Serving People with Cardiovascular Disease in the State-Federal Vocational Rehabilitation Program: A Sequenced Case Management Approach from Outreach to Case Closure

Types of Cardiovascular Disease

CVDs include many conditions. Most prevalent among these are coronary heart disease, cerebral vascular disease (stroke), peripheral artery disease, and aortic atherosclerosis (Lopez et al., 2023). The most common CVD (one-third to one-half of all cases) is coronary heart disease, which is caused when blood flow to the heart is reduced or cut off by the presence of plaques (Lopez et al., 2023). If the heart goes for too long without blood, the heart muscle weakens and deteriorates over time. Decreased blood flow through the heart muscle causes angina (heart pain), myocardial infarction (MI; heart attack), and/or heart failure (Lopez et al., 2023, Introduction section).

Ischemic strokes occur due to a blockage of blood flow to the brain, whereas hemorrhagic strokes cause leakage of blood into part of the brain (Mayo Clinic, 2024). Both types of strokes decrease oxygen to the affected part of the brain and result in the death of brain cells. Ischemic strokes are most common, accounting for 80% of strokes, whereas hemorrhagic strokes account for the remaining 20% (Mayo Clinic, 2024). Transient ischemic strokes, sometimes referred to as mini strokes, are similar to ischemic strokes, but the reduction in blood supply to the brain is temporary and does not cause permanent damage. Up to 80% of all strokes are preventable by controlling modifiable risk factors (Williamson, 2021).

Peripheral artery disease (PAD) occurs with a narrowing of blood vessels supplying blood to the legs and feet, and less commonly to the arms, hands, and fingers. Aortic atherosclerosis results from a bulging or swelling of the aorta, the main artery that translocates blood from the heart to the rest of the body. Arteries that branch off the aorta, supplying blood to different parts of the body, can also be affected. Aortic atherosclerosis is a long-term condition that is usually without symptoms until an emergency occurs. Aortic atherosclerosis can cause multiple physical symptoms if an embolism develops and travels through the blood to another part of the body (Cleveland Clinic, 2025; Lopez et al., 2023).

Narrowing of the coronary arteries that supply blood to the heart caused by CVDs can cause heart attacks (Lopez et al., 2023). The blockage can be partial or complete. Some symptoms of a heart attack may be sudden and intense, causing significant pain, but others may come on slowly with only mild pain (AHA, 2024). However, some individuals may not experience any symptoms. Other individuals may attribute their symptoms to some other condition.

Risk Factors and Vulnerable Populations

Nine mutable or modifiable factors account for 90% of the risk of having a CVD and first heart attack. These factors include (a) smoking (which accounts for 36% of risk), (b) too many fats in the blood, (c) hypertension, (d) diabetes, (e) diets low in fruits and vegetables, (f) abdominal obesity, (g) psychosocial factors, (h) high alcohol consumption, and (i) lack of exercise (Lopez et al., 2023; National Heart, Lung & Blood Institute, 2014). Other risk factors include a family history of CVD, chronic stress which can cause sleep disruptions, and increased cholesterol and inflammation throughout the body. Individuals may cope with chronic stress by smoking, overeating, excessive alcohol intake, sleeping too much, and decreased exercise (AHA, 2020; Lopez et al., 2023; National Heart, Lung and Blood Institute, 2014). Co-occurring disorders that can cause CVDs include diabetes mellitus, hypertension, human immunodeficiency virus, and metabolic syndrome (Lopez et al., 2023, Etiology section). Metabolic syndrome is characterized by too much fat around the belly. A history of chest wall radiation, microalbuminuria (a marker of early kidney injury), inflammatory markers, respiratory diseases, depression, and anxiety are additional risk factors (Khan et al., 2023). Chronic stress is another risk factor for CVD, but the mechanisms through which they are related, including potential causal links, are speculative (Vaccarino & Bremner, 2024). Non-modifiable risk factors include family history, age, and sex.

CVDs affect both men and women and people in virtually every age bracket (Cleveland Clinic, 2025). Incidence increases with age, but it is higher in men at a younger age than it is in women. The incidence in women becomes higher after menopause, even higher than the rates for men at the same ages (Ryczkowska et al., 2022).

