Predictors of employment outcomes among supported employment program participants with spinal cord injury

1 Introduction

In 2016, spinal cord injury (SCI) affected approximately 282,000 persons (range 243,000–347,000) in the United States, with about 17,000 new injuries per year (National Spinal Cord Injury Statistical Center (NSCISC), 2016). Since the 1970s, the age at injury has been trending upwards, with average age increasing from 29 to 42 years of age at the time of injury. Although less common than some other disabling neurologic conditions such as cerebrovascular accident, SCI has a disproportionately large economic impact for several reasons. A major factor is that most persons with SCI are of working age at the time of injury. The physical sequelae of SCI are numerous and co-occurring with permanent, life-altering physiological changes, including pressure wounds, neurogenic bowel and bladder, spasticity, and neurogenic pain in addition to paralysis. Furthermore, both mental health diagnoses and traumatic brain injury are frequent co-morbidities in those with SCI (Budisin et al., 2016; Elovic & Kirschblum, 1999; Macciocchi, Seel, Warshowsky, Thompson, & Barlow, 2012). Despite these catastrophic consequences, many persons with SCI want to work and judge themselves capable of work (Tomassen, Post, & van Asbeck, 2000; Young & Murphy, 2002). Like most, persons with SCI have much to gain through employment, including increased economic self-sufficiency, higher life satisfaction, and improved health status and psychological well-being (Meade, Reed, Saunders, & Krause, 2015). In fact, occupation is one of the highest rated needs by people in the community living with SCI (Kennedy, Lude, & Taylor, 2006).

Despite the known benefits of work, many of which maximize social participation, employment rate following SCI has been historically low. Although there are many studies of factors related to employment following SCI, little is known about what factors predict outcomes of employment interventions for persons with SCI. A recent systematic review of factors associated with employment outcomes following SCI identified 20 modifiable and 12 non-modifiable factors (Trenaman, Miller, Querée, & Escorpizo, 2015). The following modifiable factors have been consistently and independently associated with employment outcome: education, vocational rehabilitation, functional independence, social support, and financial disincentives. In a retrospective evaluation of employment history of 238 veterans with SCI, Mobility and Occupation subscale scores on the Craig Handicap Assessment and Report Technique (CHART) were higher for those who were employed, however, depressive symptoms and self-assessed, health-related quality of life did not differ significantly between employed and unemployed veterans (Ottomanelli, Sippel, Cipher, & Goetz, 2011). Receipt of Social Security benefits was a disincentive for employment, but military service disability benefits (i.e., Veterans Affairs benefits) were not. Notably, in this group, neither education, gender, ethnicity, nor severity of injury predicted employment status. In other studies, race was not a predictor nor was severity of injury (Krause & Anson, 1996; Meade et al., 2015). Collectively these findings suggest personal factors may outweigh factors related to injury severity.

While factors associated with employment following SCI are well identified, the field lacks empirical data on what factors predict positive employment outcome from vocational rehabilitation interventions. This knowledge gap is, in large part, due to the lack of research on intervention effectiveness in SCI (Trenaman, Miller, & Escorpizo, 2014). Indeed, to date there has only been one randomized controlled trial of vocational interventions in SCI. The results of that randomized clinical trial (RCT), referred to as the Spinal Cord Injury Vocational Integration Program (SCI-VIP) study, demonstrated that the Individual Placement and Support (IPS) model of supported employment (SE) significantly improved employment rates of persons with SCI when compared to conventional vocational rehabilitation practices (Ottomanelli et al., 2012; Trenaman et al., 2014). Participants in the study who obtained employment had higher levels of social integration, community mobility, and time spent in productive roles (Ottomanelli, Barnett, & Goetz, 2013). A longitudinal, observational follow up study of IPS in SCI centers of the Veterans Health Administration (VHA) showed 24 months of IPS yielded a 43.2% employment rate (Ottomanelli et al., 2017). The study sample was heterogeneous and reflected typical veterans with SCI treated as either inpatients or outpatients. Veterans with a lifetime or current history of psychiatric diagnoses or traumatic brain injury (TBI) were also included. Among a sub-sample of persons who started IPS as outpatients and who had no history of TBI, the employment rate was greater than 50%. To date, there are no published studies that examine factors associated with positive employment outcomes among persons with SCI receiving IPS services.

