Leonard Matheson, PhD, CVE Vicki Kaskutas, MHS, OTR/L Mary Seaton, MHS, OTR/L

1. New Client-Centered Approaches to Work Rehabilitation of Persons with Acquired Brain ImpairmentWashington University School of Medicine Program in Occupational Therapy Leonard Matheson, PhD, CVE Vicki Kaskutas, MHS, OTR/L Mary Seaton, MHS, OTR/L Deborah Turley, BS, OTR/L Matthew Dodson, OTD, OTR Timothy Wolf, NIH T32 Pre-Doctoral Fellow

2. Historical OT Work Practice • OT Industrial Models from WWI • Work Hardening for Workers’ Compensation Clients • Rancho Los Amigos Hospital 1970’s • From AJOT 1985 > Current = 110 ± papers. • CARF 1987 > Current = 400 ± programs (high 1500 ±). • Musculoskeletal or neuromuscular injuries. • Focus on physical impairments & pain. • Usually Intervene after MMI or P&S. • Months or years post-injury.

3. Why the Historical Tie to MSD? Days Lost Work-Related InjuriesU.S. Private Industry Source: U.S. Bureau of Labor Statistics 2005

4. Current Work Practice • Workers’ Comp injury funding. • Musculoskeletal or neuromuscular injuries. • Focus on physical impairments & pain. • Work Conditioning often in place of WH. • Usually Intervene after MMI or P&S. • Weeks or months post-injury.

5. Why expand beyond MSD to ABI? • Emerging Occupational Problem in U.S. • 1 million ED visits annually for TBI; >90% are MTBI • 15% with MTBI impaired 1 year later. • Illness-related ABI rapidly increasing. • Societal Changes: • Aging Workforce, Warfare, & Terrorism. • Emerging Technologies: • Imaging • OT Alternatives to Neuropsych testing • OT’s have a great skill set for ABI & Work!

6. Driving Beliefs & Values • Work is one of seven OT domains that must be raised with all clients of working age. • OT must address work whenever the client identifies work as a priority, no matter the setting. • Early intervention prevents loss of worker role. • Many people with cognitive impairments can work. • People need to experience successes and failures to make a realistic self-appraisal of work capacity.

7. New Work Practice Possibilities • Mix of funding sources for expanded OT services. • Full range injuries and illnesses. • Focus on occupational performance limitation and interface of person – environment – job demands. • Intervene before MMI or P&S. • Weeks post-injury. • Usually pre-discharge from medical care.

8. New Model of OT Work Practice • Occupational Performance Center (OPC) • Client-centered, job-focused, in-hospital. • Assessment & work rehab for in / out patients. • Small footprint & efficient space utilization. • Re-usable structured simulations for eval & intervention. • Collaboration: • Washington University Program in Occupational Therapy • HealthSouth Corporation • The Rehabilitation Institute of St. Louis

9. OCCUPATION OCCUPATIONAL PERFORMANCE AND PARTICIPATION PERFORMANCE SOCIAL SUPPORT PHYSIOLOGICAL SOCIAL & ECONOMIC SYSTEMS COGNITIVE PERSON (INTRINSIC FACTORS) ENVIRONMENT (EXTRINSIC FACTORS) CULTURE & VALUES SPIRITUAL BUILT ENVIRONMENT & TECHNOLOGY NEUROBEHAVIORAL PSYCHOLOGICAL NATURAL ENVIRONMENT PEOP Christiansen and Baum, 1991,1997, 2003

10. WUOT Occupational Performance CenterService Goals • Support healthy future orientation & maintain motivation. • Increase social participation. • Enhance quality of life through work. • Help people make informed decisions if they can’t work. • Smooth transition from hospital to community.

11. WUOT Occupational Performance CenterClient-Centered Interventions • OPC Structured Intake Interview • Job Performance Measure • Selective standardized ability testing • O*NET Ability Questionnaire • Structured Work Activity Groups (SWAG) • Occupational performance alternatives to neuropsychological testing

12. OPC OT Work Rehab Process • Understand the role of work in the client’s life prior – get an occupational history. • Understand client’s work goals; client-centered care. • Identify client’s supports and barriers to achieving work goals. • Measure and understand client’s work. • Measure baseline performance relative to target job.

13. OPC OT Work Rehab Process • Compare present performance to level needed on the job. • Develop treatment plan. • Use simulated and real work, best to get into the context of the actual workplace for trials. • Measure the feasibility of the client to be an employee. • Identify accommodations needed and work with employer to get these into place.

