Vocational rehabilitation factors associated with successful return to work outcomes for clients with Parkinson’s disease

Abstract

PURPOSE:

This study investigated the extent to which demographic characteristics, receipt of Social Security benefits, and vocational rehabilitation (VR) services influence competitive employment outcomes for people with Parkinson’s Disease who were unemployed at the time they enrolled in the state-federal Vocational Rehabilitation (VR) program.

METHOD:

The Rehabilitation Services Administration’s Case Service Report (RSA-911) database for Fiscal Year 2014 was examined using a purposeful selection logistic regression analysis.

RESULTS:

Results indicated that participants who received on-the-job support (both short-term and long-term), job placement, maintenance, and college or university tuition assistance from the VR program were significantly more likely to achieve competitive employment than were participants who did not receive those services. Participants who received assessment services were less likely to achieve competitive employment than were those who did not receive assessment services. In addition, receiving a greater number of VR services over a shorter period of time and not receiving Social Security disability benefits were positively associated with competitive employment outcomes.

CONCLUSION:

Overall, the number and type of VR services received had more influence on competitive employment outcomes than did client demographic variables.

Keywords

Parkinson’s disease vocational rehabilitation employment outcome supported employment rehabilitation services administration

1 Introduction

Parkinson’s disease (PD) is a chronic, progressive, multisystem neurodegenerative disorder. The combination of motor and non-motor symptoms can dramatically affect daily functioning, established roles, community participation, and quality of life (O’Sullivan, 2007; Schrag & Banks, 2006). Although the median age at onset of PD is roughly 62 years (National Parkinson’s Foundation [NPF], 2017), 35% of PD diagnoses are made before the age of 65 (Wickremaratchi et al., 2009) and roughly 10% of people with PD are diagnosed between 21 and 55 (Schrag & Schott, 2006). Due to age being the main risk factor, PD typically affects people who are nearing the nadir of their careers and preparing to exit the workforce; however, the U.S. Bureau of Labor Statistics (BLS, 2013) estimated that the percentage of Americans aged 65–74 in the workforce will rise to 31.9% by 2022— a 20% increase from 2012 (26.8%). Taken together, a desire to either remain in the workforce longer or to return to work and the projected 100% growth rate of people with PD in the workforce by 2030 (Dorsey et al., 2007) make it reasonable to expect that individuals with PD may be able to benefit from vocational rehabilitation (VR) interventions in larger numbers for the foreseeable future.

Although the cardinal motor features of PD (i.e., bradykinesia, muscular rigidity, rest tremor) are problematic, the commonly reported non-motor features of depression, anxiety, cognitive dysfunction, and fatigue may contribute more to one’s reduced working capacity and, therefore, premature exit from the workforce (Martikainen et al., 2006). Given the paucity of research on PD and employment (Banks & Lawrence, 2006; Blalock et al., 2002; Jasinka-Myga et al., 2012; Martikainen et al.; McDaniels, 2018), one could conclude that individuals with PD may leave the workforce earlier than their unaffected peers; however, employment barriers faced by people with PD are not well understood. This is not surprising given the fact that employment for individuals with PD has not been identified as a priority of health care professionals (Frech & Damaske, 2012). This lack of interest in employment for individuals with PD is troubling due to the well-documented positive benefits of working for individuals with chronic illness (e.g., improved mental health, decreased depression, lower anxiety, improved psychosocial functioning, improved quality of life; Dutta et al., 2008; Frese & Mohr, 1987; Goldblum & Kohlenberg, 2005; Koerts et al., 2016; Koch et al., 2001; McDaniels; Prause, & Dooley 2001; Shamir, 1986).

The state-federal Vocational Rehabilitation (VR) program is the nation’s largest provider of employment supports for Americans with disabilities and is available to people with PD and other disabling conditions in all 50 states and the United States territories (Rehabilitation Services Administration [RSA], 2013). This program provides a wide range of services focused on integrated competitive employment, including assessment, job placement, on-the-job support, vocational and rehabilitation counseling, job search assistance, and assistive technology (Rubin, Roessler, & Rumrill, 2016). Any individual with a disability who can benefit from these services and who requires assistance to prepare for, enter, engage in, or retain gainful employment is eligible to participate in the VR program. Recipients of Social Security Disability Benefits are presumed to be eligible for VR services if future employment is feasible following receipt of services.

Research is extremely limited regarding the effectiveness of VR services in promoting successful employment for people with PD. It is likely, however, that people with PD would benefit from the same services that benefit other VR consumers (e.g., advocacy, accommodations, flexible schedules). Parkinson’s disease diagnoses are steadily increasing, and the fact that many of these individuals have extensive employment histories means that people with PD constitute a potentially valuable labor resource for American employers. Of particular interest in this study are VR services and supports that are required to help unemployed people with PD enter or, in most cases, re-enter the workforce in jobs commensurate with their skills, experience, and desires.

1.1 Purpose of the study

In an effort to better understand the VR-related factors that influence return-to-work outcomes for clients with PD, the present study utilized the most recently available data from the US Department of Education’s Rehabilitation Services Administration (RSA-2013) Case Service Report (RSA-911) database. The specific purpose of this study was to investigate the relationship between client demographic variables, receipt of Social Security disability benefits, and VR service-related variables and employment outcomes for people with PD who were unemployed at the time they enrolled in the state-Federal VR program.

