Navigating Community Reintegration for Individuals with Disabilities

1. Navigating Community Reintegration for Individuals with Disabilities Courtney Laser, PT Baton Rouge Rehabilitation Hospital

2. Work Statistics • Individuals with disabilities have higher rate of unemployment than individuals without disabilities • Allsup disability study for 4th quarter, 70% higher unemployment rate • Unemployment rate is 12.4% for individuals with disabilities

3. Stroke • Strokes are occurring in working age population • 45% survivors are less than 65 years old • 27% survivors are less than 55 years old • Return to work after stroke ranges from 19-73%

4. Spinal Cord Injury • Return to work after a spinal cord injury ranges from 21-67% • Employment rate 1 year post injury 11.7%, 20 years post 35.2% • Young men have higher incidence of spinal cord injuries

5. Traumatic Brain Injury • Receiving much more attention due to increasing number of younger soldiers with post-war injury • 40% return to work after 1-2 years post injury

6. Barriers for Return to Work • Transportation greatest issue with return to work • Employment opportunities • Job choice and available hours • Wages are lower among disabled individuals • Education Level • Age

7. Continuum of Care • Goal is a seamless transition throughout the rehab process • Inpatient Rehabilitation through community reintegration

8. Speech Pathologist Case Management Rehab Counselor PATIENT FAMILY Physical Therapist Occupational Therapist Nurse Dietician Physician Interdisciplinary Rehab Model Recreation Therapist Respiratory Therapist

9. Interdisciplinary Team • Physiatrist • specialize in physical medicine and rehabilitation • Nurse • provides daily medical care • Dietician • manages dietary requirements • Case Manager • discharge planning

10. Interdisciplinary Team • Recreation Therapist • provides leisure activities • Respiratory Therapist • respiratory support • Rehabilitation Counselor • psychosocial support • vocational rehab

11. Physical Therapists • Treat the musculoskeletal and neuromuscular impairments that affect movement and function • Focus on strength, balance, posture, pain management, coordination and quality of movement • “Gross Motor” • Assess need for wheelchair, ambulatory device and orthotics

12. Occupational Therapists • Maximize independence in activities of daily living (ADLs) • Focus on incorporating strength, balance and coordination into application of skill • Treat movement of the upper extremities • Treat cognitive and visual deficits • “Fine Motor”

13. Speech-Language Pathologists • Cognitive Development • Memory, sequencing, executive function • Behavior modification • Communication -written and verbal • Swallowing

14. Patient • Know the patient’s life roles • Learn who the patient is besides the injury/disability • Spouse/Partner • Parent • Employment • Recreation/Leisure

15. Rehabilitation • Identify needs for physical and cognitive deficits • Identify potential functional progress • Therapists’ treatments are based on research and clinical experience • Dealing with long term disability • if patient does not return to prior level of function, can still function in new way

16. Rehabilitation • Modifications of living situation, mobility and roles/responsibilities • different living environments • wheelchair for mobility versus ambulating • orthotics to compensate for muscle strength • adaptive equipment for ADLs

17. Inpatient Rehabilitation • Length of stay dependent on payer and patient progress • Learn how to regain self-care, mobility and cognitive skills • Focus is on working within current functional level and building upon recovery • Task will be relearned or compensatory strategies • Working within the closed environment of the rehab setting

18. Inpatient Rehabilitation • Counselors educating patient and family on their diagnosis and prognosis • neurologic events impact the whole family unit • Importance of family involvement and support • Remain hopeful but prepare • Understand the grieving process • Prepare for discharge • Patient and family educated how to continue in home setting • Implications of living in a different facility

19. Outpatient Rehabilitation • Regaining self-care, mobility and cognitive skills • May experience return of muscle groups providing greater independence and reducing adaptive equipment • Continue to work in a closed environment and progress into more community based • improve application of skills learned in closed environment

20. Outpatient Rehabilitation • Progress function to improve independence • Therapists must find the balance focusing on return of function and independence with current function -Advanced Technology

