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Vocational rehabilitation following traumatic brain injury.

Assisting people with traumatic brain injury (TBI) to engage in work or other prodcutive activities is a major challenge confronting the vocational rehabilitation system. In all six of the RSA Traumatic Brain Injury Regional Centers there has been a strong focus on vocational issues. Some of the activities common to the four original centers (those located in Denver, Chicago, New York, and Houston) include:

* training state vocational rehabilitation staff,

* improving the quality of supported employment services to survivors of TBI,

* addressing issues of funding on-going support services, and

* involving employers in the development of community networks to enhance opportunities for survivors to engage in productive activity.

Each center has taken a somewhat different approach to these tasks. The centers have also generated some collaborative efforts.

Inter-Center Networking

The four vocational rehabilitation coordinators have been meeting regularly via teleconference for the last year; representatives from the two new centers were added in December 1992. In addition to sharing information and resources, they have explored areas of potential policy development.

They concurred that one of the most common obstacles in the state rehabilitation system mentioned by counselors during training programs was case management. The coordinates jointly prepared an initial memorandum detailing their belief that rehabilitation clients who are survivors of TBI are perceived by counselors as requiring more case management services (e.g., assistance with family problems, housing, transportation, accessing state and federal systems) than clients with other disabilities. In many cases, this perception is accurate. However, even though the provision of case management services can often make the difference between successful and unsuccessful vocational outcomes, such services, unfortunately, take an inordinate amount of counselor time, a scarce commodity in most state rehabilitation offices. Counselors are not rewarded for expending time on these activities, and many counselors are not prepared to provide such services. The coordinators therefore recommended that recognition of the need for case management services as part of the spectrum of rehabilitation services be formally acknowledged and that mechanisms be established to allow for the provision of such services to survivors of TBI. Each coordinator is contacting the state rehabilitation offices in her region and asking for specific input on this issue. Action in this arena will be ongoing for the next year. When data have been collected, the coordinators will prepare recommendations for policy change.

Each center has its own unique vocational activities, as described in the following.

Comprehensive Regional Traumatic Brain Injury Rehabilitation and Prevention Center (TBI-NET)

New York, New York

TBI-NET's Grand Rounds is a case-study approach that provides technical assistance to counselors in regional vocational rehabilitation offices in New York, New Jersey, and Puerto Rico. Prior to each Grand Rounds session, cases are selected by a local rehabilitation office and submitted to the TBI-NET technical assistance team (confidentiality is protected). The team--which includes a neuropsychologist, the Chief of Vocational Rehabilitation Services of Mt. Sinai's Department of Rehabilitation Medicine, and a community resource consultant--travels to the rehabilitation office, where the neuropsychologist presents key information about the existing neuropsychological/psychological report, concentrating on the report's relevance and applicability to vocational issues. Both successful and problematic actions in the course of the rehabilitation process are reviewed, with input from the team. This forum provides participants the opportunity for an open exchange of ideas to facilitate the development of vocational strategies and to capitalize on existing resources. When possible, community agency representatives are invited to attend these meetings. Frequently, the participants become partners with the technical assistance team in developing innovative treatment strategies and interventions. Counselors benefit from the interactive approach, which produces a repertoire of ideas and new ways of thinking about the target population. Validation of counselors' efforts helps minimize doubts about their management of TBI cases.

TBI-NET's Vocational Mentoring Project provides counseling and placement in competitive employment for people with TBI and recruitment and training of volunteer mentors (co-workers or supervisors) who provide natural supports at the worksite. This project helps TBI survivors return to their pre-injury jobs or obtain new employment. Mentoring is an appropriate intervention that can remote job retention while fostering the employer's ability to provide the support needed by people with severe disabilities. It is a low-cost intervention that encourages the employer to meet the needs of the individual with TBI through the use of available professional support. This project, which has also been used in educational settings, includes outreach and special counseling for minorities.

Midwest Regional Heal Injury Center for Rehabilitation and Prevention

Chicago, Illinois

The Midwest Center, in conjunction with the Illinois Institute of Technology, is developing computer-based training as a cost effective means for conveying information crucial to employment of people with TBI to state vocational rehabilitation personnel. Four informational modules are plannned, with Neuroanatomy and Medical Aspects currently being field tested; Functional Assessment and Work Implications in development; and a module on Families under consideration. During the development of these modules, at the recommendation of state vocational rehabilitation subcontractors and advisory committee members, the audience for these products was broadened to include allied health professionals, rehabilitation professionals in the private sector, and students in pre-service training programs.

In the area of supported employment, the Midwest Center funded technical assistance to vendors in Wisconsin through Mary Ridgely of Employment Resources, Inc., during the first 2 grant years. During the third and fourth years, the Midwest Center will continue its commitment to the supported employment model through a demonstration grant funded by the Rehabilitation Services Administration, U.S. Department of Education. This grant will fund a collaborative effort among a rehabilitation facility serving a semi-rural area, the Illinois Department of Rehabilitation Services (IDORS), and the center.

The Midwest Center advocates a strong program evaluation component to measure the effectiveness of each product and project. All product development includes field testing focused on knowledge acquisition, perceived needs, and satisfaction. For example, the state vocational rehabilitation training in Illinois includes five evaluation measures:

* a needs questionnaire;

* a pre/post test;

* a participant satisfaction survey;

* a quality assurance review of a sample of first year training participants (generated by IDORS), with a second review planned for spring of 1993; and

* a joint Midwest Center-IDORS effort to compile comparative statistics for counselors who did and did not receive training (comparing outcomes in 1988-90 to 1991-94).

Additional feedback about the content and potential audience for training is solicited from advisory groups whose members include vocational rehabilitation professionals from many settings, consumers (including several who are also professionals or employers), and vocational rehabilitation educators.

