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2023 HSR&D/QUERI National Conference Abstract

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1017 — Fidelity to the Supported Employment Model is Associated with Employment Among Veterans with TBI History: A Formative Evaluation

Lead/Presenter: Terri Pogoda,  COIN - Bedford/Boston
All Authors: Pogoda TK (Center for Healthcare Organization and Implementation Research), Marchany, K (Center for Healthcare Organization and Implementation Research, Boston) Yee, J (Center for Healthcare Organization and Implementation Research, Boston) Keleher, V (Research, Tuscaloosa VA Medical Center, Tuscaloosa) Might, R (Vocational Rehabilitation, Louis Stokes Cleveland VA Medical Center, Cleveland) Toscano, R (Research, Tuscaloosa VA Medical Center) Zogas, A (Center for Healthcare Organization and Implementation Research, Boston) Carlson, KF, (Center to Improve Veteran Involvement in Care, Portland) Resnick, SG (Mental Illness Research, Education and Clinical Center, West Haven)

We evaluated the extent to which VA medical centers (VAMCs) implemented evidence-based Supported Employment (SE) for Veterans with traumatic brain injury (TBI) history. SE is an intensive, individualized vocational rehabilitation program for those whose disabilities interfere with finding and maintaining employment. SE providers work closely with Veterans, their treatment teams, and employers to ensure that clinical and vocational supports are in place to facilitate workplace success. Fidelity to the SE model has been associated with better employment outcomes.

In May 2020, study mentor trainers began conducting individual weekly external facilitation sessions with SE leadership and providers from each of the participating 12 VAMCs. Through videoconference, mentor trainers reinforced SE principles and provided technical assistance on integration with clinical teams, Veteran engagement, job development, and follow-along support for Veterans with TBI history. Approximately one-year post-implementation, each VAMC received an evaluation by an outside reviewer to assess the level of SE implementation in the fidelity domains of Staffing, Organization, and Services.

Fidelity scores ranged from 77-109 out of 125: 6 sites achieved “Good Fidelity” (range = 100-109) and 6 sites achieved “Fair Fidelity” (range = 77-91). Each SE program had strong Staffing. For the Organization domain, overall VAMC focus on promoting competitive employment was low, needing improvement at 9 sites. Frequent contact between the SE and clinical providers to learn about Veterans’ symptoms, skills, strengths, limitations, and preferences was also challenging at 7 sites. For the Services domain, nearly all SE programs were engaged in rapid job search for competitive employment within 30 days of working with Veterans. However, across sites SE providers were not contacting employers as frequently as SE principles suggested, building networks to educate employers about the unique strengths that Veterans can bring to the workplace, or connecting with employers to address workplace accommodations when necessary. Among the 67 Veterans enrolled, a logistic regression model adjusted for sociodemographics indicated that younger age (adjusted odds ratio [aOR] = .86, 95% Confidence Interview [CI] = .80-.94), a lower fidelity score on Staffing (aOR = .30, 95% CI = .11-.80), and a higher fidelity score on Organization (aOR = 1.22, 95% CI = 1.02-1.46) were associated with obtaining employment.

This study contributes to the evidence base that higher fidelity to SE principles is associated with employment success among Veterans with TBI history. These findings are aligned with SE studies focusing on other clinical populations. The negative association between Staffing and employment may reflect all 12 SE programs being rated highly on this factor with little variability. The positive relationship between Organization and employment highlights the importance of SE and clinical teams collaborating to support Veteran recovery in the employment domain. No association between Services and employment likely indicates a combination of SE providers’ strengths in individualized job searches that were consistent with Veteran preferences, while being restricted by COVID-19 protocols that limited time in the community.

SE fidelity reviews are a quality improvement mechanism that identify strengths, weaknesses, and strategies for improvement, and allow SE programs to measure progress over time.