Although underrepresented racial and ethnic groups comprise 40% of the US population (Javed et al., 2022), CVD disproportionally affects members of these groups. Black people are twice as likely as white people to die from CVD, and American Indians are twice as likely as whites to be diagnosed with coronary heart disease (Javed et al., 2022). In the US, people living in poverty and in southern states have the highest death rates due to CVD, and those who live in the West have the lowest (AHA, 2024; CDC, 2014). American minoritized populations such as Alaska Natives, Pacific Islanders, Hispanics/Latinos, and African Americans are especially vulnerable to CVD. Black people have the highest rates of high blood pressure among all identifiable racial and ethnic groups in the US, and they are more than twice as likely as white people to develop CVDs (Million Hearts, 2015). Regardless of race or ethnicity, the risk of CVD increases dramatically in old age (Andrew & Andrew, 2017; Falvo & Holland, 2018; Wickert et al., 2013).

Across socioeconomic strata, races, and ethnicities, inequities exist in access to advances in prevention and treatment. Individuals with lower levels of education and those with lower incomes experience increased risk factors for CVD and CVD mortality. Lower education is associated with lower health literacy, which decreases one's prospects for continued good health (including cardiovascular health) over time. Poor socioeconomic conditions in early life can lead to the development and maintenance of risky health behaviors that can result in CVD in adulthood. Many environmental factors also contribute to disparities in health and healthcare. Neighborhoods of individuals most at risk of CVD are characterized by lack of access to healthy foods, with only small grocery and convenience stores nearby. These neighborhoods have commonly been referred to as food deserts. Poor walkability and lack of access to spaces for physical activity contribute to sedentary lifestyles, obesity, and other CVD risk factors (e.g., diabetes mellitus). Living in unsafe neighborhoods can result in chronic stress. Air pollution in certain neighborhoods, especially in the form of particulate matter, is another risk factor for CVD. Low socioeconomic status is linked to less social capital and fewer opportunities to receive social support, an important contributor to health-related quality of life (Javed et al., 2022).

The healthcare system itself introduces additional barriers that can increase risk factors and CVD among vulnerable populations. The lack of healthcare facilities, hospitals, and cardiologists in these communities is of great concern. An unequal geographic distribution of cardiologists has been documented, and many poor and rural communities cannot easily access these specialists. They also lack healthcare facilities in their communities for general care. Lack of proximity to general health and cardiac care often requires individuals to make long commutes to access treatment. It may be extremely difficult to make and keep appointments if one has no transportation. Also, reliable public transportation is often unavailable in rural areas. In addition to geographic location, hours of operation and timing of appointments in healthcare facilities can be barriers. Among minoritized individuals who are employed, many work in low-paying service or retail jobs (Javed et al., 2022). Employers in these occupations often do not provide employees with health insurance coverage. In addition, these employers may not allow for time off to attend medical appointments or employees may be required to take unpaid leave that they cannot afford to take.

Women with CVDs also experience health disparities. These include pregnancy complications, breast cancer therapy, higher rates than men of autoimmune disorders, rheumatic diseases, depression, and household-related stress (Regitz-Zagrosek & Gebhard, 2023). Regitz-Zagrosek and Gebhard (2023) also noted that women's symptoms of heart attacks are different than they are for men. Women are more likely to experience non-specific chest pain symptoms, as well as intrascapular, right arm, epigastric, or intermammary pain. They are also more likely to experience nausea, fatigue, and shortness of breath and to delay seeking care for their symptoms.

Symptoms and Functional Limitations

CVD is associated with multiple symptoms that can impede functioning in virtually every aspect of personal and social activity. Among the most common effects of CVDs are limited stamina and fatigue, dizziness or light-headedness, and temporary or long-term gross motor and fine motor limitations (Job Accommodation Network [JAN], 2025). However, because CVD includes different conditions, the functional limitations described below will not all be applicable to every individual who has experienced a CVD.

CVD can make it difficult to work full-time due to decreased stamina and fatigue, and to carry out activities of daily living such as household chores. Dizziness makes it difficult to stand or sit for prolonged periods of time and can occur when getting up from sitting positions or sitting down from standing positions. Gross motor limitations result in problems with ambulation, balance, coordination, climbing, walking, sitting down, pulling up to stand, and crawling. Fine motor limitations cause problems with carrying out a variety of independent living and vocational tasks such as bathing, brushing teeth, eating with utensils, fastening buttons, tying shoelaces, preparing meals, writing with a pen or pencil, drawing, typing on a keyboard, twisting doorknobs, and playing a musical instrument (Cleveland Clinic, 2025; JAN, 2025).

