 280 –290. doi:10.2975/31.4.2008 .280.290 Department of Veterans Affairs Office of Public Affairs Media Relations. (2009, January). Fact sheet: VA and spinal cord injury. Washington, DC: Department of Veterans Affairs. Retrieved from http://www1.va .gov/opa/publications/factsheets/fs_spinal_cord_injury.pdf Ottomanelli, L., Barnett, S. D., & Goetz, L. L. (2013). A prospective examination of the impact of a supported employment program and employment on health-related quality of life, handicap, and disability among Veterans with SCI. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 22, 2133–2141. doi:10.1007/s11136-013-0353-5 Ottomanelli, L., Bradshaw, L. D., & Cipher, D. (2009). Employment and vocational rehabilitation service use among veterans with spinal cord injury. Journal of Vocational Rehabilitation, 31, 39 – 43. Ottomanelli, L., Goetz, L., McGeough, C., Suris, A., Sippel, J., Sinnott, P., . . . Cipher, D. J. (2009). Methods of a multisite randomized clinical trial of supported employment among veterans with spinal cord injury. Journal of Rehabilitation Research and Development, 46, 919 –930. doi: 10.1682/JRRD.2008.10.0145 Ottomanelli, L., Goetz, L. L., Suris, A., McGeough, C., Sinnott, P. L., Toscano, R., . . . Thomas, F. P. (2012). Effectiveness of supported employment for veterans with spinal cord injuries: Results from a randomized multisite study. Archives of Physical Medicine and Rehabilitation, 93, 740 –747. doi:10.1016/j.apmr.2012.01.002 Ottomanelli, L., & Lind, L. (2009). Review of critical factors related to employment after spinal cord injury: Implications for research and vocational services. The Journal of Spinal Cord Medicine, 32, 503–531. Resnick, S. G., & Rosenheck, R. (2007). Dissemination of supported employment in Department of Veterans Affairs. Journal of Rehabilitation Research and Development, 44, 867– 877. doi:10.1682/JRRD.2007 .02.0043 Wehman, P., Wilson, K., Parent, W., Sherron-Targett, P., & McKinley, W. (2000). Employment satisfaction of individuals with spinal cord injury. American Journal of Physical Medicine & Rehabilitation/Association of Academic Physiatrists, 79, 161–169.
Received November 4, 2013 Revision received April 3, 2014 Accepted April 15, 2014 䡲
