Optimizing medical care to facilitate and sustain employment after spinal cord injury.

Abstract

INTRODUCTION Unemployment among persons with disabilities is a serious and prevalent problem. The Department of Labor's Bureau of Labor Statistics reported that, as of May 2014, the employment rate for people without disabilities was 71.4 percent, but only 25.3 percent for persons with any disability [1], an employment gap of 46.1 percent. According to a comprehensive review of the literature between 1978 and 2008, the average rate of employment during that period for people with spinal cord injury (SCI) was only 35 percent [2], Such data may reflect that, in the past few decades, vocational rehabilitation has been viewed as a secondary goal after SCI. Increasingly, however, return to work (RTW) is being rediscovered as a vital element of successful rehabilitation based on evidence that it improves quality of life, psychological adjustment, and social functioning. This, in turn, improves health, which decreases healthcare utilization [3-4]. Ways of providing appropriate vocational and medical support for RTW have been developed for both traumatic brain injury (TBI) [5] and serious mental illness [6], One method, evidence-based supported employment, which consists of intensive individualized service that integrates vocational rehabilitation into clinical care, can greatly improve the likelihood of RTW for people with serious mental illness [6-7], Community reintegration of Veterans with complex mental and physical disabilities is a priority area for the Department of Veterans Affairs (VA). Initial findings of two sequential VA-funded, 5-year national, multisite, longitudinal studies of RTW for Veterans with SCI indicate that evidence-based practice supported employment is more effective than traditional vocational rehabilitation [8-9]. One of the most frequently reported reasons for not working after SCI is inability to perform the physical demands of the job (60%) [10]. Vocational accommodations, however, can be helpful for overcoming the physical demands of work. Another important obstacle to RTW is hospitalization [11], Because a person with SCI must monitor many bodily functions that previously required little attention, the critical challenges that must be met after SCI in order to recover autonomy and RTW are a heightened self-awareness and a meticulous self-care routine. Without health education and motivation, however, the skills needed for such a radical change in daily life may never fully develop. RTW, however, can fuel that motivation. Anticipation, prevention, and, when prevention fails, rapid medical intervention are required to maintain the health--and employment--of people with SCI who want to work. Herein, we discuss the vocational implications of impairments typical of SCI (Table) and strategies for managing these impairments so as to improve Veterans' outcomes in seeking and maintaining work after SCI. OPTIMIZING CARE THROUGH COLLABORATION AND INCLUSION For RTW to succeed over time despite the complexity of SCI, a proactive, preventive health strategy is needed that addresses medical challenges through continuous interdisciplinary collaboration between persons with SCI and their healthcare team. A care plan must be developed that is flexible and responsive to evolving needs while the person seeks, gains, and maintains employment (Figures 1 and 2). Vocational rehabilitation specialists can be critical in mediating among a person with SCI, healthcare providers, and potential or current employers. Persons with SCI, however, may need to be coached to be their own advocates and to draw not only on the expertise of healthcare teams and vocational counselors but also on the support of their social networks for assistance with related activities such as transportation and bowel and bladder care routines at work. Employers, recognizing what people with disabilities can bring to the work team and the customer, are joining in the discussion of the implications of reasonable accommodations as required by the Americans with Disabilities Act [12]. …