Memory problems and other cognitive impairments can interfere with performing job and daily living tasks. Individuals may forget scheduled appointments, when to take medications, where home and job tools are located, and steps in instructions for completing tasks. They may have difficulties interacting with co-workers, family members, and friends due to mood changes, erratic behaviors, and speech impairments. If they have paresthesia or paralysis, walking will be difficult, and they may need assistive devices to help them ambulate.

Numerous medical appointments and long periods of recovery from medical procedures can interfere with daily activities such as household chores, spending time with family and friends, hobbies, and employment. It can also be challenging for some individuals with CVD to get to medical appointments, especially if they are medically restricted from driving, unable to drive, lack a strong social support system to assist with taking them to appointments, or reside in areas where public transportation or accessible transportation services are not available. Their symptoms can necessitate prolonged absences from work or flexibility in scheduling so they can attend doctors’ appointments or participate in other treatment regimens to manage their illnesses (Falvo & Holland, 2018; JAN, 2025). Co-occurring medical conditions and medication side effects can result in additional functional limitations.

Treatment

CVDs are treated using a variety of modalities, depending on the type of condition. These include medications, surgical procedures, allied health services, and medical devices. Individuals often require multiple modalities to treat their CVDs. Examples of common medications used to treat CVDs include the following (AHA, 2025). Embolizing agents are blood clotting medications delivered by catheters to stop the flow caused by hemorrhagic strokes. Anticoagulants such as Warfarin decrease the clotting ability of the blood in the blood vessels or prevent clots from becoming larger and creating more serious complications. Anti-coagulants are often used to treat ischemic strokes. Anti-coagulants are also used to prevent first or recurrent heart attacks or strokes. Although anti-coagulants are colloquially known as blood thinners, they do not actually thin the blood.

Antiplatelet agents, aspirin being the best known, although there are many others, stop blood clotting in conditions such as heart attack, unstable angina, ischemic strokes, and transient ischemic attacks. They are used preventively when plaque is found in the arteries but have not built up enough to form blockages. They can also be used for people who have stents and a high risk of bleeding. For those with stents, antiplatelet agents can also reduce the risk of future heart attacks and prevent clotting.

Angiotensin-converting enzyme (ACE) inhibitors relax and widen blood vessels, lower blood pressure, and improve the heart's ability to pump blood. ACE inhibitors are used to treat CVDs such as high blood pressure and heart failure. Beta blockers are used because they can lower blood pressure, slow how fast the heart beats, and improve the heart's ability to pump blood. Beta blockers treat CV conditions and risk factors such as high blood pressure, angina caused by reduced blood flow to the heart muscle, and some abnormal heart rhythms. For people who have already had heart attacks, beta blockers can also prevent recurrences.

Statins decrease LDL (bad) cholesterol levels to prevent more plaque from building up in the arteries. If statins do not work or if individuals cannot tolerate their side effects, other medications that lower cholesterol may be used. Diuretics (water pills) help the body to eliminate sodium and excess fluids through urination. Diuretics help to reduce blood pressure and excessive swelling due to fluid build-up in parts of the body, such as the ankles and legs.

Vasodilators (e.g., nitroglycerine) widen the blood vessels in the heart to increase the supply of blood and oxygen and reduce the heart's workload. Vasodilators are used to relieve chest pain, treat heart attacks, and treat high blood pressure, including high blood pressure during pregnancy. Nitroglycerine transdermal patches are applied to the skin to prevent angina.

Arrhythmia medications are prescribed to patients who have had bypass surgery because irregular heartbeat often occurs after these surgeries. Surgical procedures are sometimes necessary. Some are minimally invasive while others require open heart surgery. The AHA (2025) provides examples of procedures, including coronary artery bypass, balloon angioplasty, valve repair and replacement, heart transplantation, and artificial heart operations. Readers are referred to AHA (2025) for more detailed information and descriptions of additional procedures.

Heart attacks and strokes are acute events that can result from blocked arteries and veins and need to be promptly treated to reduce long-term disability. Minimally invasive procedures, such as angioplasty and stent placement in blocked arteries and veins, open them up to increase blood flow. Angioplasty is a procedure that is used to open up blood vessels to improve blood flow to the heart that has been partially or completely obstructed by plaque build-up. Balloon angioplasty is the insertion of a balloon into a catheter, insertion of the catheter through the vessel that is obstructed, and then inflation of the balloon to press the plaque against the arterial wall and allow the blood to flow through the artery. A stent, which is a tubular device that works like a scaffold keeping the blood vessel open, may be used along with angioplasty (AHA, 2025; Medline Plus, 2024).

