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

对退伍军人医疗保健的预期影响：支持就业（SE）是一个有效的证据- 基于实践，通过工作指导和无限支持，专注于竞争性就业。这 研究旨在增加多发性创伤/创伤性脑损伤（PT/TBI）退伍军人获得SE的机会， 更多的退伍军人可以发挥他们的职业潜力。确保患有PT/TBI的退伍军人能够 获得有效的职业康复服务可能有助于防止许多下游健康和 功能问题。 项目背景：许多OEF/OIF/OND退伍军人都经历过PT/TBI，这可能导致 功能限制和就业挑战。Pogoda等人发现， 在VHA PT/TBI诊所，约20%的人报告说他们失业并正在寻找工作， 其中，71.6%的人被诊断出患有TBI，并且正处于黄金工作年龄。Carlson等人报告说， 患有PT/TBI的退伍军人有兴趣接受SE服务，但通常不会被告知 职业康复计划。虽然SE是针对退伍军人与严重的精神疾病（SMI）， 高达25%的SE病例可用于非SMI临床人群。然而，最近的一项审查 发现超过一半的VA SE项目的工作量低于其工作量， 能够为更多的退伍军人服务。此外，很少有PT/TBI诊所将退伍军人转介给SE。 项目目标：本研究的目的是增加PT/TBI退伍军人获得SE的机会。这 将通过以下方式实现：（1）确定将退伍军人推荐给SE的可行障碍和促进因素， 为这些客户提供SE服务并留住这些客户，并整合SE和PT/TBI诊所团队，（2）开发 和完善SE-TBI计划的干预包/工具包，以及（3）实施干预 并在当地VA医疗中心对其有效性进行定性和定量评估 （VAMC）低于SE案例容量。 项目方法：以卫生实施综合推进行动研究为指导 服务（i-PARIHS）框架，对于目标1，我们将通过以下方式确定SE-TBI的障碍和促进因素： 在（a）4个具有以下特征的VAMC中采访SE职业康复专家和PT/TBI提供者： 成功SE-TBI方案，以及（B）12个VAMC低于SE案件量能力。根据调查结果 从目标1开始，我们将调整和完善现有的工具包材料，以开发可定制的干预措施 包括基于菜单的选择的包（例如，教育材料、营销做法， SE和PT/TBI诊所团队之间的整合），以最大限度地提高SE转诊的成功率， 实施.最后，对于目标3，在目标1的12个低于SE案件量的VAMC中， 通过外部和内部的促进，我们将实施一套干预措施，以加强创伤后/创伤性脑损伤 参与SE并记录：（a）其对PT/TBI退伍军人数量变化的有效性 从干预前到干预后的转介和社会企业案例量，（B）利益攸关方（社会企业职业康复 专家、PT/TBI提供者、患有PT/TBI的退伍军人）对实施和SE计划的看法 进步，（c）退伍军人职业和非职业的结果，（d）SE计划的保真度。我们将遵循 每个站点在18个月的实施和评估期内的进展情况。

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.