Outline Background What's the problem Research Findings R ETURN - - PowerPoint PPT Presentation
Vocational Rehabilitation supporting a return to work: lessons from stroke Kate Radford, PhD. MSc. DipCOT. Associate Professor in Rehabilitation Research Division of Rehabilitation and Ageing, University of Nottingham
Associate Professor in Rehabilitation Research Division of Rehabilitation and Ageing, University of Nottingham Kate.radford@nottingham.ac.uk B102, Division of Rehabilitation and Ageing, Medical School
Background – What's the problem
Research Findings
RETURN TO WORK AFTER STROKE
WHAT WE DID, WHAT WE FOUND AND FOR WHOM An Early Stroke Specialist VR model
IMPLEMENTATION – RTW OT PILOT
WHAT WAS VALUED (PATIENTS) WHAT WE LEARNED
HOW DOES THIS TRANSLATE TO OTHER CONDITIONS?
work (Daniel et al 2009, Stroke Association 2006, 2015)
2009)
van Velzen et al. 2009).
et al 2010
for stroke (Baldwin and Brusco 2011)
Workplace (job retention) intervention PT and OT 3 months 27% intervention in work Vs 12% controls. 6 months 60% intervention in work Vs 20% controls.
Guidelines support need for vocational rehabilitation (VR)
(NICE guidelines for Stroke Rehabilitation 2013)
complex rehabilitation (Kalra and Walker, 2009)
the UK Government agenda
Building Capacity to Work (DWP, 2004), Health, Work and Well Being (DWP, 2005), Working for a healthier Tomorrow (DH and DWP, 2008), Universal Credit: welfare that works, (2010)
vocational rehabilitation (VR) services
NSF Long Term Neurological Conditions (2005), The National Stroke Strategy (2007),Co-ordinated, Integrated and Fit for Purpose, Scottish Executive (2007), Better Heart Disease And Stroke Care Action Plan, The Scottish Government (2009), Liberating the NHS (2010), Darzi (2007), Black, (2008), Black and Frost, (2011), Marmot Review 2010, NICE guidelines for Stroke Rehabilitation 2013, DWP 2013, NHS England 2014, DWP 2015 & 2015, The ‘five year forward view’ (NHS England, 2014).
DWP, 2006a and 2006b, NSF for LTNC, 2005, Black 2008, Black and Frost, 2011, National Clinical Guidelines for Stroke 2012, NICE guidelines for Stroke Rehabilitation 2013
employment related services
Workforce Plus: An Employability Framework for Scotland, 2006 BSRM/RCP Inter-agency Guidelines, 2004, BSRM, 2010
Black, 2008 Black and Frost 2011
Work is a Health Outcome - The NHS
Most rehab (and follow-up) has ended by 6 months
Many people fall into service gaps and their needs are not met
Gladman et al (2008), Playford et al (2011)
The lack of a sanctioned VR pathway~ people with milder stroke fall through the net and receive little or no support. Sinclair et al (2014)
Most services see few people with LTNC for VR - <10
per year.
Only 20% of services see clients at the point of diagnosis
>50% of services have a waiting time of >1 month Wide range of HC professionals involved in delivery but
mainly OT’s (77%) and Psychologists (61%)
30% of HCP respondents had never received any
Playford et al, 2011 Mapping Vocational Rehabilitation Services for people with Long term neurological conditions: Summary report. Department of Health. March 2011. Available from: http://www.ltnc.org.uk.
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Vocational Rehabilitation
(Tyerman and Meehan, 2004)
Cognitive Psychological Physical Environmental Factors Personal Factors
CONTEXT STROKE
E.g. beliefs and attitudes Confidence, Experience
Family support Employer beliefs Access to rehab
Vestling et al, 2003, Leung and Man, (2005) Lindstrom et al 2009, Kauranen et al 2012
No attention dysfunction or aphasia (HR 2.0 and HR 3.0) predictors of 18 months work outcomes
Tanaka et al 2014, Doucet et al, 2012 Alaszewski et al 2007, van Velzen et al 2011, Lock et al, 2005
Fulfils basic needs
financial, psychological emotional well-being self esteem social status sense of achievement Independence freedom security
‘He who seeks rest finds
work finds rest’.