Medical devices for the treatment of cardiovascular conditions include pacemakers, prosthetic valves, heart defibrillators, and patches to close holes in the heart. For individuals with heart arrhythmias (i.e., disorders that cause the heart to beat too fast, too slow, or irregularly), pacemakers or defibrillators can be implanted in the abdomen or chest. Pacemakers discharge electrical pulses to stimulate the heart to beat at a regular rate and to coordinate the chambers of the heart (MedlinePlus, 2024). Implantable cardio defibrillators (ICD) monitor heart rhythms and deliver shocks to the heart if the ICD detects dangerous, life-threatening arrythmias. ICDs can prevent sudden cardiac arrest, and some operate as both a pacemaker and a defibrillator. The implantation of pacemakers and defibrillators is a minimally invasive procedure requiring only one- or two-night stays at the hospital to ensure devices are working correctly. Heart transplants are used to replace a badly damaged heart with one from a deceased donor and require a long recovery period.

New diagnostic tools, medications, and treatment interventions continue to be available, and clinical trials are ongoing. For a complete list and description of all types of CVD, diagnostic tools, medications, devices, and surgical procedures, readers are referred to AHA (2025) and other references cited in this article.

Cardiac Rehabilitation

Cardiac rehabilitation programs help patients to (a) regain autonomous functioning through exercise programs, (b) control modifiable risk factors through psychoeducation, and (c) manage psychiatric conditions like anxiety and depression through learning stress management techniques (Mampuya, 2012). Cardiac rehabilitation is a physician-supervised, structured program that uses a comprehensive interdisciplinary approach. Cardiac rehabilitation can be delivered on an in-patient basis or out-patient visits, and participants can learn strategies and activities that they can implement at home to continue the benefits of services over time.

Psychosocial Implications

The psychosocial challenges for individuals with CVDs are not surprising given that these individuals often experience multiple symptoms, significant functional impairments, co-occurring physical and psychiatric conditions, and societal stigma (Falvo & Holland, 2018). Psychological distress, including fears and anxieties about one's personal safety and possible death, can stem from the chronic, episodic, and sometimes life-threatening nature of these conditions. Fears related to dying can occur among those who have had a heart attack, stroke, or emergency surgical procedures. Some individuals with these conditions may even be suicidal if they have experienced an overwhelming sense of powerlessness, hopelessness, isolation, or chronic pain.

Smart (2020) noted that, especially in our health-conscious society, individuals with disabilities that are linked to unhealthy behaviors (e.g., smoking, eating unhealthy foods, excessive alcohol consumption, failure to exercise) are often viewed by others as weak, lazy, or irresponsible. Even individuals with CVDs who do not participate in unhealthy behaviors may be treated with antipathy. Resentment toward these individuals is often verbalized by family members, neighbors, and co-workers. Individuals with CVDs are often blamed by others for raising health care premiums, usurping scarce medical and healthcare resources, and increasing the costs of disability that are incurred by taxpayers (Smart, 2020). Blame from others may be internalized as self-blame that undermines the willingness of people with CVD to participate in activities to manage their conditions (Koch & Rumrill, 2017).

On the other hand, some individuals with CVDs experience a vast improvement in their overall quality of life after treatment, surgery, or cardiac rehabilitation. Sometimes, the experience of feeling like they have endured a close call with dying can prompt people to make major adjustments to their lifestyle (e.g., quit smoking, eat healthier foods, exercise). They may also re-evaluate their lives, asking themselves, “Am I doing what brings me the most satisfaction?” Then, they may begin to participate in activities that bring them greater life satisfaction such as starting new careers, moving closer to extended family, retiring, spending more time socializing, and traveling.

Vocational Implications

People with CVDs experience a wide range of functional limitations and psychosocial adjustment issues that can substantially interfere with their ability to work. Their symptoms can necessitate prolonged absences from work or flexibility in scheduling so they can attend doctor's appointments or participate in other treatment regimens to manage their illnesses (Falvo & Holland, 2018; JAN, 2025). The symptoms associated with fatigue, poor oxygenation of the blood, and medication side effects can create additional impediments to performing essential job functions. Co-occurring depression can lead to absenteeism, impairment in completing cognitive tasks, and presenteeism (i.e., loss of productivity due to working while sick). Other employment barriers for rehabilitation consumers with CVD include negative reactions and workplace discrimination on the part of co-workers and employers; mistreatment and discrimination based on other characteristics of these individuals (e.g., race, gender, age); limited access to on-the-job accommodations; and unawareness of VR services to support job retention (Rubin et al., 2016).