2 Method

2.1 Participants

The sample in this study consisted of 673 clients with a self-reported PD diagnosis whose VR cases were closed as either successful (i.e., competitively employed in integrated community employment settings after receiving services) or not successful (i.e., not employed after receiving services). To be included in the study, participants had to (a) have a primary diagnosis of PD; (b) be unemployed at the time of application for VR services; and (c) have their cases closed by state VR agencies in Fiscal Year 2014. Participants who were engaged in any type of paid employment at the time of their application for VR services were excluded from the present study; VR clients with PD who were employed at the time of application for services will be included in a subsequent study.

Study participants reported a mean age of 37.28 years (SD = 15.34). Of the 673 clients in this study, 376 (56%) were males and 297 (44%) were females. In terms of racial/ethnic identification, 484 (72%) individuals in the sample identified as Caucasian; 98 (15%) as African American; 62 (9%) as Hispanic or Latina/o; 15 (2%) as Native American or Alaska Native; and 14 (2%) as Asian, Native Hawaiian or Pacific Islander. Regarding education levels, 119 (18%) participants had less than a high school diploma (i.e., no formal schooling, elementary education, secondary education but no high school diploma), 311 (46%) had completed high school but had not attended college, 89 (13%) held associate’s degrees, 95 (14%) had bachelor’s degrees or higher, and 59 (8%) had participated in or were currently enrolled in special education programs. Detailed demographic information about the participants is shown in Table 1.

Table 1
Demographic characteristics of rehabilitation clients with Parkinson’s disease

Demographic Characteristics n %

Age

15–35 306 45.5

36–54 268 39.8

55–64 81 12.0

65–73 18 2.7

Gender

Male 376 55.9

Female 297 44.1

Race

Caucasian 484 71.9

African-American 98 14.6

Native American or Alaska Native 15 2.2

Asian, Native Hawaiian or Pacific Islander 14 2.1

Hispanic or Latina/o 62 9.2

Education Level

Special education 59 8.8

Less than high school 119 17.7

High school 311 46.2

Associate degree 89 13.2

Bachelor degree or higher 95 14.1

SSI/SSDI* recipient

Yes 282 41.9

No 391 58.1

Demographic Characteristics	n	%
Age
15–35	306	45.5
36–54	268	39.8
55–64	81	12.0
65–73	18	2.7
Gender
Male	376	55.9
Female	297	44.1
Race
Caucasian	484	71.9
African-American	98	14.6
Native American or Alaska Native	15	2.2
Asian, Native Hawaiian or Pacific Islander	14	2.1
Hispanic or Latina/o	62	9.2
Education Level
Special education	59	8.8
Less than high school	119	17.7
High school	311	46.2
Associate degree	89	13.2
Bachelor degree or higher	95	14.1
SSI/SSDI* recipient
Yes	282	41.9
No	391	58.1

Note. SSI = Supplemental Security Income; SSDI = Social Security Disability Insurance.

2.2 Variables

The present study extracted variables from existing categories within the RSA-911 database. The RSA-911 database contains three general types of variables: client demographics, VR services, and employment outcomes. The independent and dependent variables considered in this study were as follows.

2.2.1 Independent variables

The demographic characteristics of study participants and VR services were considered predictors in this study. Demographic characteristics included age, gender, race/ethnicity, educational level, and cash benefits at the time of enrollment in VR services. Cash benefits were operationally defined as receipt of supplemental security income (SSI) and/or social security disability insurance (SSDI). This cash benefits variable was used as a proxy for severity of disability in this study, because people with disabilities who receive SSI or SSDI benefits are generally viewed as having more severe limitations than people with disabilities who do not receive those benefits (Ditchman et al., 2013). Research shows that most individuals with PD who received SSDI reported severe fatigue as a symptom that contributed to their work disability (Zesiewicz et al., 2007). VR services analyzed within the study included assessment, mental and physical restoration services, vocational training, college tuition assistance, job placement, and workplace support services. The complete list of VR services (28) is shown in Table 2. The demographic covariates and VR service predictor variables are described below.

Age (continuous variable).

Gender (0 = male, 1 = female; categorical variable).

Race (0 = Caucasian, 1 = Black or African American, 2 = Hispanic or Latina/o, 3 = Native American or Alaska Native, 4 = Asian, Native Hawaiian or Other Pacific Islander; categorical variable).

Education level at application (0 = special education, 1 = less than high school diploma [i.e., no formal schooling, elementary education, secondary education but no high school diploma] 2 = high school diploma but no college, 3 = associate’s degree, 4 = bachelor’s degree or higher; categorical variable).

Cash benefits (0 = not receiving SSI/SSDI, 1 = receiving SSI/SSDI; categorical variable).

Vocational rehabilitation services (0 = not provided, 1 = provided; categorical variable).

Table 2
Description of vocational rehabilitation services

Types of VR services Descriptions of VR services

1. Assessment Services provided and activities performed to determine an individual’s eligibility for vocational rehabilitation services, to assign an individual to a priority category of a state vocational rehabilitation agency that operates under an order of selection, and/or to determine the nature and scope of vocational rehabilitation services to be included in the individualized plan for employment (IPE); included in this category are trial work experiences and extended evaluation.

