Development of community follow-up in a comprehensive rehabilitation center.

The purpose of rehabilitation is to increase the independence of the person receiving services when he or she returns to the community, either through increased employment or improved daily living skills. To measure the degree of improvement in employment or daily living, follow-up is necessary. The Commission on the Accreditation of Rehabilitation Facilities requires follow-up as a part of the outcomes measurement of efficiency, effectiveness, and satisfaction. Accreditation bodies for vocational training such as the Southern Association of Colleges and Schools have recommended follow-up of employers of former students at least one year after employment. Recent drafts of proposed reporting requirements of the 1992 Amendments to the Rehabilitation Act necessitate more detailed information on the earnings, employment and satisfaction of former rehabilitation clients for periods up to three years.

Despite this increased emphasis on post-service assessment, there is little in the recent rehabilitation literature which describes the actual efforts of comprehensive rehabilitation centers to implement follow-up, to share information with rehabilitation counselors in the field, and the impact of follow-up on subsequent placement. Bolton (1981) provided the most comprehensive review of follow-up of vocational rehabilitation programs. In the studies he reviewed, about two-thirds of the former vocational rehabilitation clients were working and fifty percent of the former clients of workshops and comprehensive centers were employed. Sankovsky and Newman (1972), with a 70% response to a mail survey, found that two-thirds of those who completed vocational training in a comprehensive rehabilitation center were employed. Cook (1983) determined from a mail survey, that 70% of former clients at the Arkansas Rehabilitation Center had been employed after leaving the Center although not all retained employment. Chope and Reagles (1976) provided a check list for characteristics of successful follow-up studies, and Carle and Adler (1980) presented the model used in a rehabilitation hospital for patients with spinal cord injury. More recently, Bolton (1991) described the use of the Work Satisfactoriness Survey to assess the response of employers to client work habits, Closson et al. (1994) assessed follow-up by telephone for clients of a rehabilitation hospital, and Vogel (1995) summarized the use of employment commission data to track longer term employment of comprehensive center clients.

With the renewed emphasis on outcomes and accountability for a range of social and health programs, follow-up results have again become important, both to assess individual success and to increase client input into program and placement planning. Staff are interested in whether the rates of success for recent programs with a greater number of clients with severe disabilities and other social and psychological problems are similar to those found in the earlier studies of the 1960's and 1970's. In addition to profiling individual client success, follow-up information from the client and employer provides important input for program content to match workplace needs and for joint planning for successful community placement. This paper describes the steps in developing the follow-up process, the types of measures used, and the initial results.

Method

Description of Rehabilitation Center

Woodrow Wilson Rehabilitation Center (WWRC) is a comprehensive rehabilitation center which provides a spectrum of services including medical rehabilitation, vocational evaluation, training and independent living services for people with a range of disabilities. A division of the Virginia Department of Rehabilitative Services, WWRC serves approximately 3,000 clients a year from throughout the Commonwealth of Virginia and surrounding states and territories. Upon completing a program at WWRC, the client receives job placement and other services from the rehabilitation field counselors in the home community.

Although some individual programs such as Head Trauma, Communications Services, Training and the Spinal Cord Injury System have had formal follow-up systems which included rerum visits, phone calls, satisfaction surveys and access to the state database on case closures, WWRC, as a whole, had no consistent, uniform policy and set of procedures in place. A phone survey of staff at similar rehabilitation centers revealed that most had little in the way of follow-up beyond informal contact with field counselors and the use of statewide information on employment. Some centers were supplementing this information with mail surveys for up to a year to the client and field counselor. Management at the Center recognized the value of collecting outcomes data and supported the design of a formal process of comprehensive follow-up in 1991.

Like most comprehensive centers, WWRC provided both vocational and medical rehabilitation organized in two major divisions: the Career and Life Services Division, which contained Vocational Evaluation, Training, and Independent Living, and the Health Services Division, which included Inpatient Medical Services, Outpatient Services, Head Trauma and Spinal Cord Injury. Center administrators decided to develop separate, but coordinated systems of follow-up for the two divisions. In addition, since both divisions already had a process in place to assess satisfaction with services which involved follow-up contact, division administrators retained the satisfaction process separate from the follow-up program and included the results of both in program evaluation reporting.