Outreach and Eligibility Determination

Many individuals with CVD do not consider themselves people with disabilities, which behooves VR counselors to employ pro-active outreach strategies with health care providers who serve people with CVDs (e.g., cardiologists, heart and lung clinics, acute- and post-acute care facilities; Koch & Rumrill, 2017). These providers may not be familiar with VR services that are available in their communities. Therefore, VR counselors must educate these providers by attending staff meetings to briefly speak about their programs, leaving brochures to be put in waiting rooms and examination rooms, meeting individually with providers, and conducting presentations at professional conferences. Additionally, the fact that many people with CVD often have other co-occurring conditions requires vigilance on the part of VR counselors to ensure that intake interviews include a full account of the impact that the person's overall medical and psychological condition has on their functioning. Understanding consumers’ overall health and its impact on their lives facilitates eligibility decisions that incorporate consideration of the individual's entire set of rehabilitation needs rather than focusing on one diagnosis. For example, an applicant for services who has CVD may also have type II diabetes, obesity, a substance use disorder, amputations, hypertension, psychiatric disabilities, and/or metabolic syndrome – which could put them at risk for heart attacks or stroke, respiratory problems, and orthopedic impairments, all of which must be taken into consideration when determining eligibility for services and rehabilitation needs. It is also of the utmost importance that VR counselors make appropriate referrals when seeking diagnostic testing, medical examinations, and psychological evaluations to aid in making eligibility determinations and developing rehabilitation plans. Finally, despite the common co-occurrence of depression and anxiety with CVDs and the availability of mental health screening tools, depression and anxiety often go unrecognized and untreated. Cardiologists rarely screen for depression, although research indicates that as many as 45% of individuals with CVDs experience depression or depressive symptoms (Mayo Clinic, 2024). Moreover, some medications for CVDs can increase psychological reactions such as agitation, hallucinations, depression, and suicidal thinking (Cleveland Clinic, 2025).

Assessment and Planning

Many individuals with CVDs have both the desire and the capability of returning to their jobs or entering new employment. The chronic, unpredictable, and often progressive nature of CVD requires that assessment and planning geared toward seeking, securing, and maintaining employment follow a cyclical rather than linear process. Assessments of client progress must be conducted throughout the initial and direct service phases of the VR process, and the individualized plan for employment (IPE) must be adjusted as needed to reflect emerging assessment data.

Of paramount importance in career planning is adhering to medical treatment plans and implementing disease self-management strategies to prevent worsening or re-occurrence of consumers’ conditions. They must take medications or use medical devices as prescribed. They must maintain their health by eliminating mutable risk factors. To do so requires smoking and vaping cessation; eating healthy foods with low sodium, sugar, and cholesterol; and engaging in exercise as prescribed by physical therapists in CVD rehabilitation programs. Social support is also necessary to assist individuals with recovery, encourage them in changing unhealthy behaviors, and provide them with emotional support as they adapt to returning to work or entering new employment. Family involvement in rehabilitation planning and the involvement of others of importance in the consumer's life can be key to ensuring that individuals with CVD achieve their health and employment goals.

Co-occurring conditions must be carefully considered in formulating the IPE. In addition to medical barriers, psychosocial barriers such as depression and anxiety, a low degree of willingness to make lifestyle changes, and societal as well as internalized stigma must be addressed. To develop plans that are most likely to result in the achievement of rehabilitation goals, VR counselors must conduct extensive intake interviews to identify all barriers and resources (both internal and external) that need to be addressed in planning (Koch & Rumrill, 2017; Rumrill & Koch, 2021).

It is important to remember that VR counselors are not immune to the biases about people with CVDs that are frequently held by the general public. Counselors must be reflective about how they feel about individuals who engage in health-compromising behaviors and habits (e.g., smoking, substance abuse, sedentary lifestyle, poor eating habits) that are CVD risk factors (Koch & Rumrill, 2017). One strategy for VR counselors to develop their awareness is to take inventory of their own unhealthy and risky behaviors along with the experiences (or lack thereof) of trying to change behaviors that could cause disability or chronic illness. This could build added empathy and insight into the self-management experiences of their customers who have CVDs (Rumrill et al., 2019).

