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Whatever it Takes.: A model for community-based services
Abstract
The Whatever It Takes model is presented as an extension of the medical/rehabilitation model. It is not presented as an alternative to the rehabilitation model, although it does represent an opposition to the manner in which the model is typically implemented in community-based programmes for individuals with acquired brain injury. After brain injury, medical complications persist and a strictly anti-medical model in a community-based programme is unwise. On the other hand, community-based programmes that attempt to treat the individual, or provide rehabilitation services, in the absence of careful consideration of environmental barriers or the need for natural supports, are not likely to meet the long-term community reintegration needs of the individual, and may be unjustly using up finite resources. There are numerous complications associated with living with the effects of acquired brain injury. There also is considerable complexity associated with a health-care system and reimbursement system that emphasize acute care. Given these complexities, and the strong probability that a cure for brain injury is not likely to be found within the next decade, even the most learned professionals in brain injury are likely to say that practical solutions are needed for the present. Most notable is the late Dr Sheldon Berroll, who provided so much leadership to the field, but when asked about solving the day-to-day problems for an individual, would often respond: 'Do whatever it takes'. This advice was not presented in desperation, but rather as practical guidance. We have attempted to describe the whatever it takes approach, and to provide some guidelines for its implementation in community integration programmes.
... For a person with ABI, returning to work has been identified as an important stage in rehabilitation, and is central to improved quality of life in the long term (Cullen, Chundamala, Bayley & Jutai, 2007;Willer & Corrigan, 1994). However, very little research has been published on the economic impacts, efficacy or costs of vocational rehabilitation, and those that do exist are most often with early postinjury groups (Humphreys et al., 2013;Radford et al, 2018). ...
... Employment CoLab aligns with recommendations from existing research, including the importance of: (1) a collaborative team approach, tailored to the person with ABI and the employer, with attention paid to the workplace, employer and work colleagues (Donker-Cools, Daams, Wind & Frings-Dresen, 2016;McRae et al., 2016;van Velzen et al., 2011); (2) support to disclose a person's ABI to the employer (Piccenna et al., 2015); (3) identification of modifiable workplace practices that may aid employee performance (Alves et al., 2020); (4) return to work plan of work tasks, job coach and coping strategies (Ntsiea, Van Aswegen, Lord & Olorunju, 2014); (5) pre-vocational skills training for the employee with ABI (Powell et al., 2015;Steel, Buchanan, Layton & Wilson, 2017); (6) work trial, and on-the-job training (Piccenna et al., 2015;Willer & Corrigan, 1994); and (7) ongoing episodic/intermittent support for the employee with ABI, the employer and/or work colleagues as required (Bond, 2004;Hart et al., 2010), and for the lifetime of the role (Willer & Corrigan, 1994). This paper details a pilot and evaluation of Employment CoLab undertaken in collaboration with a vocational rehabilitation specialist service in Melbourne, Victoria, with one of their employees assigned to the role of CoLab consultant. ...
... Employment CoLab aligns with recommendations from existing research, including the importance of: (1) a collaborative team approach, tailored to the person with ABI and the employer, with attention paid to the workplace, employer and work colleagues (Donker-Cools, Daams, Wind & Frings-Dresen, 2016;McRae et al., 2016;van Velzen et al., 2011); (2) support to disclose a person's ABI to the employer (Piccenna et al., 2015); (3) identification of modifiable workplace practices that may aid employee performance (Alves et al., 2020); (4) return to work plan of work tasks, job coach and coping strategies (Ntsiea, Van Aswegen, Lord & Olorunju, 2014); (5) pre-vocational skills training for the employee with ABI (Powell et al., 2015;Steel, Buchanan, Layton & Wilson, 2017); (6) work trial, and on-the-job training (Piccenna et al., 2015;Willer & Corrigan, 1994); and (7) ongoing episodic/intermittent support for the employee with ABI, the employer and/or work colleagues as required (Bond, 2004;Hart et al., 2010), and for the lifetime of the role (Willer & Corrigan, 1994). This paper details a pilot and evaluation of Employment CoLab undertaken in collaboration with a vocational rehabilitation specialist service in Melbourne, Victoria, with one of their employees assigned to the role of CoLab consultant. ...
Background and objectives: In Australia, people with disability continue to experience low employment rates (48%), compared to the national average (79%), and employment is even lower (30%) for people with acquired brain injury (ABI). This paper evaluates a pilot study of a new mainstream employment pathway following ABI, called Employment CoLab.
Method: Employment CoLab was piloted across multiple industries using a mix of reasonable employer adjustments, insurance-funded supports and/or access to capacity-building supports. Semi-structured interviews were undertaken with four stakeholders; (1) Employees with ABI (n =5, age 31-49 years, time since injury M(R)=11(4-26) years); (2) Employers/co-workers (n =3); 3) Allied health professionals / vocational providers (n =4); and (4) Injury insurance funders who hold portfolio responsibility for disability employment (n =5). An explorative economic evaluation was also conducted to compare the cost to the funder for Employment CoLab compared to traditional employment pathways.