Ohio Valley Center for Head Injury Prevention and Rehabilitation

Columbus, Ohio

The Ohio Valley Center, one of the two new centers established in December 1992, seeks effective methods of enhancing independent, productive, and satisfying lifestyles via services that are based on the unique needs and personal goals of each individual and are available in or near a person's own community. Of the eight projects proposed under the umbrella of this center, five will address vocational rehabilitation.

Rocky Mountain Regional Brain Injury Center

Denver, Colorado

The Rocky Mountain Center chose to address the dual problems of enhancing the quality of supported employment services for survivors of TBI and identifying sources of funding for provision of extended services by creating replicable demonstration projects which focus primarily on the use of natural supports in the workplace. A request for proposals (RFP) was developed by the Supported Employment Advisory Committee and staff members and distributed throughout the region. Two projects were selected from a number of excellent proposals. The selection committee included staff, survivors (including one employed as a job coach), and rehabilitation professionals. One of the projects, located in northern Utah, is run by a coalition of public and private service agencies and coordinated by the state rehabilitation agency. The second project, located in a rehabilitation facility in Mandan, North Dakota, serves survivors in Mandan, Bismarck, and surrounding rural areas. This project is designed to work closely with the state agency, which serves as a referral source and provides some services. The directors of both projects have joined the Supported Employment Advisory Committee and make regular progress reports via teleconference to the committee, whose members then provide immediate feedback and offer technical support. We expect to learn a great deal from the struggles and successes experienced by each of these projects.

In training state vocational rehabilitation staff in the region, we have attempted to meet the needs of each state, with the result that each training session has been different. In Colorado, counselors expressed a desire to have supervisors receive some of the same learning experiences that they had received. In response, a separate training session was developed for supervisory staff. In South Dakota, staff from all parts of the agency and supervisors received training jointly. In North Dakota, counselor training was held in conjunction with the annual family conference of the state head injury association, allowing counselors, survivors, and families to interact over an extended period. Wyoming has also requested that the training be opened to other groups, to allow for networking in a state where resources are so physically dispersed that communication becomes problematic. Utah has requested that training focus on supported employment. Meeting the unique needs of each state presents exciting challenges to the Rocky Mountain Center staff.

Southeastern Comprehensive Head Injury Center

Birmingham, Alabama

Of the utmost importance to the Southeastern Center will be the full and successful implementation of a newly designed vocational rehabilitation service delivery model for the client with head injury. Known as the Interactive Community Based Model (ICBM), this system has been successfully piloted in three sites in Alabama. While ICBM is a relatively simple model, it does necessitate communication between the care coordinator, family members, the survivor, rehabilitation counselors, advocacy/peer groups, and community-based organizations and agencies. A client moves systematically through ICBM in a timeframe suited to his or her particular needs. The interactive nature of the model is demonstrated through the client's ability to move forward and, equally important, to move backward, should behavior, health, or other situations dictate. The client is given every opportunity to adjust his or her work readiness behavior appropriately and meaningfully.

Southwest Regional Brain Injury Rehabilitation and Prevention Center

Houston, Texas

The Southwest Center believes that both rehabilitation counselors and neuropsychologists have responsibility for helping people with TBI to achieve full community integration. The two professions must act interdependently to produce positive vocational outcomes. The Checklist for Writing Neuropsychological Reports in Functional Terms for Vocational Rehabilitation is a document designed to facilitate communication between the two professional groups and to improve services to people who have TBI. The Checklist project has two objectives:

* to suggest a list of functionally relevant questions for the rehabilitation counselor to ask the neuropsychologist when requesting a report, and

* to assist neuropsychologists in writing functional reports when they are conducting assessments of persons with TBI who are or will be receiving services from a vocational rehabilitation counselor. The Checklist has been reviewed by the center's Advisory Board and the Committee on Living and Working. A training manual and workshop package is being prepared.

The Southwest Center has also undertaken a unique effort to reach its goal of developing and implementing an outreach program to expand the knowledge and skills of rehabilitation personnel--especially counselors--who provide services to people with TBI. These programs, known as State Instructional Institutes, are developed by the Curriculum Committee, with a steering committee for each state made up of representatives from that state. The goals of the institutes are to prepare rehabilitation counselors to work more effectively with the recipients of their services and to promote the involvement of consumers in the design and implementation of service delivery systems. Each 3-day institute brings together 150-200 invited participants, including rehabilitation counselors, special education teachers, case managers, independent living counselors, professionals from community service agencies, survivors of TBI and their families, medical professionals, policy makers, and rehabilitation administrators. Participants expand their working knowledge about prognostic indicators and the continuum of recover following TBI and current strategies for providing effective services. During 1991-92, five Instructional Institutes were held, one each in the states of New Mexico, Oklahoma, Texas, Louisiana, and Arkansas. Additional Institutes are planned for the remaining period of the project to build on the information, skills, and abilities acquired in the initial institutes.

Each of the six regional brain injury centers is following a unique path to the same goal: to improve the quality and availability to service systems which assist survivors to engage in productive activity. The centers use different approaches to strengthen the skills of professionals who assist TBI survivors in their return to employment. By sharing the outcomes of their projects and programs, the six centers are creating a national network of data and experience that can benefit service systems throughout the country and ultimately enhance the capacity of survivors of traumatic brain injury to participate fully in the social and economic structure of their communities.
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Author:Mikrut, Sharon L.
Publication:American Rehabilitation
Date:Jun 22, 1993
Previous Article:A model systems approach to the rehabilitation of people with traumatic brain injury.
Next Article:Outreach from the regional centers to improve services for brain injury survivors in the community.

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