21. Outpatient Rehabilitation • Skills focused on return to work/school • Found in research that rehab does not have a great focus on return to work • Focus on eliminating the barriers that exist in returning these populations to work, school and leisure

22. Outpatient Rehabilitation • Counseling continues on diagnosis and prognosis • Assist patient and family with their relationships, as roles may have change • Social interactions and interpersonal communication • Understanding that therapy is not a life long process • Locating resources • Begin vocational rehabilitation process

23. Assistive Technology • Assistive technology enables the patient to become more independent with self-care, work/school and leisure • Mobility and independence will be maximized with good working relationship of therapist and assistive technology practitioner (ATP)

24. Assistive Technology • Low tech and high tech • Communication • Manipulation • Mobility

25. Selecting A Wheelchair • Diagnosis and prognosis • Physical function • Activities • Environments • Transportation • Funding

30. Driving • Driving is associated with successful community reintegration • Ability to drive safely is impacted in these populations • Requires physical function and higher level of cognitive functioning • Can begin driving process as therapists’ feel patient is able to manage in the community and cleared by physician • May occur during outpatient therapy or years later

31. Driving Evaluations • Completed by Driving Rehab Specialist (DRS) • Clinical Assessment • Vision Skills • Cognition • Strength and Range of Motion • Sensation • Coordination • Balance • Break Reaction Time

32. Driving Evaluations • On Road Assessments • Ability to transfer self and adaptive equipment into car • Management of vehicle controls • Maneuvering of vehicle • Road management • controlling speed, appropriate lane changes and stops, and following road rules/laws • Judgment and decision making

33. Results of Driving Evaluation • Determine if patient is safe to drive, with or without modifications • Determine what adaptive equipment is needed • vehicles will not be modified without DRS recommendations • Driver’s training • Rehabilitation is needed to further improve skills

34. Adaptive Driving Equipment • Adapted vehicle can give the patient independence in the community • Modifications can be made to car, truck or van • vehicle decision will involve patient, DRS and qualified vehicle modification dealer • Physical ability may determine type of vehicle • transfer in/out • must drive from wheelchair

37. Primary Driving Controls • Used with impaired arm and hand function

38. Pedal Adaptations

39. Hand Controls

42. Return to Work • Good communication of therapists and vocational rehab counselors is important • What barriers exist in returning to work • internal or external • modifications • Work goals must be realistic • Motivation to return to work

43. Recreation • Sports provide psychological and physical benefits

44. Conclusion • Individual can have same roles with modifications • It is important for the continuum of care, from rehab to community reintegration to remain patient centered • The return to work barrier of transportation can be decreased with education and access to vehicle modifications • vocational rehab should be initiated before patient is wanting to return to work and/or drive

45. Patient Centered • Individuals with disabilities may have greater self acceptance, life satisfaction, personal relationships, financial independence and overall greater quality of life with return to work

46. References • Berkowitz M (1998). Spinal Cord Injury: An analysis of medical and social costs. Demos • Hackett M, Glazier N, Jan S, Lindley R (2012). Returning to paid employment after stroke: The psychosocial outcomes in stroke (POISE) cohort study. Plos ONE, 7(7). • Obrien A, Wolf T (2010). Determining work outcomes in mild to moderate stroke survivors. Work 36, 441-447. • Ownsworth T (2010). A metacognitive contextual appoach for facilitating return to work following acquired brain injury: Three descriptive case studies. Work 36, 381-88. • Treger I, Shames J, Giaquinto S, Ring H (2007). Return to work in stroke patients. Disability and Rehabilitation, 29(17), 1397-1403. • Lidal I, Huynh T, Biering-Sorensen F (2007). Return to work following spinal cord injury: a review. Disability and Rehabilitation, 29(17) 1341-1375.

47. References • Social Security Disability Representation. www.allsup.com • National Spinal Cord Injury Statistical Center. www.nscisc.uab.edu • www.ride-away.com • Job Accommodation Network. www.askjan.com