Dylan Thomas
Perceived importance of work (OR 5.10) Not perceiving themselves as a burden on others (OR
3.33)
Support from others (OR 3.66) Retaining the ability to run a short distance (OR 2.77) Higher socioeconomic codes (OR 2.12)
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MI Grant, E Sinclair, J Terry, C Sampson, C Edwards, MF Walker, NB Lincoln, A Drummond, J Phillips, L Watkins, E Rowley, N Brain, B Guo, M Jarvis, M Jenkinson
Objectives
1. Interview and observational study of current provision 2. Intervention development (Case Studies, Lit review and Expert Panel) 3. Feasibility trial with economic analysis 4. Qualitative interviews with stroke survivors, employers and commissioners to explore usefulness, acceptability and implementation issues
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Aim
To determine what exists, where and how stroke survivors
work needs are currently met
To identify barriers to work return within existing provision
(So that we could develop an intervention to bridge gaps and return stroke survivors to work)
Sinclair et al, Disabil Rehabil, 2014; 36(5): 409–417
and knowledge of the health care system
and hidden disabilities missed early after stroke
expertise
Sinclair et al, 2013, Disabil Rehabil, 2014; 36(5): 409–417 Coole C et al (2012) J Occ Rehabil DOI 10.1007/s10926-012-9401-1 Radford et al, JHSRP, 2013, 18 (2S) 30-38.
Aim
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Method
Stroke survivors recruited from acute and rehab stroke units OT-led stroke-specific vocational rehabilitation (ESSVR) Usual Care (UC) Postal follow-up; 3, 6 and 12 months
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Inclusion Criteria
Exclusion Criteria
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Primary Outcome
Secondary Outcomes
Work Limitations Questionnaire
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Rehabilitation Services (hospital and out-patient) Wider VR Team
GP DWP Services:
adviser Workplace Services:
Health Adviser
Health Physician
Third Sector:
brokers
adviser
adviser Stroke Physician
Work/ education Liaison Acute Stroke Unit Stroke Specialist Vocational Rehab Case co-ordinator PATIENT & FAMILY
0-12 months
Employer
ESSVR Intervention
student
impact on work/education
pacing to manage fatigue
increasing activity to increase stamina, concentration and confidence; practicing work skills
to work.
(BSRM, Tyerman and Meehan, 2010 Grant et al.,2012, Grant et al., 2014 – in press)
Case coordination model; Fadyl and McPherson, 2009
Early Stroke Specific VR - assumptions
with the same responsibilities.
demands of the job
than new work or re-training after stroke - Process demands
early & effective engagement with employers HEALTH SERVICES ARE WELL PLACED TO DO THIS
Results: Participants
ESSVR = 23 UC = 23
78 excluded
33 failed to meet inclusion criteria 40 declined 5 other reasons
Randomisation
Excluded (n=973) Not stroke (40% n=389) Retired or below working age (75% n=729) Unemployed (2.9% n=28) 1098 admitted to acute stroke ward
Participants
Characteristic ESSVR (n=23) Control (n=23)
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5 10 15 20 25 30 35
Minor Moderate Moderate/S evere Severe Missing
NIHSS; Stroke Severity (%)
SSVR Control
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2 4 6 8 10 12 14 16 18 20 22
3m 6m 12m
Nottingham Extended Activities of Daily Living; Median Score
SSVR Control
Stroke severity
Functional ability
Functional ability
Feasibility
20 40 60 80 100 3m 6m 12m
SSVR Control
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Primary Outcome
20 40 60 80 100 3m 6m 12m
SSVR Control
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Secondary Outcomes
1 2 3 4 5 6 7 8 3m 6m 12m
% Productivity Loss
SSVR Control
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Self-reported Productivity Loss
Work Limitations Questionnaire
Time taken to return to work
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Days to return to work Number Mean Median Range SD
Intervention group
Control group 14
85.57 82.50 8-190 62.12
Income & Benefits Status
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4000 9000 14000 19000 Baseline 3m 6m 12m
Average Annual Income (£)
SSVR Control
Discussion
at 12m and more returned to their pre-stroke working hours
standardised and bespoke questionnaires
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ESSVR is a job retention model - may potentially influence RTW rates in people with mild and moderate stroke BUT
require re-training
and ‘create a team’ involving Health (NHS), Employment services, private and charitable sectors.
Radford K, Edmans J, Hooban K, Terry J (in preparation) Findings:
Community Stroke Team during preceding year - 2 RTW
patients seen in 6 months, 18/24 (71%) discharged RTW, 2 retired, one on mat leave, 3 did not return (2 due to alcohol, 1
stroke (as per trial), seen within a mean 21 days post stroke.
