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PPO 13-123 – HSR&D Study

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PPO 13-123
Supported Employment for Veterans with Traumatic Brain Injury: Needs and Barriers
Kathleen F. Carlson MS PhD
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: January 2014 - December 2014

BACKGROUND/RATIONALE:
Approximately 7% of Iraq and Afghanistan War (OEF/OIF/OND) Veterans who use VA services are treated for traumatic brain injury (TBI)-related sequelae each year. Between fiscal years 2010 and 2012, more than 67,000 OEF/OIF/OND Veterans were provided with TBI-related care. TBI of all severity levels, including mild TBI, can lead to chronic symptoms that interfere with daily functioning and contribute to disability. Unemployment rates are high among civilians with TBI and may be even higher among Veterans with TBI given common co-occurring mental and physical health conditions. The VA TBI/Polytrauma System of Care (PSC) was designed to serve Veterans with TBI in need of rehabilitative services. VA program offices are interested in expanding Supported Employment (SE), an evidence-based vocational rehabilitation program, to Veterans with TBI who are treated in the TBI/PSC. Currently, SE is provided VA-wide to Veterans with serious mental illness, but is not systematically available to other clinical populations. SE is intensive relative to other vocational services and may not be the right-sized intervention for all Veterans with TBI who experience employment challenges. There is little information on the needs for or interests in vocational rehabilitation services, or the acceptability of an intensive service like SE, among Veterans with mild versus moderate or severe TBI.

OBJECTIVE(S):
Focusing on OEF/OIF/OND Veterans with mild versus moderate/severe TBI, the aims of this project were to: 1) Quantify unemployment and describe employment challenges; 2) Assess knowledge and use of community and VA vocational services; 3) Examine interest in and acceptability of VA SE to meet Veterans' vocational needs; and 4) Identify perceived facilitators and barriers to accessing and utilizing VA SE services.

METHODS:
This was a 1-year, two-phase mixed-methods pilot study conducted through the VA Portland Health Care System HSR&D Center, in collaboration with VA Central Office partners and investigators from VA Centers in Boston, Minneapolis, and San Diego. In Phase 1, we conducted focus groups and interviews with 37 Veterans in Portland and Boston. Participants were asked to discuss employment difficulties and their knowledge and perceptions of vocational services, focusing primarily on the SE model. Qualitative results were used to modify a survey instrument for use in Phase 2. Prior to its use, the survey instrument was piloted for readability and relevance with six additional OEF/OIF/OND Veterans with TBI history, and revised as needed. In Phase 2, we mailed a survey to 1,800 randomly sampled OEF/OIF/OND Veterans using a modified Dillman approach. The sampling frame included Veterans who were confirmed via a clinician-administered Comprehensive TBI Evaluation to have incurred one or more TBIs during deployment. Veterans with moderate/severe TBI were oversampled. Survey respondents were asked about their employment status, productivity, and barriers to achieving employment goals; their knowledge and past receipt of VA and non-VA vocational services, and interests in future receipt of vocational assistance; and their interest in the SE model as well as perceived barriers and facilitators to accessing and utilizing SE. Standardized measures were used to assess these and other factors of interest (e.g., physical and mental health; functioning; social support) when possible.

FINDINGS/RESULTS:
Phase 1 focus group/interview participants ranged in age from 24 to 69 years and had varied education levels. The majority (n=34) had a history of mild TBI. Thirteen were employed full or part-time, 6 were unemployed and looking for work, and 10 reported being unable to work. Veterans identified both individual- and contextual-level employment challenges. Symptoms potentially attributable to TBI or comorbid mental health conditions (e.g., post-traumatic stress disorder, sleep problems, pain, and cognitive or emotion regulation issues) were described as individual barriers to productivity. Lack of formal education or civilian work experience, difficulty translating military skills to civilian settings, and encountering stereotypes of Veteran volatility in the workplace were additional barriers to finding or maintaining employment. Veterans' interests in and use of SE services was limited by: 1) An engrained military culture that perceived asking for help as a weakness; 2) Concerns about loss of VA benefits; and 3) Lack of awareness of VA vocational rehabilitation programs.

Phase 2 surveys were returned undeliverable for 349 Veterans. Among the remainder of the sample, 614 Veterans (42%) returned completed surveys, including 388 with a history of mild TBI and n=226 with moderate/severe TBI history. Among respondents with a history of mild versus moderate/severe TBI, 43% and 51% were not working in a paying job, respectively; of these, 34% and 22% were actively looking for work. Few respondents (n<10) reported they had used SE; only 15% and 20% of those with mild versus moderate/severe TBI, respectively, had heard of SE. After reading a description of SE, 40% and 45% of those with a history of mild versus moderate/severe TBI reported they would be moderately interested or very interested in the program if it were offered to them. Approximately one-half of respondents reported they would be likely to try SE if it were recommended to them by their medical provider, mental health provider, or case manager/social worker; proportions were similar (~50%) regardless of provider type or respondents' TBI severity.