Living in poverty is a well-documented risk factor for CVD (Mayo Clinic, 2024). Therefore, VR counselors should be prepared to assess a client's needs for referrals to community agencies that can assist with food security, access to clean and abundant water, shelter, rent subsidy, home repairs, transportation, safety, access to healthcare (including mental health services), childcare, and other important matters.

Counseling and Guidance

Responding to consumers’ mental health needs is just as important as it is to respond to their physical health needs. When individuals with CVD experience co-occurring depression, anxiety, or substance use disorders, referrals to mental health professionals become important. However, VR counselors must keep in mind that, for individuals with conditions that are highly stigmatizing, the mere mention of mental health services may be interpreted as the VR counselor being judgmental or even blaming them for their condition (Koch & Rumrill, 2017). Therefore, when recommending mental health services for these consumers, readers must be cautious to communicate that the purpose of these services is not to diagnose and treat them for a psychosomatic condition, but rather to (a) validate that psychological distress is a common reaction in response to serious, potentially life-threatening health conditions; (b) support them in processing normal emotional responses; (c) help them to identify coping resources and supports; and (d) treat co-occurring mental health conditions that may arise.

Despite the potential severity of CVDs, changing one's lifestyle to control modifiable risk factors can mitigate severe and even deadly outcomes and result in significant gains in one's quality of life. Therefore, tailored counseling and guidance focused on supporting consumers to effectively manage their risk factors is a critically important VR-related service. This service will increase the likelihood that individuals with CVD can maintain or return to employment that includes health insurance so that these individuals do not have to make difficult choices about paying for healthcare or financially supporting themselves and their families.

People with CVDs should also be referred to appropriate support groups, self-management education programs, and self-help literature to put their personal experiences into perspective, reduce feelings of isolation and alienation, and learn coping strategies and other approaches to better manage their conditions. The incident that precipitated the CVD may have been traumatic for the individual, so screening for post-traumatic stress disorder (PTSD) and applying trauma-informed care principles is an important element of VR-sponsored counseling and guidance. It is also important to note that CVDs affect the person's entire family and social support system, so relationship counseling and other supports that take family dynamics into account may be necessary aspects of mental health services (Smart, 2020).

Job Development, Placement, Retention, and Accommodation Planning

Individuals with CVD often experience challenges as they seek to enter or re-enter the workforce. Job applicants and incumbent employees can encounter negative reactions from both employers and co-workers (e.g., ignoring their requests for accommodations, responding to requests with hostility or harassment, treating these workers with incivility) when they disclose their disabilities and make accommodation requests (Rumrill et al., 2013). In the job development and placement process, workplaces that are inclusive and promote the health and well-being of their employees should be targeted. In addition to conducting job analyses, assessment of the organizational cultures of potential workplaces is necessary. Workplace policies and procedures should be examined to determine if these promote inclusion; healthy work environments; flexibility in how and where work is performed; teamwork; appreciation of diversity; and intolerance of harassment, workplace bullying, and incivility (Glade et al., 2020). Then, observation of interactions between co-workers and interviews with employers and employees about the workplace culture will provide the consumer and VR counselor with additional evidence of the setting's attitudinal accessibility.

It is important to keep in mind that traditional full-time placement at an established job site could exacerbate symptoms, worsen conditions, or impair the overall health and functioning of some individuals with CVD. In these cases, alternatives such as telecommuting and home-based employment may need to be considered (Strauser, 2021). Fortunately, many employers are beginning to provide these opportunities to their employees because of the cost-effectiveness of these options (JAN, 2025). VR counselors can educate employers who do not provide their employees with these alternatives about the ease and cost-effectiveness of telecommuting and working from home.

In job development and placement, employers often need to be educated by the employee, the rehabilitation counselor, or both about CVD in the workplace. Employers may have their own biases and misunderstandings about the functional limitations associated with CVD and how accommodations (most of which are no cost or very inexpensive and can benefit all workers) are not an act of favoritism on the part of the employer but are provided to enable these individuals to be productive, reliable, and competent employees (Rubin et al., 2016). Co-workers, especially those who will be working most closely with the individual, are also likely to be unaware of the individual's disability-related needs.