2. Diagnosis and Treatment of Impairments Surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy, speech therapy, and drugs and supplies; this category includes diagnosis and treatment of mental and emotional disorders.

3. Vocational Rehabilitation Counseling and Guidance Discrete therapeutic counseling and guidance services necessary for an individual to achieve an employment outcome, including personal adjustment counseling; counseling that addresses medical, family, or social issues; vocational counseling; and any other form of counseling and guidance necessary for an individual with a disability to achieve an employment outcome; this service is distinct from the general counseling and guidance relationship that exists between the counselor and the individual during the entire rehabilitation process.

4. Graduate College or University Training Full-time or part-time academic training that leads to a degree recognized as being beyond a baccalaureate degree, such as a Master of Science, Arts (M.S. or M.A.) or Doctor of Philosophy (Ph.D.) or Doctor of Jurisprudence (J.D.); such training may be provided by a college or university.

5. Four-Year College or University Training Full-time or part-time academic training that leads to a baccalaureate degree, a certificate, or other recognized educational credential; such training would be provided by a four-year college or university or technical college.

6. Junior or Community College Training Full-time or part-time academic training above the high school level leading to an associate degree, a certificate, or other recognized educational credential. Such training would be provided by a community college, junior college, or technical college.

7. Occupational/Vocational Training Occupational, vocational, or job skill training provided by a community college and/or a business, vocational/trade, or technical school to prepare students for gainful employment in a recognized occupation; this training does not lead to an academic degree or certification.

8. On-the-Job Training Training in specific job skills by a prospective employer; generally the individual is paid during this training and will remain in the same or a similar job upon successful completion; this category also includes apprenticeship training programs conducted or sponsored by an employer, a group of employers, or a joint apprenticeship committee representing both employers and a union.

9. Apprenticeship Training Work-based employment training program that combines hands-on, on-the-job work experience in a skilled occupation with related classroom instruction; includes supervision and structured mentoring; provides for wage increases as a apprentice’s skills increase; is based on an employer-employee relationship; and provides an industry recognized certificate of completion of the program.

10. Basic Academic Remedial or Literacy Training Literacy training or training provided to remediate basic academic skills needed to function on the job in the competitive labor market.

11. Job Readiness Training Training to prepare an individual for the world of work (e.g., appropriate work behaviors, methods for getting to work on time, appropriate dress and grooming, methods for increasing productivity).

12. Disability-Related, Augmentative Skills Training Service includes, but is not limited to, orientation and mobility, rehabilitation teaching, training in the use of low vision aids, Braille, speech reading, sign language, and cognitive training/retraining.

13. Miscellaneous Training Any training not recorded in one of the other categories listed, including GED or high school training leading to a diploma.

14. Job Search Assistance Job search activities that support and assist a consumer in searching for an appropriate job; may include help in preparing resumes, identifying appropriate job opportunities, and developing interview skills, and may include making contacts with companies on behalf of the consumer.

15. Job Placement Assistance A referral to a specific job resulting in an interview, whether or not the individual obtained the job.

16. On-the-Job Supports-Short Term Support services provided to an individual who has been placed in employment in order to stabilize the placement and enhance job retention; such services include short-term job coaching for persons who do not have a supported employment goal consistent with the employment goal on the individualized plan for employment (IPE).

17. On-the-Job Supports-Supported Employment On-going support services and other appropriate services needed to support and maintain an individual with a most significant disability in supported employment for a period of time generally not to exceed 18 months; such services, such as job coaching, are for individuals who have supported employment and long-term supports identified on the individualized plan for employment (IPE).

18. Transportation Travel and related expenses necessary to enable an applicant or eligible individual to participate in a vocational rehabilitation service; includes adequate training in the use of public transportation vehicles and systems.

19. Maintenance Maintenance means monetary support provided for those expenses such as food, shelter and clothing that are in excess of the normal expenses of the individual, and that are necessitated by the individual’s participation in an assessment for determining eligibility and vocational rehabilitation needs or while receiving services under an individualized plan for employment (IPE).

20. Rehabilitation Technology The systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of, and address the barriers confronted by, individuals with disabilities in areas that include education, rehabilitation, employment, transportation, independent living, and recreation; includes rehabilitation engineering services, assistive technology devices, and assistive technology services.

21. Reader Services Services for individuals who cannot read print because of blindness or other disability; includes reading aloud and transcribing printed information into Braille or sound recordings if requested by the individual; generally are offered to individuals who are blind or deaf-blind but may also be offered to individuals unable to read because of serious neurological disorders, specific learning disabilities, or other physical or mental impairments.

22. Interpreter Services Sign language or oral interpretation services performed by specially trained persons for individuals who are deaf or hard of hearing, and tactile interpretation services for individuals who are deaf-blind; includes real-time captioning services; does not include language interpretation.

23. Personal Attendant Services Those personal services that an attendant performs for an individual with a disability such as bathing, feeding, dressing, providing mobility and transportation, and so on.

24. Technical Assistance Services Technical assistance and other consultation services provided to conduct market analyses, to develop business plans, and to provide resources to individuals in the pursuit of self-employment, telecommuting, and small business operation outcomes.

25. Information and Referral Services Services provided to individuals who need assistance from other agencies (through cooperative agreements) not available through the vocational rehabilitation program.