14. Case #1: Doug • 33 year-old s/p resection of cancerous brain tumor (oligodendroglioma in the left parietal lobe). • Seizure disorder post-surgically. • Impairments identified by Doug include: • Word finding problems • RUE/LE tingling

15. Occupational History • Understand the client’s work and education history and the role work plays in the client’s life. • Identify the client’s vocationally related successes and failures. • Occupational Profile • Determine who the client is, their needs/concerns, and how these concerns affect engagement in occupational performance. (Practice Framework, 2002)

16. Doug’s Occupational History • Early in long-planned-for career. • Bachelor’s in Psychology • Master’s in Industrial / Organization Psychology • Job as Lead in Change Management for a large international corporation for 1 year • 4 years experience in Change Management

17. Vocational Goals • Employment interests & pursuits • Employment seeking & acquisition • Job performance • Retirement preparation & adjustment • Volunteer exploration • Volunteer participation (Practice Framework, 2002)

18. Doug’s Work Goals • Return to previous job as Change Management Lead for a Fortune 500 corporation on a part-time basis • Gradually increase to full-time work • Identify accommodations needed to work

19. Doug’s Supports & Barriers • Financial • 75% short term disability, wife employed • Emotional • Family and employer very supportive • No premorbid history, no obvious problems • Physical • Skull wound healing, but impairment evident • Physically fit prior to incident and now • Vocational • Good educational preparation • Loyal employee with strong work ethic • Large, stable employer • Job requires high level of processing, organization, & interaction

20. Generic Job Analysis Tools • Dictionary of Occupational Titles • http://www.occupationalinfo.org • Work description • Physical demand level (weight lifted) • Sedentary, Light, Medium, Heavy, Very Heavy • O*NET (Occupational Information Network) • http://online.onetcenter.org • Tasks, Skills, Abilities, Knowledge, Work Activities, Work Styles, Work Context, Work Values, Interests, Wages & Employment

21. Client-Specific Job Analysis • Worker interview • Employer’s interview • Employer’s written job description • On-site evaluation by OT • Analyze tasks performed, skills, positions, pace and rate of work, equipment, tools/machines, contexts, personal protective equipment, schedule, habit, routines.

22. Job Performance Measure (JPM) • Individualized interview process to identify tasks from the the client is required to perform on his or her job. • The client rates his or her performance & satisfaction on a 10-point scale. • Modeled after Canadian Occupational Performance Measure (COPM) using O*NET content structure. • Used to: • Identify focus of assessment and intervention. • Identify metacognitive inconsistencies & safety concerns. • Track status and progress.

23. Doug’s Assessment Results • Oral Directions Test – 75% white male machinists • Wonderlic Personnel Test – • Norm reference: 62% total pop., 17% college grads • Criterion reference: Doug – 23, manager/supervisor – 26 • Structure Work Activity Group • Needed to listen to messages twice to ensure accuracy and understand the details. • When multitasking his verbal comprehension decreases. • Effective organization noted, used memory tools indep.

24. Doug’s Treatment Plan • Long Term Goals • Perform the essential functions of his job at a level competitive for employment. • Return to previous job on modified schedule in 1 mos. • Effectively negotiate work accommodations with employer. • Short Term Goals • Visit worksite and effectively interact with coworkers and supervisor. • Use tape recorder effectively during work simulation. • Teach self how to use a new software program. • Prepare/deliver a training intervention to a small group.

25. relation to work evident more client centered specific conditioning equipment readily available can be graded not intrinsically motivating equipment specific longer set up time can use with few clients therapist’s unfamiliarity larger space required Purposeful SimulatedWork Advantages Disadvantages

26. relation to work evident very client centered intrinsically motivating very specific conditioning encourages self management easily transferable best predictor of job performance supplies not easy to get as job specific equipment expensive harder to grade equipment specific longer set up time can use with 1 client therapist unfamiliarity larger space required Occupation-Based Actual Work Advantages Disadvantages

27. Feasibility Evaluation Checklist • General criteria for competitive employment are observed during administration of test protocol & work simulations • Productivity • Attendance, quality/quantity of work, tolerance to work • Safety • Safety rules, protective behavior, body mechanics, maintain work environment • Interpersonal Behavior • Self awareness, interaction, response to supervision, attitude • Separate forms for OT and client self-report

28. Doug’s FEC • Accurate perception of his skills and behaviors • Productivity • Rated quantity less with unfamiliar tasks • Quality was good with all tasks • Safety • Interpersonal Behavior • Good coworker/employee behaviors noted • Response to change rated lower, dress code too!

29. Reasonable Accommodations • Job Accommodations Network http://www.jan.wvu.edu/ • Worksite accessibility • Job restructuring • Reallocating marginal job functions that an employee is unable to perform because of a disability; altering when and/or how a function, essential or marginal, is performed. • Modified work schedules & leaves • Adjusting arrival or departure times, providing periodic breaks, altering when certain functions are performed, allowing an employee to use accrued paid leave, or providing additional unpaid leave. • Modified policies • Modifying leave policies, making accommodations for conduct standards, modified dress code or hygiene requirement, working from home • Equipment & services • Equipment to modify the environment, personal need items may get accommodation, Personal Assistance Services in the form of work-related assistance (such as readers, help with lifting or reaching, page turners), but generally not for personal attendant care

30. Doug’s Return to Work Plan • Modified work schedule – half days x 6 wk • Resume work roles gradually • Use of tape recorder, especially in meetings

31. Doug’s Perspective • Response to intervention & first 6 months on the job. • Life now.

32. WUOT Occupational Performance CenterClient-Centered Interventions • OPC Structured Intake Interview • Job Performance Measure • Selective standardized ability testing • O*NET Ability Questionnaire • Structured Work Activity Groups (SWAG) • Occupational performance alternatives to neuropsychological testing

33. OPC Structured Intake Interview • Initial Vocational PlanHighlights: • Job Duties & Work Environment • Earnings & Leave Status • Perceived Job-Function Limits • Work History • Stated Vocational Goals • Favorite Activities I Can’t Do • Initial Assessment Plan & Work Goals

34. Work-Oriented Measures • Personnel Test for Industry Oral Directions Test • Wonderlic Personnel Test • Career Assessment Inventory • Watson-Glaser Critical Thinking Appraisal • Most norm-referenced to employee groups. • More valid for work than neuropsych tests.