Procedure for Vocational Service Follow-up

The Career and Life Services Division developed formal follow-up policy and procedures with input from program supervisors, teachers, field counselors, and students. The following was the policy statement developed during the fall of 1993.

Training staff will collect and disseminate information about the status of former clients. To obtain this information, Training staff will survey a sample of former students or their counselors three months and six months after leaving the Center, and students and their employers one year after leaving the Center.

The procedures described when and how staff would contact the client, rehabilitation counselor and employer. Staff began the testing and implementation of follow-up procedures during 1994 and completed the first full year of follow-up July 1, 1995. Most contact was by telephone. The follow-up staff was to contact the field counselor at three months post service, the client or field counselor at six months, and the client and employer at one year after discharge. After contacting similar rehabilitation centers in the region, staff found no standardized follow-up instrument which the vocational teachers and evaluators felt met their needs. For the three- and six-month contact, staff developed in-house a simple questionnaire borrowing items from a survey used by a rehabilitation institution in another state with feedback from counseling and training staff. Included were questions about employment, receipt of other services, assistive technology needs, an updated address and phone number and the need for any further services at the Center. If the student needed further services, follow-up staff forwarded the information to the appropriate staff and department. These survey forms, completed three months post discharge and six months post discharge for those in Training, Prevocational Training and Vocational Evaluation, provided the information for a quarterly follow-up report and were placed in the individual student record.

Follow-up staff contacted both those who did and did not complete Training at the Woodrow Wilson Rehabilitation Center one year post discharge. Staff developed a longer questionnaire for the one-year contact with the help of teachers and counselors. The questionnaire included multiple choice answers and took approximately five minutes to complete by phone. Questions varied depending on whether the client was currently employed or unemployed. Examples of the types of questions were hours working, whether the training at the Center helped with the activities of work, and how the training could be modified to better meet the needs of the work place. This survey was pre-tested with a group of forty former clients, half employed and half unemployed, and modified from their responses for further use. The staff supplemented the survey responses with information from the agency statewide automated database of all clients seen in the system including gender, age, level of school completed, client closure status, date of employment, job titles, and wages.

Staff at the Center also contacted the employers of the former clients for an assessment of the quality of the training and work characteristics of former students, initially by mail. The survey instrument used was the Minnesota Satisfactoriness Scales, developed at the University of Minnesota, which included 28 questions about work behaviors for which the employee received a rating by a supervisor on a three point scale relative to others in the work group. Use of and analysis of this scale by the Hot Springs, Arkansas Rehabilitation Center confirmed the applicability of the subscales and scores to a population of workers with disabilities (Bolton, 1991).

Procedure in Health Services

For the Health Services Division, the Center appointed a work group in 1992 with representatives from the Counseling Department, Communications Services, Physical Therapy, Social Work, Outpatient and Program Evaluation to develop policies and procedures for follow-up. The group reviewed the existing efforts at follow-up at the Center including patient satisfaction surveys, individual efforts by departments and documentation of follow-up visits and clinics. Upon completing this review, the group then developed the following policy and procedures in 1993:

POLICY: All WWRC clients who participate in a primary medical rehabilitation program are provided one or more follow-up services to assess for community readjustment and the need for additional services. These contacts also serve to provide WWRC with information about the quality and continuity of services rendered here and/or in the community, as well as monitor the client's level of functioning. Follow-up services may be face-to-face, by telephone with the client, or indirect through a family member or community agency working with the client. Appropriate steps are taken to address any problem identified. All follow-up services are documented in the client's medical record.

The committee continued to meet to develop the procedures for follow-up. A key in the process was the social worker, both hospital and outpatient. At the final team rounds for the hospital inpatient prior to discharge, the hospital social worker would inquire if the patient/family would be willing and able to return and would assure that recommendations for follow-up were implemented by notifying the outpatient social worker via a follow-up information form. The process for outpatients was similar with initiation for follow-up coming from the outpatient social worker rather than the hospital social workers.