IPS was originally developed for those with serious mental illness (SMI), and several studies identified factors associated with outcomes in this population. In an international, 6-center RCT of employment for people with SMI, those with a history of work, unmet social needs, and better relationships with their vocational workers were more likely to both obtain and sustain employment (Burns et al., 2007, 2009). These data suggested that satisfaction with current life circumstances may decrease motivation to work. In a regression analysis of four recent RCTs of IPS among persons with mental illness, work history was the only significant predictor for obtaining a job among those receiving IPS. In this study, Supplemental Security Income (SSI), with or without Social Security Disability Insurance (SSDI), was associated with fewer total weeks worked (Campbell, Bond, Drake, McHugo, & Xie, 2010). With other types of vocational services (not IPS), persons with less severe psychiatric disorders (e.g., mood disorders or fewer psychotic symptoms) were more likely to obtain competitive employment. Work history being the only significant predictor of employment outcomes with IPS challenges the notion of using mental health diagnosis, current psychiatric symptoms, or substance use disorders as exclusion criteria for IPS services. That is, perceived “high-risk” clients can benefit from IPS and should be eligible for services. As the sample excluded persons with SMI who had medical conditions “that would preclude working or participating in assessment interviews,” this study does not shed light on how physical symptoms impact IPS outcomes either alone or in combination with mental health disorders.

A recent secondary analysis of unemployed SSDI beneficiaries with mental illness also found work history to be the strongest predictor of employment (Metcalfe, Drake, & Bond, 2017). Interaction between treatment group and work history indicated IPS benefited those without a recent job history (previous 2 years) more than those with a recent work history. The study also showed that fewer physical problems, as measured by the Short Form Health Survey (SF-12), was a modest predictor of securing competitive employment. Other modest predictors of obtaining competitive employment were fewer years of receiving disability benefits and Hispanic ethnicity. This research suggests that IPS may compensate for poor work history and supports the principle of basing eligibility for services on desire to work rather than factors related to disability. In a brief report of a similar population, the top three provider-rated barriers to employment were general medical problems, uncontrolled psychiatric symptoms, and poor engagement in SE services (Milfort, Bond, McGurk, & Drake, 2015). Therefore, work history is the most consistent predictor of employment outcome in the mental health literature. Physical symptoms may also play a role in outcomes but the significance of their impact remains understudied and merits furtherattention (Metcalfe et al., 2017).

Predictors of response to employment interventions have not been studied among a medical population of persons with physical disabilities and other co-morbidities. The objective of the present study is to explore whether there are client factors associated with employment outcomes in persons with SCI who participated in a 24-month IPS program. We hypothesized that work history and factors related to medical issues and handicap (supports) would be associated with employment outcomes.

2 Methods

A secondary analysis was conducted on data from a longitudinal observational study of IPS for veterans with SCI that extended the work of a previous RCT with the same population (Ottomanelli et al., 2012, 2013). The Predictive Outcome Model Over Time for Employment (PrOMOTE) was a prospective, multi-site project evaluating employment history, quality of life, and economic outcomes in SCI. The study had local institutional review board approval. As details of both studies have been previously reported (Ottomanelli et al., 2009, 2012, 2017), this report provides only an overview of those methods. For the purposes of this analysis, examined factors included:

Sociodemographic: age, gender, educational history, and work experience;

2.1 Subjects and settings

The study population was veterans receiving inpatient or outpatient medical or rehabilitative care at SCI centers within Veterans Affairs Medical Centers (VAMCs) (n = 7) from interdisciplinary SCI care teams. That is, veterans with new spinal cord injuries receiving acute inpatient rehabilitation, veterans with chronic SCI receiving inpatient medical care, or veterans with chronic SCI who received outpatient healthcare were eligible to enroll in the study. Inclusion criteria for a baseline interview on employment, health, and quality of life were (1) 18 to 65 years of age and (2) medically and neurologically stable. To qualify for enrollment in the IPS supported employment program, veterans had to meet the following additional criteria: (1) not currently have a paying job in the community, (2) express a desire to be employed, and (3) live≤100 miles from the hospital. Veterans with untreated psychosis, untreated alcohol or drug dependence, or a terminal illness were ineligible for IPS. Of the 1047 veterans who enrolled in the study and completed baseline interviews, 279 met eligibility and enrolled in the IPS SE program. Of these, 213 had not participated in the previous RCT and are included in this outcomes analysis (n = 213) (Fig. 1).