26. Benefits Counseling Assistance provided to an individual who is interested in becoming employed, but is uncertain of the impact work income will have on any disability benefits and entitlements being received, and/or is not aware of benefits, such as healthcare, available to support any work attempt.

27. Customized Employment Services Services that involve a blend of flexible strategies that result in the provision of individually negotiated and designed services, supports, and job opportunities for an individual leading to an employment outcome of customized employment, including self-employment.

28. Other Services All other vocational rehabilitation services that cannot be recorded elsewhere; included here are occupational licenses, tools and equipment, and initial stocks and supplies.

Types of VR services	Descriptions of VR services
1. Assessment	Services provided and activities performed to determine an individual’s eligibility for vocational rehabilitation services, to assign an individual to a priority category of a state vocational rehabilitation agency that operates under an order of selection, and/or to determine the nature and scope of vocational rehabilitation services to be included in the individualized plan for employment (IPE); included in this category are trial work experiences and extended evaluation.
2. Diagnosis and Treatment of Impairments	Surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy, speech therapy, and drugs and supplies; this category includes diagnosis and treatment of mental and emotional disorders.
3. Vocational Rehabilitation Counseling and Guidance	Discrete therapeutic counseling and guidance services necessary for an individual to achieve an employment outcome, including personal adjustment counseling; counseling that addresses medical, family, or social issues; vocational counseling; and any other form of counseling and guidance necessary for an individual with a disability to achieve an employment outcome; this service is distinct from the general counseling and guidance relationship that exists between the counselor and the individual during the entire rehabilitation process.
4. Graduate College or University Training	Full-time or part-time academic training that leads to a degree recognized as being beyond a baccalaureate degree, such as a Master of Science, Arts (M.S. or M.A.) or Doctor of Philosophy (Ph.D.) or Doctor of Jurisprudence (J.D.); such training may be provided by a college or university.
5. Four-Year College or University Training	Full-time or part-time academic training that leads to a baccalaureate degree, a certificate, or other recognized educational credential; such training would be provided by a four-year college or university or technical college.
6. Junior or Community College Training	Full-time or part-time academic training above the high school level leading to an associate degree, a certificate, or other recognized educational credential. Such training would be provided by a community college, junior college, or technical college.
7. Occupational/Vocational Training	Occupational, vocational, or job skill training provided by a community college and/or a business, vocational/trade, or technical school to prepare students for gainful employment in a recognized occupation; this training does not lead to an academic degree or certification.
8. On-the-Job Training	Training in specific job skills by a prospective employer; generally the individual is paid during this training and will remain in the same or a similar job upon successful completion; this category also includes apprenticeship training programs conducted or sponsored by an employer, a group of employers, or a joint apprenticeship committee representing both employers and a union.
9. Apprenticeship Training	Work-based employment training program that combines hands-on, on-the-job work experience in a skilled occupation with related classroom instruction; includes supervision and structured mentoring; provides for wage increases as a apprentice’s skills increase; is based on an employer-employee relationship; and provides an industry recognized certificate of completion of the program.
10. Basic Academic Remedial or Literacy Training	Literacy training or training provided to remediate basic academic skills needed to function on the job in the competitive labor market.
11. Job Readiness Training	Training to prepare an individual for the world of work (e.g., appropriate work behaviors, methods for getting to work on time, appropriate dress and grooming, methods for increasing productivity).
12. Disability-Related, Augmentative Skills Training	Service includes, but is not limited to, orientation and mobility, rehabilitation teaching, training in the use of low vision aids, Braille, speech reading, sign language, and cognitive training/retraining.
13. Miscellaneous Training	Any training not recorded in one of the other categories listed, including GED or high school training leading to a diploma.
14. Job Search Assistance	Job search activities that support and assist a consumer in searching for an appropriate job; may include help in preparing resumes, identifying appropriate job opportunities, and developing interview skills, and may include making contacts with companies on behalf of the consumer.
15. Job Placement Assistance	A referral to a specific job resulting in an interview, whether or not the individual obtained the job.
16. On-the-Job Supports-Short Term	Support services provided to an individual who has been placed in employment in order to stabilize the placement and enhance job retention; such services include short-term job coaching for persons who do not have a supported employment goal consistent with the employment goal on the individualized plan for employment (IPE).
17. On-the-Job Supports-Supported Employment	On-going support services and other appropriate services needed to support and maintain an individual with a most significant disability in supported employment for a period of time generally not to exceed 18 months; such services, such as job coaching, are for individuals who have supported employment and long-term supports identified on the individualized plan for employment (IPE).
18. Transportation	Travel and related expenses necessary to enable an applicant or eligible individual to participate in a vocational rehabilitation service; includes adequate training in the use of public transportation vehicles and systems.
19. Maintenance	Maintenance means monetary support provided for those expenses such as food, shelter and clothing that are in excess of the normal expenses of the individual, and that are necessitated by the individual’s participation in an assessment for determining eligibility and vocational rehabilitation needs or while receiving services under an individualized plan for employment (IPE).
20. Rehabilitation Technology	The systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of, and address the barriers confronted by, individuals with disabilities in areas that include education, rehabilitation, employment, transportation, independent living, and recreation; includes rehabilitation engineering services, assistive technology devices, and assistive technology services.
21. Reader Services	Services for individuals who cannot read print because of blindness or other disability; includes reading aloud and transcribing printed information into Braille or sound recordings if requested by the individual; generally are offered to individuals who are blind or deaf-blind but may also be offered to individuals unable to read because of serious neurological disorders, specific learning disabilities, or other physical or mental impairments.
22. Interpreter Services	Sign language or oral interpretation services performed by specially trained persons for individuals who are deaf or hard of hearing, and tactile interpretation services for individuals who are deaf-blind; includes real-time captioning services; does not include language interpretation.
23. Personal Attendant Services	Those personal services that an attendant performs for an individual with a disability such as bathing, feeding, dressing, providing mobility and transportation, and so on.
24. Technical Assistance Services	Technical assistance and other consultation services provided to conduct market analyses, to develop business plans, and to provide resources to individuals in the pursuit of self-employment, telecommuting, and small business operation outcomes.
25. Information and Referral Services	Services provided to individuals who need assistance from other agencies (through cooperative agreements) not available through the vocational rehabilitation program.
26. Benefits Counseling	Assistance provided to an individual who is interested in becoming employed, but is uncertain of the impact work income will have on any disability benefits and entitlements being received, and/or is not aware of benefits, such as healthcare, available to support any work attempt.
27. Customized Employment Services	Services that involve a blend of flexible strategies that result in the provision of individually negotiated and designed services, supports, and job opportunities for an individual leading to an employment outcome of customized employment, including self-employment.
28. Other Services	All other vocational rehabilitation services that cannot be recorded elsewhere; included here are occupational licenses, tools and equipment, and initial stocks and supplies.