The preferred mode of contact was originally to be an outpatient visit. If the patient could not return for an outpatient follow-up visit, WWRC staff would make contact by phone. If not contacted by phone, the patient would receive a letter and survey. Home visits with the mobile clinics would be used for a limited number of former patients.

The implementation of the procedure for follow-up required a survey instrument. Since WWRC was in the process of moving from the use of an in-house program evaluation system to the use of the nationally standardized Functional Independence Measure (FIM), the committee recommended the use of the FIM Follow-up Coding Sheet. This shortened version of the FIM included a functional assessment and other questions about the patient status after discharge including living arrangement, vocational status, and ongoing therapy or services. The Uniform Data Services provided automated reports on the follow-up FIM similar to those for the FIM which compared FIM scores and living situations of clients from other centers within the region and nationally (Benton, 1994). In general, medical rehabilitation offered more standardized outcomes instruments which have developed in response to financial and regulatory pressures.

A major issue emerged over who would administer the follow-up FIM and caused a major delay in the implementation of the medical follow-up. The Commission on the Accreditation of Rehabilitation Facilities recommended that a person who has not delivered services to the client perform follow-up contact to ensure the objectivity of the data. Other possible options used at other rehabilitation centers included contracting with a consulting service to conduct the surveys, contact by outpatient social workers, and use of a trained volunteer. Training in the application of the FIM was required of whoever performed the follow-up.

Woodrow Wilson Rehabilitation Center assigned a registered nurse in Outpatient Services to coordinate both follow-up services and to gather follow-up information. This nurse combined the medical knowledge to gather the inpatient history from charts to schedule appropriate post discharge clinical services as well as the clinical ability to administer the follow-up FIM survey.

The timing of the follow-up contact was another critical issue. There was a need to contact the clients soon enough after services before too many other factors intervened. The Committee decided on 90 days based on accreditation body recommendations and common practice. Implementation of the follow-up process began in 1994, with the first full year of data available in March 1995 for the year ending December 31, 1994.

Results

For the first year of reporting one-year follow-up for Training students who left the Woodrow Wilson Rehabilitation Center between July 1, 1993 and June 30, 1994, staff were able to contact 116 (56%) former clients. The most common reason for not contacting the students were no phone (27%), no answer (6%), moved (5%), and refused (3%).

Sixty-five percent of the former training students contacted were employed. This figure included both clients who completed and did not complete the training program. This employment rate was similar to the figure of 67% derived on a quarterly basis through the agency statewide database and was comparable with findings in the earlier literature that two-thirds of clients who complete rehabilitation and one-half of the clients of comprehensive centers are employed at follow-up (Bolton, 1981). Sixty-seven percent of those working were employed in the clerical, service and technical sectors, the rest in processing, machine trades, benchwork, and agricultural sectors, with seventy-six percent employed in the same sector as the training area. Most jobs were in the private sector (92%) at an average weekly wage of $199, and eighty-three percent rated their job as good or excellent. About one-third received benefits such as paid vacation and health insurance. Respondents provided information on types of equipment used, additional training needed on the job and how they secured the employment. For those not employed, questions covered possible barriers they encountered. Teachers, rehabilitation counselors and program managers received a report which included answers to all questions as well as responses from the open comments section to plan for improvements in program and curricular adjustments.

During the first year, for the three-month follow-up, staff were able to contact the counselors of 77% of the Training students, 85%, of the Prevocational Training students, and 88% of the Vocational Evaluation students. Fifty-one percent of the Training students had met their discharge goals of employment, while 67% of the Prevocational and 59% of Vocational Evaluation students met their discharge goals, primarily further counseling and training. Ninety-two percent of the Training students were living in the community rather than institutions or assisted living.

The initial sample of the Satisfactoriness Scales included 24 responses. The Center group scored better than norms for all workers for the following items: following work rules, getting along with supervisor, promptness, not becoming upset, not needing discipline, staying alert, not complaining, not saying odd things, not acting if not listening and not wandering about. Many of these items were in the personal adjustment category, indicating a good preparation for the work environment. Analysis of a larger group of returns would be necessary to confirm the findings.