IMPACT:
Employment challenges among OEF/OIF/OND Veterans with a history of TBI appear to be significant. Although many would be interested in utilizing SE, few have heard of the program. Ensuring that Veterans with TBI can access SE or other effective vocational rehabilitation services may help prevent downstream health and functional problems. Knowledge from this project will be used to inform VA efforts to expand SE to this population. Subsequent research is needed to identify factors associated with referral to, retention in, and successful outcomes from vocational rehabilitation and, in particular, SE services among Veterans in the VA TBI/PSC.

PUBLICATIONS:

Journal Articles

  1. Wyse JJ, Pogoda TK, Mastarone GL, Gilbert T, Carlson KF. Employment and vocational rehabilitation experiences among veterans with polytrauma/traumatic brain injury history. Psychological Services. 2020 Feb 1; 17(1):65-74.
  2. Dismuke-Greer CE, Nolen TL, Nowak K, Hirsch S, Pogoda TK, Agyemang AA, Carlson KF, Belanger HG, Kenney K, Troyanskaya M, Walker WC. Understanding the impact of mild traumatic brain injury on veteran service-connected disability: results from Chronic Effects of Neurotrauma Consortium. Brain injury. 2018 Jun 11; 32(10):1178-1187.
  3. Phelan SM, Bangerter LR, Friedemann-Sanchez G, Lackore KA, Morris MA, Van Houtven CH, Carlson KF, van Ryn M, Harden KJ, Griffin JM. The Impact of Stigma on Community Reintegration of Veterans With Traumatic Brain Injury and the Well-Being of Their Caregivers. Archives of physical medicine and rehabilitation. 2018 Nov 1; 99(11):2222-2229.
  4. Carlson KF. Military, Work, and Health Characteristics of Veterans and Reservists from the Study for Employment Retention of Veterans (SERVe). Military psychology : the official journal of the Division of Military Psychology, American Psychological Association. 2018 Mar 20; 29(6):491-512.
  5. Pogoda TK, Carlson KF, Gormley KE, Resnick SG. Supported Employment for Veterans With Traumatic Brain Injury: Provider Perspectives. Archives of physical medicine and rehabilitation. 2018 Feb 1; 99(2S):S14-S22.
  6. Carlson KF, Pogoda TK, Gilbert TA, Resnick SG, Twamley EW, O'Neil ME, Sayer NA. Supported Employment for Veterans With Traumatic Brain Injury: Patient Perspectives. Archives of physical medicine and rehabilitation. 2018 Feb 1; 99(2S):S4-S13.e1.
  7. Pugh MJ, Swan AA, Carlson KF, Jaramillo CA, Eapen BC, Dillahunt-Aspillaga C, Amuan ME, Delgado RE, McConnell K, Finley EP, Grafman JH, Trajectories of Resilience and Complex Comorbidity Study Team. Traumatic Brain Injury Severity, Comorbidity, Social Support, Family Functioning, and Community Reintegration Among Veterans of the Afghanistan and Iraq Wars. Archives of physical medicine and rehabilitation. 2018 Feb 1; 99(2S):S40-S49.
  8. Carlson KF, O'Neil ME, Forsberg CW, McAndrew LM, Storzbach D, Cifu DX, Sayer NA. Risk of hospitalization due to motor vehicle crashes among Iraq and Afghanistan War Veterans diagnosed with traumatic brain injury. Neurorehabilitation. 2016 Jun 30; 39(3):351-61.
Journal Other

  1. Carlson KF, Pogoda TK, Gilbert T, Mastarone G, O ME, Sayer NA. Prevalence and correlates of unemployment among Iraq and Afghanistan war veterans with deployment-related TBI history enrolled in the veterans health administration. [Abstract]. Brain Injury : [Bi]. 2017 Jul 5; 31(6-7):719-1017.
Conference Presentations

  1. Carlson KF, Pogoda TK, Resnick SG. The Provision of Supported Employment to Veterans with TBI in VHA. Paper presented at: Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury Summit; 2016 Sep 13; Falls Church, VA.
  2. Carlson KF, Pogoda TK, Resnick SG, O'Neil ME, Twamley EW, Sayer NA. Vocational Service Needs and Interests among Veterans with Traumatic Brain Injury. Paper presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  3. Carlson KF, Pogoda TK, Resnick SG, O'Neil ME, Sayer NA. Supported Employment for Veterans with Traumatic Brain Injury: Needs and Barriers. Poster session presented at: American Congress of Rehabilitation Medicine Annual Meeting; 2015 Oct 27; Dallas, TX.
  4. Carlson K., Pogoda TK, Resnick SL, O'Neil ME, Twamley EW, Sayer NA. Supported Employment for Veterans with Traumatic Brain Injury: Needs and Interests. Poster session presented at: VA Traumatic Brain Injury Research State-of-the-Art Conference; 2015 Aug 24; Washington, DC.
  5. Carlson KF, Pogoda TK, Resnick SG, O'Neil ME, Sayer NA. Supported Employment for Veterans with Traumatic Brain Injury: Needs and Interests. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.


DRA: Brain and Spinal Cord Injuries and Disorders
DRE: none
Keywords: Outcomes - Patient, Reintegration Post-Deployment, TBI
MeSH Terms: none

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