2.2.2 Dependent variable

Competitive employment was the dependent variable in this study. RSA defines competitive employment as working either full-time or part-time in a competitive integrated employment setting, in self-employment, or in a state-managed Business Enterprise Program, where the person is paid minimum or above-minimum wage. Minimum wage is the state or federal minimum wage, whichever is higher. Participants who obtained competitive employment after receiving VR services were considered to have successful outcomes, and participants who did not obtain competitive employment after receiving VR services were considered to have unsuccessful outcomes.

2.3 Procedure and data analysis

A quantitative correlational design (Shadish et al., 2002) was used to examine the relationship between the predictor variables and the competitive employment criterion. Data for this study were extracted from the RSA-911 database for Fiscal Year 2014. SPSS version 22 was used for all data analyses. Bivariate descriptive statistics were calculated to ascertain proportions and mean values for the predictor and criterion variables, and multiple logistic regression analysis was used to investigate the associations between variables. We used purposeful selection of the variables, which was suggested by Hosmer and colleagues (2013) to build the most parsimonious and best-fit logistic regression model (Shadish et al., 2002). Our purposeful selection adhered to the following steps:

Examine the bivariate relationships between the predictor variables and the dependent variable that are significantly associated with the dependent variable at an alpha level of 0.25.

Enter all selected variables into the logistic regression model.

Identify independent variables that are significantly related to the dependent variable and independent variables that are not significant. Remove variables with changes in parameter estimate (β) that are less than 20%.

Add back variables that were not selected in step 1, one variable at a time into the logistic regression equation. Any of these variables that are significant at the 0.1 level are included in the model.

Examine interactions among variables.

Examine the model’s adequacy and model fit using the chi-square goodness-of-fit test; Hosmer and Lemeshow goodness-of-fit test; and Nagelkerke R² (Kleinbaum & Klein, 2010).

3 Results

Descriptive results indicated that, after receiving VR services, 45.3% of participants achieved competitive employment. The three most frequently provided services were assessment (received by 58.2% of the sample), VR counseling and guidance (44.0%), and diagnosis and treatment (39.4%), and the three least frequently provided services were basic academic remedial and literacy training, readers, and personal attendant services which were provided to less 1% of the participants.

The mean number of months that participants were enrolled in VR services was 36.74 (SD = 29.72, Min = 2, Max = 272), and the mean number of services received was 3.69 (SD = 2.46). Participants who obtained competitive employment stayed in the VR system for shorter periods of time on average (M = 33.85; SD = 30.01) than participants who did not achieve competitive employment (M = 39.13 SD = 29.31; t (673) = 2.30, p < 0.05). Also, participants who obtained competitive employment received a greater number of services (M = 4.22 SD = 2.56) than participants who did not achieve competitive employment (M = 3.26 SD = 2.28; t(673) = –5.13, p < 0.01).

This study utilized multiple logistic regression analysis to investigate the relationship between (a) demographic and VR service variables and (b) employment outcomes within the study sample (Table 3). In the multiple-step purposeful selection process, the first step involved assessing the one-to-one relationships among predictor variables and the competitive employment criterion. First-step results indicated that age, race, cash benefits, vocational rehabilitation counseling and guidance, graduate-level college or university training, four-year college or university training, job readiness training, job search assistance, job placement assistance, on-the-job supports-short term, on-the-job supports-supported employment, maintenance, rehabilitation technology, information/referral, benefits counseling, and other services were significantly related to competitive employment at p < 0.20.