Overall, supervisors rated 79% of the group in the top half of all their workers, 21% percent in the bottom half, with none in the bottom quarter. The training areas included carpentry, business, computer, custodial, drafting, nurse's aide, cabinetmaker, stock clerk, food service, welding, electromechanical assembly and the external training option where clients receive training in a variety of fields in community settings.

The initial FIM follow-up information for 28 medical inpatients at the Woodrow Wilson Rehabilitation Center between January 1, 1994 and December 31, 1994, found 82% at home. Seven percent were working and 18% were retired either for age (14%) or disability (4%). Forty-six percent were responsible for their own health maintenance with 18% using an unpaid helper and 29% a paid attendant. The average FIM score increased 7.8 points from discharge to follow-up, confirming that patients continued to receive benefits after discharge. Additional follow-up contact also showed that 59% of the medical clients received additional services at WWRC either through Supported Living Services or Outpatient Services.

With this information, program staff have begun to develop targets for improvement. The report provided a comparison of the WWRC measures with comparable institutions in the region and nation, and staff used these comparative figures to develop goals and objectives for change. Reviewing these figures was the program evaluation committee composed of department heads who further analyzed client progress to account for discrepancies and made recommendations for improvement. The continuous quality improvement committee also examined the data for indications of problem areas. Follow-up staff used the information to schedule additional services as needed and to contact community resources such as home health or placement personnel to resolve issues identified.

Discussion

The Woodrow Wilson Rehabilitation Center is a large and complex organization with many varied activities occurring. Getting useful follow-up information on diverse programs requires the careful tracking of client progress and several different survey instruments. The common elements of the WWRC policy on follow-up are that staff attempt to reach all clients, phone is the primary method of contact, and a variety of instruments are used which are most appropriate to the program and client needs. Meeting accreditation requirements/standards is an important benefit of the formal follow-up program.

A comprehensive follow-up program requires specific assigned resources to be successful. Keeping track of which clients to contact when requires careful attention and dedicated staff work. Interviewing by phone requires training as well as knowledge of WWRC programs and services to be responsive to questions which may arise. To successfully reach clients by phone, staff must be available during evening and week-end hours to reach those who are at work. It is important to link the scheduling of follow-up services with the administration of surveys. One rehabilitation hospital which had separated the scheduling of follow-up services from data gathering had follow-up staff who were unaware of the information available for planning client reentry and additional services.

In implementing the follow-up process, staff have made adjustments in method and material to streamline the process. With limited staff resources and literacy among clients, phone contact appeared to be the most effective despite the number who remained without phones. Modification of the in-house questionnaires continued as staff gained more experience on the usefulness of the types of replies received. The information gathered at three and six months from the field counselor was similar enough that the staff felt that a contact at three months and one year was sufficient. Staff had a major problem soliciting the release of information for employer contact from former students by mail. Students now sign the release of information when discharged from the Center. Administering the Satisfactoriness Survey by phone proved less cumbersome than contacting the employer by mail.

The follow-up information must be used as well as useful. From the surveys, staff must be sure that clients who indicate the need for further services receive them. Staff receive copies of quarterly and annual reports with the results of the follow-up surveys to aid in program planning and adjustment and to make recommendations for change such as the type of equipment used. The availability of follow-up information such as knowing whether the client had to relocate to find work and what were the most useful means of locating jobs has increased the focus of staff on community reintegration. Follow-up information from comparable institutions, as available from the FIM report, is useful in developing goals for improvement in areas such as discharges to home rather than institutions. Similar follow-up information on vocational programs elsewhere would be additional helpful data for developing targets and bench marking.

In addition to information for planning and improving curricula and programs, community follow-up provides contact with field staff and client to iron out problems, and more current addresses to maintain future contact. Understanding the client, family and referral source perception of services and assessment of transition to community is important to improve the community re-entry and placement process. Follow-up provides the opportunity to incorporate the client's view of meeting discharge goals and employer view of performance and adjustment to forge a stronger link between training and successful employment and community readjustment.

References

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