Vocational rehabilitation: models, evidence and guidelines to support the development of a service for a neurological population’ 16 th December 2019 Sarah Porter Occupational Therapist
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
St George’s University Hospitals NHS Foundation Trust
• 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
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
• 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
neurological population
St George’s University Hospitals NHS Foundation Trust
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)
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
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)
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
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, evidence and guidelines to support the development of a service for a
neurological population
St George’s University Hospitals NHS Foundation Trust
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
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
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
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
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
St George’s University Hospitals NHS Foundation Trust
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
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
Research into practice
Predicting a RTW after brain injury
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
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
Research into practice
Barriers to RTW
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
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
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
Considerations when developing a service
Client group and what to offer
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
• 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
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
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.
Considerations when developing a service
Client group and what to offer
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
• 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
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
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
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
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
Developing a service
Practicalities
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
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
• 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
• Everyone and their circumstances are different
• 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.
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
Developing a service
Practicalities
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
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
• 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
• Everyone and their circumstances are different
• 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
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
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)
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
Patient thoughts on vocational rehabilitation
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
Thank you
St George’s University Hospitals NHS Foundation Trust
www.stgeorges.nhs.uk
@StGeorgesTrust
References
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
• 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
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• Trexler, LE, Parrott, DR (2018) Models of brain injury vocational rehabilitation: The evidence for resource
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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
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Vocational Rehabilitation: models, evidence and guidelines to support the development of a service for a neurological
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St George’s University Hospitals NHS Foundation Trust
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