Table 3
The relationship between significant predictor variables and competitive employment for people with Parkinson’s disease

Predictors B SE B Sig Odds Ratio 95% CI

Cash benefits –0.529 0.172 0.002 0.589 0.421 0.825

Assessment –0.367 0.174 0.035 0.693 0.493 0.974

On-the-job supports/supported employment 1.370 0.393 0.000 3.935 1.823 8.494

On-the-job supports/short term 1.003 0.328 0.002 2.727 1.433 5.189

Job placement assistance 0.977 0.195 0.000 2.655 1.810 3.894

University training 0.714 0.274 0.009 2.042 1.193 3.494

Maintenance services 0.566 0.234 0.016 1.762 1.113 2.790

Predictors	B	SE B	Sig	Odds Ratio	95% CI
Cash benefits	–0.529	0.172	0.002	0.589	0.421	0.825
Assessment	–0.367	0.174	0.035	0.693	0.493	0.974
On-the-job supports/supported employment	1.370	0.393	0.000	3.935	1.823	8.494
On-the-job supports/short term	1.003	0.328	0.002	2.727	1.433	5.189
Job placement assistance	0.977	0.195	0.000	2.655	1.810	3.894
University training	0.714	0.274	0.009	2.042	1.193	3.494
Maintenance services	0.566	0.234	0.016	1.762	1.113	2.790

Note. Final Model χ²(7, N = 673) = 87.94, p < 0.001; Nagelkerke R² = 0.16; Hosmer and Lemeshow goodness-of-fit test =χ²(8, N = 673) = 2.77, p = 0.94.

In the second step, the significant variables determined in step 1 were put into the logistic regression model using the enter method. Results indicated that, in the presence of other variables, age, race, vocational rehabilitation counseling and guidance, graduate college or university training, four-year college or university training, job readiness training, job search assistance, rehabilitation technology, information and referral, benefits counseling, and other services were not significantly related to competitive employment at a p level of 0.05. In the third step, those non-significant variables were removed one at a time. It was revealed that removal of age rendered four-year college or university training a significant predictor of competitive employment. In the fourth step, the variables that were not recruited in step 1 (i.e., gender, education level, assessment, diagnosis and treatment, junior or community college training, occupation or vocational training, on-the-job training, disability related skills training, miscellaneous training, transportation, interpreter services, and customized employment services) were put into the logistic regression one at a time. The result indicated that assessment services were significantly and negatively associated with competitive employment in the presence of other variables.

As for the fifth, sixth and seventh steps, the test results indicated that predictor variables had a significant relationship to competitive employment: χ²(7, N = 673) = 87.94, p < 0.001. The final model comprised one demographic variable and six VR service predictors. The Nagelkerke R² score of 0.16, which shows the strength of the relationship between the predictors and the criterion or outcome variable, indicated a moderate effect. The Hosmer et al. (2013) goodness-of-fit test was not significant χ²(8, N = 673) = 2.77, p = 0.94, indicating a good fit between the model and the data (Hosmer et al. 2013). The classification plot, which depicts the accuracy of classifications of the outcome variable, indicated that the model accurately classified 50.8% of VR clients who achieved competitive employment and 80.4% of VR clients who had unsuccessful outcomes. Taken in aggregate, the seven-predictor model was able to predict competitive employment outcomes.

As for the one demographic predictor that was retained in the final model, results revealed that receipt of cash benefits was related to a 42% reduction (OR = 0.58; 95% CI, 0.42–0.82) in the odds of obtaining competitive employment. Results also indicated that six VR services were significantly associated with competitive employment.

The odds of having cases closed in competitive employment status were 3.93 times greater for participants who received on-the-job support services (supported employment) than they were for those who did not receive those services (OR = 3.93; 95% CI, 1.82–8.49).

The odds of having cases closed in competitive employment status were 2.72 times greater for participants who received short-term on-the-job support services than they were for those who did not receive those services (OR = 2.72; 95% CI, 1.43–5.18).

The odds of having cases closed in competitive employment status were 2.65 times greater for participants who received job placement services than they were for those who did not receive those services (OR = 2.65; 95% CI, 1.81–3.89).

The odds of having cases closed in competitive employment status were 2.04 times greater for participants who received four-year college or university training services than they were for those who did not receive those services (OR = 2.04; 95% CI, 1.19–3.49).

The odds of having cases closed in competitive employment status were 1.76 times greater for participants who received maintenance services than they were for those who did not receive those services (OR = 1.76; 95% CI, 1.11–2.79).

The odds of having cases closed in competitive employment status were 31 percent lower for participants who received assessment services than they were for those who did not receive those services (OR = 6.69; 95% CI, 0.49–0.97).

4 Discussion

The purpose of this investigation was to provide profiles of the client demographic and service-related variables that were most strongly associated with success in the state-federal VR system for clients with PD who were unemployed at the time of enrollment in VR services. An understanding of these characteristics is critical to both expanding the knowledge base for this understudied population and improving service delivery for unemployed clients.

4.1 Overall success rate

In terms of employment outcomes, fewer than half (45.3%) of individuals with PD attempting to enter or return to work were successfully rehabilitated through VR services. In context, this is a substantially lower rate than the overall success rate for all VR clients nationwide (Rubin et al., 2016), highlighting the need to examine both the barriers to employment and types of employment services being provided to individuals with PD (Rumrill & Koch, 2014). Moreover, these results underscore the necessity of investigating additional PD-related disease variables, which are unavailable in the RSA-911 dataset, that would allow for a more comprehensive assessment of variables related to VR success for clients with PD. As more Americans are electing to delay retirement for personal and financial reasons, the ability to obtain and retain employment through utilization of the VR system becomes increasingly relevant for people with this adult-onset condition.