The accommodation planning process with people who have CVD is likely to be a complex endeavor because of the multitude of functional limitations these individuals may experience, compounded by the extent of negative stereotypes and stigma promulgated by both the medical community and society at large. Steps that can be taken to better ensure that necessary accommodations will be implemented include (a) educating individuals about the employment protections afforded by the Americans with Disabilities Act (ADA) and other legislation; (b) engaging in a collaborative process of identifying workplace barriers and accommodation needs; and (c) assisting individuals to develop the self-advocacy and communication skills to request, implement, and evaluate accommodations (Roessler & Rumrill, 2015). Also, depending on the nature of the job and the consumer's functional limitations, some individuals may be able to self-accommodate.

Due to the fact that individuals with CVD may not consider themselves to have disabilities, the first step in accommodation planning is to educate them about how legislation such as the ADA defines disability and protects their rights related to securing, maintaining, and advancing in employment (Rubin et al., 2016). Additionally, because many of these individuals have hidden disabilities and have encountered negative reactions when disclosing their disabilities to others, VR counselors should carefully listen to their concerns about disclosure and past negative experiences related to disclosure. VR counselors can then explore with them the advantages and disadvantages of disclosure, the circumstances under which disclosure may be advantageous, how and when to disclose, and to whom to disclose (Rumrill et al., 2013).

JAN (2025) is a helpful resource for accommodation planning. Through their website, rehabilitation professionals, consumers, and employers can learn about the functional limitations associated with CVD as well as possible accommodations. Among the accommodations, JAN recommends for CVD are work from home, flexible scheduling and work leave, ergonomics, elimination of physical exertion, and service animals to address decreased stamina and fatigue. For dizziness and light-headedness, JAN recommends additional breaks, avoidance of prolonged walking (e.g., through accommodations such as accessible parking and workspaces near elevators), chairs with armrests and locking casters so they can get up without experiencing dizziness or light-headedness, and alternation between standing and sitting. Ergonomics, lifting and reaching devices, stand/lean stools, grab aids, mobility devices, and service dogs are recommended accommodations for temporary or long-term gross motor limitations. For fine motor limitations, recommendations include speech recognition software, alternative mice that are easier to grab and manipulate, grip aids, and reachers. Time off to attend medical appointments or recover from medical procedures is recommended, as is work from home, flexible scheduling, and leave. If individuals are temporarily restricted from driving after medical procedures, they might be able to find a co-worker to give them rides to work. Otherwise, VR agencies can provide transportation assistance by paying neighbors or families to give them rides or to purchase Lyft services.

Many individuals with CVD have functional limitations that change over time, or they experience changes to their work environments that may impact their capacity to continue working (e.g., the addition of new equipment, the hiring of new supervisors, remodeling of workplaces that could introduce new barriers that could impair the ability of workers with CVD to maintain their employment; Koch & Rumrill, 2017). Readers are referred to Roessler et al. (2018) for information about the Work Experience Survey (WES), a valid and reliable assessment tool that has been used by individuals with different disabilities and chronic illnesses and is applicable to the accommodations planning process for those with CVD as well. The potential application of the WES for use with individuals with CVD is promising because it can be used for periodic reassessment of their accommodation needs as their symptoms improve or worsen over time.

In his description of the RETAIN Kentucky statewide return to work and stay at work intervention that concluded in 2025 after serving more than 3,200 Kentucky residents with mid-career disabilities, Stapleton (2024) underscored the importance of follow-along services to address workers’ changing accommodation needs over time, services that go beyond traditional case closure timeframes (up to six months in the case of RETAIN Kentucky), and close monitoring of the worker's health status by medical and mental health professionals as keys to long-term employment success for people with disabilities in the COVID-19 era. The Crux model of vocational case management developed by Roessler et al. (2018) provided the basis for the RETAIN Kentucky intervention, and it featured a cyclical rather than linear process of consumer assessment, case planning, and service delivery that allows for changes to the return to work plan as the consumer's needs change in the present era of rapidly shifting economic, political, workforce, and public health dynamics. In RETAIN Kentucky, the Crux model was driven by a triage approach whereby employers, VR professionals, and healthcare providers worked collaboratively to address the worker's health-related and vocational needs in a unified fashion. Of course, the worker with CVD or other disability is the conductor of the planning and service delivery process, which is guided entirely by the person's stated return to work or stay at work goals.