Results: Employment CoLab offered a new approach for people with ABI to gain and sustain open employment. Four major themes were identified from participant interviews: valuing employment and diversity; barriers to mainstream employment; reflections on being employed; and being supported over time. The economic evaluation was unable to detect if the pathway was, or was not, less costly when compared to traditional employment pathways.
Conclusions: Employment CoLab is a person-centred collaborative approach which, together with effective social disability insurance approaches, has built new opportunities for inclusive mainstream economic participation following ABI.
... Returning to work is an important stage in rehabilitation for a person with ABI, and long been identified as central to effective community-based support and improved quality of life long term (Cullen, Chundamala, Bayley & Jutai, 2007;Willer & Corrigan, 1994). However, a range of factors have been identified that may lead to poor employment outcomes following ABI. ...
... This plan aligns with the recommendations of Ntsiea and colleagues (2014), as it includes an evaluation of the working tasks, hours, environment, job coaching and advice on coping strategies. Furthermore, Employment CoLab includes a work trial and on-the-job training, both of which have been identified as enablers to increasing employment and productivity following ABI (Piccenna et al., 2015;Willer & Corrigan, 1994). ...
... This is enabled by Australia's new no-fault lifetime support scheme of the NDIS. It is also consistent with the return to work approach described by Willer and Corrigan (1994) that includes flexible, individualised placement and support and a lifetime resourcing focus, as enablers to return to work following ABI. In addition, they identified that for those with the most severe injuries, 'needs of individuals last a lifetime; so should their resources', and they discussed the importance of services being planned for the life of the individual or, at least, until they are no longer needed (Willer & Corrigan, 1994, p. 657). ...
Background and objectives
People with acquired brain injury (ABI) have traditionally experienced low employment rates, compared with the national average and others with disability in Australia. To positively impact mainstream economic participation following ABI, a co-design approach was used to investigate open employment pathways available and consider necessary pathway features to enable employment for people with ABI.
Method
A qualitative focus group methodology was used with four groups: people with ABI; health professionals working with this group; employers providing work for people with ABI and social and injury insurers funding employment services. The project was delivered in two phases: (1) review existing work pathways in Australia and gather knowledge about enablers and barriers to employment following ABI and (2) use ABI lived experience, employers’ experience and allied health and social insurer expertise to develop a new pathway to mainstream employment.
Results
Co-design helped to identify enablers and barriers to employment of people with ABI, as well as practical strategies to facilitate workplace diversity and inclusion. Enablers included replacing interviews with an onsite assessment to meet key staff and trial work tasks, employer education on ABI, the use of compensatory cognitive aides and graded on-the-job support. This guided the development of a new employment pathway, tailored for people with ABI, called ‘Employment CoLab’.
Conclusions
The Employment CoLab pathway, when coupled with person-centred collaborative and effective social disability insurance approaches, offers opportunities to build inclusive, sustainable and scalable economic participation and mainstream wages for people with ABI.
... This finding suggests that different strategies and additional efforts will be required to promote vaccination in this group. Among those who did not want to get vaccinated but were willing to discuss vaccination, the top reason for not wanting to get vaccinated was that it was not a top priority due to more pressing needs; providing clients with food, hygiene, referrals to housing, and medical and mental health care may assist them in meeting their basic needs and allow them to prioritize COVID-19 prevention [30,31]. ...
Unhoused people have higher COVID-19 mortality and lower vaccine uptake than housed community members. Understanding vaccine hesitancy among unhoused people is key for developing programs that address their unique needs. A three-round, rapid, field-based survey was conducted to describe attitudes toward COVID-19 vaccination. Round 1 assessed vaccine brand preference, round 2 assessed intention to accept a financial incentive for vaccination, and round 3 measured vaccine uptake and assessed reasons for vaccine readiness during implementation of a financial incentive program. A total of 5177 individuals were approached at COVID-19 vaccination events for unhoused people in Los Angeles County from May through November 2021. Analyses included 4949 individuals: 3636 (73.5%) unsheltered and 1313 (26.5%) sheltered. Per self-report, 2008 (40.6%) were already vaccinated, 1732 (35%) wanted to get vaccinated, 359 (7.3%) were not yet ready, and 850 (17.2%) did not want to get vaccinated. Brand preference was evenly split among participants (Moderna 31.0%, J&J 35.5%, either 33.5%, p = 0.74). Interest in a financial incentive differed between those who were not yet ready and those who did not want to get vaccinated (43.2% vs. 16.2%, p < 0.01). After implementing a financial incentive program, 97.4% of participants who indicated interest in vaccination were vaccinated that day; the financial incentive was the most cited reason for vaccine readiness ( n = 731, 56%). This study demonstrated the utility of an iterative, field-based assessment for program implementation during the rapidly evolving pandemic. Personal engagement, a variety of brand choices, and financial incentives could be important for improving vaccine uptake among unhoused people.