4.2 Client demographic factors

Only one client demographic predictor was retained in the final regression model, namely, receipt of cash disability benefits. Participants in this study who were receiving Social Security disability benefits at the time of enrollment in VR services were 42% less likely to be successfully rehabilitated than their counterparts, which underscores the powerful systemic disincentive to seek, secure, and maintain gainful employment that exists within Social Security programs (Strauser, 2013). Indeed, the benefits paid by the Social Security Administration’s two disability programs (i.e., SSDI and SSI) are predicated on the beneficiary being too disabled to work (Marini, 2003). When this determination is made during the mid-to-late career developmental stages, people with chronic conditions such as PD may find it difficult to regain motivation to return to the workforce (Koch & Rumrill, 2017). Unemployment and receipt of disability benefits then conjoin in a long-term self-fulfilling prophecy that is very difficult to change. Strauser and colleagues (2010) reported that only one percent of VR clients who received SSDI benefits at the time of application for services were successfully rehabilitated in competitive employment. In order to successfully change this pattern, people with PD need assistance in understanding disability benefits, especially the implications of paid employment to those benefits.

4.3 Service-related factors

Participants in this study who received more VR services over a shorter period of time were more likely to be successfully employed than their counterparts who received fewer services over a longer time interval. As noted by Power (2013), clients who have work histories and those who are motivated to work benefit from increased intensity of services, an effect observed across many similar studies conducted with different disability populations (Cimera et al., 2015; Kaya et al., 2016; Rumrill et al., 2017). For VR clients with adult-onset chronic illnesses, Rubin et al (2016) recommended an early intervention approach that infuses the Individualized Plan for Employment (IPE) with a variety of medical, psychosocial, and vocational services resembling the triage method in emergency and acute healthcare. The present findings appear to support such a high-intensity approach (i.e., more services over a shorter period of time) for VR clients with PD who are seeking to enter or re-enter the workforce.

Some notable trends emerged from this study in terms of how the types of VR services impacted client success rates. There were five VR services (i.e., on-the-job support (supported employment), short-term on-the-job support, job placement, four-year college or university training, and maintenance) that were positively associated with successful competitive employment outcomes for clients with PD, whereas assessment was the lone VR service that significantly contraindicated successful case closure.

4.3.1 On-the-job support, supported employment and short-term

On-the-job supported employment services (3.93 OR) and short-term on-the-job support services (2.72 OR) were both strongly associated with successful employment outcomes for VR clients with PD. The high predictive value (these were the two strongest predictors of successful employment in this study) of on-the-job support is noteworthy when considering how to best structure career or re-entry VR services for clients with PD. Specifically, it calls to attention the “boom or bust” potential for these clients directly after they secure competitive employment opportunities. VR professionals working with clients with PD should consider the possible need for on-the-job supports before the client has been placed into a job –ideally as early as the case conceptualization and planning phases. Possible on-the-job support services should be noted in the Individualized Plan for Employment (IPE). Depending on the work history and health-related characteristics of the client (e.g., length of time out of work, severity of symptoms, education level, soft skills, previous work history, level of functional impairment), the VR counselor should determine which on-the-job supports may be necessary to sustain the client’s desired job, as well as the likely duration of those supports. Of course, these on-the-job supports can be adjusted as needed once the client obtains initial employment.

Most importantly, the counselor must ensure that the job coach is prepared to begin work with the client immediately after employment is secured, from the client’s first scheduled day of work (Wehman, 2013). This may require additional communication with the employer to emphasize the importance of these services ahead of time. The job coach should be well-informed about the unique needs of workers with PD and be well-versed in the accommodation strategies that have proven effective for these individuals (Job Accommodation Network, 2018).

4.3.2 Job placement services

Provision of job placement services (2.65 OR) was also related to employment success for VR clients with PD. The importance of this service is likely indicative of the demographic and work history characteristics of VR clients with PD who are seeking to enter or return to the labor market. PD is more likely to manifest itself in the twilight of a person’s career (although participants in this study were under 40 years of age on average) which, given the constantly changing job search and application processes in the modern economy, may require the person to update his or her job seeking skills. Older workers with PD, especially those who have disengaged from the workforce as was an inclusion criterion in this study, may also need rehabilitation professionals to engage in selective placement assistance on their behalves. The present findings suggest that targeted placement assistance to help unemployed people with PD identify job leads, complete job applications, prepare for interviews, and articulate their needs for workplace accommodations are effective and important VR interventions.

Relatedly, client work history factors must be taken into consideration in designing and implementing job placement services for clients with PD. If the client’s most recent job was a long-term position, say for 10 years or more, which is more common for older workers than it is for younger workers, she or he will likely need assistance developing and/or updating a resume. If the client has had a long interruption in his or her employment, the VR counselor may need to assist him or her in identifying relevant and current transferrable skills that may not be self-evident.

In addition to matching clients with PD to possible job opportunities in accordance with their interests and skills, VR professionals must endeavor to make employers amenable to hiring and accommodating workers with PD. Older clients with PD may experience a double disadvantage based on their disability status and age, not to mention any additional minority group memberships based on gender, race/ethnicity, religion, and/or sexual orientation. As an element of job placement services, it may be necessary to educate employers on the benefits of hiring experienced workers with PD and to dispel the myths about the costs of employing older workers and workers with disabilities that continue to be cited as prominent employer concerns (Walker, 2007).

