Improving Access to Supported Employment for Veterans with Polytrauma/Traumatic Brain Injury

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Anticipated impacts on Veteran healthcare: Supported Employment (SE) is an effective evidence- based practice that focuses on competitive employment through job coaching and unlimited support. This research aims to increase access to SE for Veterans with polytrauma/traumatic brain injury (PT/TBI) so that more of these Veterans can reach their vocational potential. Ensuring that Veterans with PT/TBI can access effective vocational rehabilitation services may help prevent numerous downstream health and functional problems. Project background: Many OEF/OIF/OND Veterans have experienced PT/TBI, which can result in functional limitations and challenges to employment. Pogoda et al. found that among Veterans evaluated in VHA PT/TBI clinics, approximately 20% reported that they were unemployed and looking for work, and of these, 71.6% had a TBI diagnosis and were in their prime working years. Carlson et al. reported that Veterans with PT/TBI have an interest in receiving SE services, yet are not routinely informed of vocational rehabilitation programs. Though SE is targeted to Veterans with serious mental illness (SMI), up to 25% of the SE caseload may be used for non-SMI clinical populations. However a recent review found that more than one-half of VA SE programs were working below their caseload capacity and were able to serve more Veterans. Moreover, very few PT/TBI clinics were referring Veterans to SE. Project Objectives: The purpose of this study is to increase access to SE for Veterans with PT/TBI. This will be achieved by (1) identifying actionable barriers and facilitators to referring Veterans to SE, providing SE services to and retaining these clients, and integrating the SE and PT/TBI clinic teams, (2) developing and refining an intervention package/toolkit for an SE-TBI program, and (3) implementing the intervention and conducting qualitative and quantitative assessment of its effectiveness at local VA Medical Centers (VAMCs) that are below SE caseload capacity. Project Methods: Guided by the integrated-Promoting Action Research on Implementation in Health Services (i-PARIHS) framework, for Aim 1, we will identify barriers and facilitators to SE-TBI by interviewing SE vocational rehabilitation specialists and PT/TBI providers at (a) 4 VAMCs that have a successful SE-TBI program, and (b) 12 VAMCs that are below SE caseload capacity. Based on findings from Aim 1, we will adapt and refine current toolkit materials to develop a customizable intervention package that includes menu-based choices (e.g., educational materials, marketing practices to facilitate integration between the SE and PT/TBI clinic teams) to maximize success in SE referral and implementation. Finally, for Aim 3, at the 12 VAMCs from Aim 1 that are below SE caseload capacity, through external and internal facilitation, we will implement an intervention package to enhance PT/TBI participation in SE and document: (a) its effectiveness for change in number of Veterans with PT/TBI referrals and SE caseload size from pre- to post-intervention, (b) stakeholder (SE vocational rehabilitation specialists, PT/TBI providers, Veterans with PT/TBI) perceptions of implementation and SE program progress, (c) Veteran vocational and nonvocational outcomes, and (d) SE program fidelity. We will follow each site's progress over an 18-month implementation and evaluation period.