Services
‘It might have been one of the goals, it would have been very unlikely that somebody would have been referred just for that’ [CST service provider].
Discuss
Having someone to call on Work preparation Signposting & referral Individualised support Employer communication Advocacy
Being able to talk things through…and ‘working
could cope and get back to work and ‘what if’ scenarios’. ‘..any writing report or action could be linked with the return, talking to managers. Or being present at meetings, that was valuable as well’.
‘Been there for me, to talk to the bosses and that and, kept, to try and keep me cool whenever I was getting angry about it’.
I valued most her offer, you know, because, just, just knowing that someone was offering to help and someone could actually intervene for me was valuable. And also, it was valuable to know that there was a service available for me. Because I didn’t know where to go from there, if you know what I mean, after the stroke, I knew I’d have to go back to work but I didn’t know where to start?’
Early identification and intervention for people who are working at
stroke onset is important in preventing job loss.
Support with a return to work typically occurs late in the stroke
pathway and many people who could benefit from support do not receive timely help, risking job loss.
Stroke survivors want stroke specialist input Employers want to communicate with health teams Existing impairment driven referral criteria for community stroke
services may prevent timely support being offered to stroke survivors and could contribute to job loss.
Implementing ESSVR requires additional resource (0.6 wte) and
training
Ability to provide timely, individually tailored support. People with stroke need intervention ‘early’, ‘later’ and
services that can ‘respond’ in a crisis and to changing needs over time.
In-reach to identify people with sudden onset conditions
early.
Condition (stroke) specific knowledge and VR
Knowledge
Go into the workplace Liaison isn’t enough. Need pathways for partnership
working with DWP, Indep and 3rd sector services to prevent people falling through service and sector gaps.
STROKE
Ask the work question
STROKE WARD Not Working at stroke onset/not intending to return
Working at stroke
Identified work needs Continue Stroke Pathway Stroke Specialist Vocational Assessment
RTW OT in ESD/Community Stroke/Community Neuro Team Identified work & rehab needs Working at onset
STROKE SPECIALIST Vocational Rehabilitation RTW OT
e.g. CST
Not Working/ intending to return
WORK SPECIALIST Service
DWP or Health Provider
Identified work & rehab needs Not Working at onset
VR SPECIALIST Service
e.g. Aylesbury
Factors that affect stroke survivors’ ability to work,
apply to most long-term health conditions
Disease related factors, e.g. fatigue, incontinence, falls,
cognitive difficulties, depression, pain
Disability related factors e.g. impaired mobility, sensation,
dexterity, loss of confidence
Environmental factors e.g. employer attitudes, the work
environment, attitudes and behaviours of healthcare professionals, family, travel to work.
Personal factors , e.g. beliefs and values, financial issues,
education, gender
People’s needs will be highly individualised depending on
where in disease trajectory/severity BUT personal, social and employment factors will determine NATURE/LEVEL of VR
Thinking Positively about work: A model of work support and vocational rehabilitation for people with cancer, Eva et al, 2012
A return to work should be an integral part of rehabilitation but
VR not always seen as the job of Health.
People with stroke need the right support at the right time –
Early intervention to prevent job loss. Different model Later, and Responsive to changing needs.
Parallels between stroke and other long term conditions Services need to develop to meet work needs of people with
long term conditions.
Health services need to develop mechanisms for cross sector
working and communicating with employers
Factors influencing a successful RTW are not limited to
disease or injury - personal, environmental and contextual factors are fundamental to employment success.
Need for RCT’s of vocational rehabilitation with process
evaluation to inform implementation
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Vocational Rehabilitation Specialist Service e.g. ‘Working Out’ Aylesbury Stroke Specialist Rehab plus Vocational Rehabilitation e.g. RTW OT in COMMUNITY STROKE or COMMUNITY NEURO TEAM VR Assessment, Signposting and Information Pack EARLY SUPPORTED DISCHARGE Work Status and Rehab Needs Identified STROKE WARD
Stroke TBI Cancer Neurological (PD, MS, Migraine, Epilepsy) Pain
Fatigue
Depression/ anxiety
Cognitive impairment
Loss of confidence
Poor mobility
Impaired vision
Sensory Loss
Factors affecting ability to work, for people with long-term health conditions Health and Work Service Workshop report , The Work Foundation, London, Tuesday 15th October