4.3.3 Four-year college or university training

Employers in the modern workforce have become increasingly reliant on individuals with four-year degrees or certificates to fill full-time positions with benefits, frequently leaving those without higher education to depend on temporary and part-time work to make ends meet. Therefore, it is not surprising, even with a population of clients who are generally advanced in age, that four-year college or university training (2.04 OR) remains a powerful ingredient to employment acquisition and retention. This has been documented in several existing RSA-911 studies involving clients with learning disabilities (Rumrill et al., 2017) blindness (Cimera et al., 2015), and autism spectrum disorders (Kaya et al., 2016).

In working with clients with PD, VR professionals should evaluate their motivation and preparedness to participate in four-year college or university training from the initiation of the VR planning phase. Particular consideration should be given to any available certificates or credentials within the client’s field of interest that will strengthen his or her employability in the current job market. Though often costly in terms of up-front expenditures, degrees and certificates continue to yield a strong return on investment in comparison to other VR services (Rumrill et al., 2016; Tansey et al., 2015).

4.3.4 Maintenance services

Maintenance services (1.76 OR) were significantly linked to successful employment outcomes for VR clients with PD. This may speak directly to the nature and life circumstances of the participants who were selected for this study. For clients seeking to return to work after PD diagnosis, there may be non-health related factors influencing their desires and abilities to reenter the workforce (e.g., financial difficulties, transportation, housing situations). Maintenance services can provide an important bridge to cover items such as food, shelter, and clothing for clients to enable them to secure employment and gain or regain financial stability. Maintenance services can also be used effectively in conjunction with four-year university or college training, as it can be difficult for students (of any age) to provide for essentials when attending school full-time. VR counselors should be mindful of such needs when working with clients with PD, and of the finding in this study that maintenance services were a significant predictor of successful employment outcomes.

4.3.5 Assessment

Assessment was the only service-related predictor that was significantly but negatively related to the competitive employment criterion (i.e. reduced odds of employment by 31%). The exact limiting nature of receipt of assessment services vis a vis successful rehabilitation is not evident from the present results, but it may be the case that experienced and motivated VR clients with PD who want to return to work quickly are discouraged by the sometimes long and drawn out assessment process that may delay development of the IPE and service provision several weeks or even months (Rumrill & Koch, 2014). As noted by Power (2013), clients seeking to return to work may not need extensive evaluation and assessment services and may instead benefit from brief measures of employability based primarily on self-reports. Power (2013) warned that long and costly assessments can result in consumers disengaging from services, which may have been the case in this study. On the other hand, participants in this study who had the strongest potential to return to or enter the workforce may not have needed assessment services from the VR program, and therefore, did not participate in those services as part of their rehabilitation process. These speculations are not resolvable through the results of this study as it was designed, but the present findings do provide a strong caution against assessing clients with PD excessively or unnecessarily.

4.4 Limitations

There are a number of limitations that should be kept in mind when interpreting the present findings. First, this study used archival data with an ex-post-facto design; therefore, it is not possible to draw cause-and-effect inferences regarding the relationships among study variables. Also, the primary disability of participants in this study, PD, was not necessarily diagnosed in accordance with clinical diagnostic criteria. In some cases, the PD classification may have come from the subjective judgments of rehabilitation counselors or from participants’ self-reports. It is therefore possible that some of the participants in this study did not actually have PD. Moreover, there are a host of PD features (e.g., depression, apathy, cognitive changes) that were not captured in the database, along with data regarding duration of PD symptoms, medications, and functional factors. These factors were not accounted for in the present study, but they may influence return-to-work decisions.

Readers should also note that the RSA-911 database is compiled for administrative purposes rather than research purposes. In that regard, rehabilitation counselors, during data collection, may have recorded services based on their recall rather than consulting with case files. In addition, although the RSA-911 database includes 18 cross-checks to minimize input errors, there may remain some inaccuracies due to counselor errors in recording of client and case service information.

This study examined data throughout the United States and did not investigate differences that may occur within and between states. Such information is critical if individual states and agencies are to improve the quality of VR services and outcomes. Future research will need to explore this line of inquiry. Also, the present study only examined data from Fiscal Year 2014. Consequently, it is unclear whether predictors of successful rehabilitation change over time for people with PD who were unemployed at the time of enrollment in VR services. Multi-year investigations of the predictors of VR outcomes within this population would enable researchers to understand VR services and outcomes within important (and often dynamic) historical, political, and economic contexts.

5 Conclusion

Results of this investigation document the importance of individualized VR services that capitalize on the experience and motivation of consumers with PD, provide educational training and maintenance supports when applicable, utilize proven job placement approaches, and emphasize the importance of on-the-job supports for clients with PD who wish to enter or re-enter the workforce. More VR services provided over a shorter period of time (i.e., more intensive services) were positively associated with successful competitive employment outcomes. Findings also underscore the powerful disincentives to paid employment in SSI and SSDI programs. Rehabilitation professionals working with people diagnosed with PD are encouraged to consider the specific service-related and demographic factors that predicted competitive employment outcomes in this investigation as a means of responsively and responsibly meeting the needs of this growing VR clientele.

Conflict of interest

None to report.

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