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Fig.1

PrOMOTE study IPS SE enrollment.

3 Results

The purpose of this paper was to examine factors that predicted employment outcomes among IPS participants with SCI who were receiving VHA healthcare, a population with the primary physical disability of SCI but which also included comorbidities such as TBI and mental health conditions. Individual factors that were significant predictors of employment included education, work experience, injury level, inpatient days, TBI history, transportation, and mobility. When these factors were examined in combination, only a work history after the SCI and number of inpatient hospital days remained significant predictors of competitive employment with IPS. Hence, a careful examination of broad domains of sociodemographic, clinical, and social supports did not find many limitations that significantly impacted employment outcome except for two specific factors. This finding supports the basic SE IPS tenet of zero exclusion, which asserts that persons with significant disabilities who want to find competitive employment in the community can benefit from IPS, regardless of level of disability.

In terms of the specific factors that influenced outcomes, the results are consistent with findings from the mental health field – work history is a strong and consistent predictor of IPS employment outcomes. In our sample, work experience after injury predicted positive outcomes, more so than being employed at the time of injury. While the co-morbidity between mental health and medical conditions is acknowledged (Craig, Tran, & Middleton, 2009; Druss, Zhao, Von Esenwein, Morrato, & Marcus, 2011), this was the first study to examine response to IPS employment interventions among a medical rehabilitation population. Among this sample, the longer IPS participants spent in the hospital, the less likely they were to obtain employment. Thus, prolonged hospitalization interferes with the ability to explore opportunities for competitive employment and participate in job development. While hospitalization to optimize medical and rehabilitation goals should not be curtailed, minimizing hospital stay once goals are achieved may be an appropriate goal of IPS services for persons with SCI. Inpatient hospitalization had greater impact on employment outcomes than severity of injury, number of medical problems, or mental health indicators. However, the number of medical complications may not fully reflect the intensity and impact of complications on well-being; an alternative explanation of this finding could be that inpatient hospitalization is a surrogate for severity of medical complications that interfere with obtaining competitive employment.

It is unclear why working at the time of injury was not significant when all predictors were combined, yet post-SCI work experience was a unique predictor of employment outcomes from IPS. Research suggests that after SCI, occupational interests change and become more compatible with the limitations of SCI (Krause & Clark, 2014). That is, post SCI rehabilitation, more realistic appraisals emerge and people may be more open to other occupational fields rather than maintaining interest in previously held positions, which in many cases may have been more physically demanding or traditional jobs. On average, our sample had been living with SCI for over a decade. From a clinical perspective, vocational providers used knowledge gained from post-SCI work experience to inform vocational plans and job searches. Hence, employment interventions were better targeted to an individual’s disability-specific barriers. Another explanation is some individuals may acquire employment post-SCI but not retain it on their own or with limited vocational assistance and need more intensive IPS follow along support services to sustain employment successfully. As this study did not examine factors such as duration of employment or prior vocational rehabilitation, more research is needed to explore this possibility. Clearly, hospital inpatients are less able to participate in community-based employment services such as job development and placement, which are most often linked to positive employment outcome (Ottomanelli, Barnett, Goetz, & Toscano, 2015).

As expected, physical functioning, whether reflected by level of motor and/or sensory impairment (clinical) or by mobility (supports), influenced IPS outcome. Inpatient hospitalization having a stronger effect emphasizes the importance of vocational and healthcare teams working together to optimize health so that individuals can participate in outpatient care and address employment in the community. In term of cognitive factors, TBI history was a modest predictor in the initial model but did not remain significant when combined with other factors. In our earlier report of employment outcomes, participants with SCI who enrolled in IPS as inpatients with a TBI history had worse outcomes than those enrolled as outpatients without a history of TBI (Ottomanelli et al., 2017). Interventional employment studies that include individuals with both conditions are rare, and the complex relationship awaits better elucidation to help inform employment interventions. Certainly, TBI alone exerts a serious impact on return to work, and SE is recognized as a best practice in the field for the TBI population (Wehman, Targett, & Avellone, 2017). Further examination of the SCI and TBI dual diagnosis population with measures of cognitive impairment rather than history of brain injury or examining the severity of the TBI in relation to outcomes may produce more significant and clinically relevant findings for these complex co-occurring conditions.