35. Personnel Test for IndustryOral Directions Test • Paper & pencil test of ability to follow oral directions. • Very useful screening tool for persons whose brain injury affects cognition. • Can be administered in a group setting. • Sometimes frustrating experience for client. • Monologue is read from script or CD-ROM. • 39 items, 15 minutes.

36. Wonderlic Personnel Test • Predicts ability to learn, understand, and solve problems on the job. • Most highly researched preplacement screening test in the U.S. • Compare client’s abilities to the abilities of people in hundreds of occupations. • 50 items, timed 12 minutes.

37. Career Assessment Inventory • Compares interests of the client in terms of Holland Occupational Types system. • Two different levels, one for persons with high school or less education and the other for persons with college education. • Links client’s interests to thousands of occupations. • 305 or 370 items, untimed, approx. 45 minutes.

38. Structured method to aggregate O*NET Task Domain information to initiate the client-centered job description process. Begin with blank form and populate from O*NET Download Task Detail Excel spreadsheet, including “Importance” scores. OPC offers 25 OAQ for our most typical clients on the OPC website. O*NET Ability Questionnaire

39. Feasibility Evaluation Checklist • Acceptability of client to employers. • Three groups of constructs: • Productivity • Safety • Interpersonal Behavior • Separate observation and self-report. • Comparing Obs to SR is excellent feedback. • 23 items, untimed, approx 5 minutes.

40. Structured Work Activity Group (SWAG) Guiding Principles • Each SWAG is a suite of related work activities centered on a “real world” theme that is housed within a virtual business. • Client is challenged with progressive demands, based on the client’s demonstration of competence. • Employee behavior is frequently evaluated. • Inexpensive easy to replicate. • Widely disseminated.

41. SWAGs Available • SWAG 1: St. Francis International Library • 150 overdue patrons, overbooked conference rooms, a stopped-up toilet in the ladies’ room, and a sick child. • SWAG 2: Gepetto’s Workshop • Safety training • Woodworking • Assembly of doll chair, wheelbarrow, and student’s bunk bed. • SWAG 3: St. Francis Hospital (soon) • Medical telephone triage • Emergency Department report rounds • Patient Treatment Unit Clerk

42. SWAG #1 Library Activities 1. Calculate Fines & Replacement Costs 2. Bookkeeping - State / Province Analysis 3. Bookkeeping - Current Inventory Control 4. Bookkeeping - Future Inventory Control 5. Mailing - Notices of Overdue Fines 6. Database Maintenance - Mailing List 7. Telephone Message Taking 8. Conference Room Scheduling

43. Mailing List Maintenance

44. Library Fines and Replacement Costs 2001: A Space Odyssey MacDonald, Nippy 2006 Breezeland Lane Wrightsville Beach, NC 28412 $6.38 $18.95

45. SWAG #2 Workshop Activities 1. Safety Training 2. Wood Alphabet Fabrication 3. Wheelbarrow Assembly 4. Doll Chair Assembly 5. Bunk Bed Assembly

46. OPC Resources • OPC Website • Resources for download: • OPC & SWAG forms • SWAG instructions • Slideshow downloads • Test publishers and purchase prices. • http://notesplace.wustl.edu/ot_opc

47. Case # 2: Joanne • 65-year-old female. • Stroke 1 month previously. • Impairments • Left Visual acuity & Visual Field • Concentration/ Processing speed • Mobility & Balance • Speech • Right hand sensation and fine motor skills • UE & LE Bilateral Weakness • Assertive and headstrong.

48. OPC Intake with Joanne • VP of Commercial Properties, earning $80,000 per year. • Highly motivated to return to previous work. • Client’s description of Work Activity Demands, Context & Performance Patterns • Specific routine and non-routine activities & tasks • Personnel hierarchy, relationships and supports

49. OPC Intake with Joanne • Goals • Not working was not an option. • Wants to return to full time work in 4 weeks. • Wants to work 5 more years. • Self-Perceived Occupational Limitations • Typing • Working on Computer • Reading • Speech • Thinking (!)

50. Initial OPC Assessment of Joanne • PTI Oral Directions Test • Untimed & repeated items = 10th percentile • Frustrated with writing and coordination problems. • Difficulty with concentration. • Wonderlic Personnel Test • Raw Score = 9, Age adjusted Score = 14 • Real Estate Manager = 24 minimum • Middle Management Job Family = 27 minimum