... La atención a los factores contextuales en rehabilitación se ve reforzada por el marco de la Organización Mundial de la Salud que enfatiza el funcionamiento de un individuo dentro del contexto de su entorno 26 . Willer et al, sugieren que el tratamiento naturalista aumenta los resultados funcionales, aborda los problemas de generalización y mejora la satisfacción y la autodirección del paciente 27 . La evidencia respalda el valor de realizar algunos aspectos de la rehabilitación dentro del entorno natural, situación que ocurriría al aplicar el protocolo del TeleCIMT en el hogar. ...
Resumen
Introducción: El actual escenario de pandemia resulta inmensamente desafiante en el ámbito de la salud. Específicamente en neurorrehabilitación, los profesionales se deben adaptar al contexto e implementar cambios en los modelos de atención que permitan entregar un servicio amplio en cobertura, seguro y efectivo. La evidencia actual plantea que la telerehabilitación aplica en sujetos con patologías neurológicas, alcanza resultados similares a las estrategias de rehabilitación presenciales. Sin embargo, la variabilidad de las modalidades empleadas y la baja calidad metodológica de los estudios, dificultan alcanzar sus beneficios. Explorar los beneficios de Contraint Induced Movement Therapy (CIMT) en modalidad a distancia (TeleCIMT), permitiría disponer de una valiosa estrategia para mejorar el acceso y la eficacia en el proceso de rehabilitación. Métodos: Estudio experimental prospectivo de grupo único, evaluado en tres ocasiones utilizando Motor Activity Log-30 y Action Research Arm y ECVI-38. La diferencia entre estas mediciones expresará el progreso o retroceso obtenido a través TeleCIMT. Los efectos serán examinados mediante análisis de varianza unifactorial intrasujetos empleando el tiempo de medición como variable independiente y las medidas de recuperación como variables dependientes. Resultados esperados: A través de esta propuesta, se busca ampliar la evidencia en telerehabilitación en sujetos con patologías neurológicas. Promoviendo el acceso a rehabilitación, entregando continuidad en los procesos terapéuticos y revirtiendo los niveles de discapacidad.
... According to Willer and Corrigan [17], the recovery of motor, learning or cognitive functions in environments familiar to the patient, is a key ingredient to maximizing the results of good rehabilitation therapy. Virtual reality technologies play a crucial role towards this recovery process, enabling the therapist to reconstruct an immersive virtual scene where the patient can practice, and which is very close to the home environment. ...
In recent years, the need to contain healthcare costs due to the growing public debt of many countries, combined with the need to reduce costly travel by patients unable to move autonomously, have captured the attention of public administrators towards tele-rehabilitation. This trend has been consolidated overwhelmingly following the Covid-19 pandemic, which has made it precarious, difficult and even dangerous for patients to access hospital facilities. We present an approach based on the rapid prototyping of virtual reality, cognitive tele-rehabilitation exercises, which reinforce the group of exercises available in the Nu!reha platform. Patients who experienced injury or pathology need to practice continuous training in order to recover functional abilities, and the therapist needs to monitor the outcomes of such practices. The group of new exercises based on the rapid prototyping approach, become crucial especially in this pandemic period. The Virtual Reality exercises are designed on Unity 3D to empower the therapist to set up personalized exercises in an easy way, enabling the patient to receive personalized stimuli, which are essential for a positive outcome in the practice. Furthermore, the reaction speed of the system is of fundamental importance, as the temporal evolution of the scene must proceed parallel to the patient’s movements, to ensure an effective and efficient therapeutic response. So, we optimized the virtual reality application in order to make the loading phase and the startup phase as fast as possible and we have tested the results obtained with many devices: in particular computers and smartphones with different operating systems and hardware. The implemented method powers up the Nu!Reha system®, a collection of tele-rehabilitation services that helps patients to recover cognitive and functional capabilities.
... According to Willer and Corrigan [34], the recovery or learning of motor or cognitive functions in the environments where it will be expressed, is the ingredient to maximize the result of a good rehabilitation therapy. The immersion deriving from the use of virtual reality instruments is winning: the patient, through the use of instruments that allow the play-therapeutic experience in three dimensions, finds himself immersed in an environment as similar as possible to the real one. ...
In recent years, the need to contain healthcare costs due to the growing public debt of many countries, combined with the need to reduce costly travel by patients unable to move autonomously, have captured the attention of public administrators towards tele-rehabilitation. This trend has been consolidated overwhelmingly following the Covid-19 pandemic, which has made it precarious, difficult and even dangerous for patients to access hospital facilities. We present a platform devoted to the rapid prototyping of Virtual Reality based, cognitive tele-rehabilitation exercises. Patients who experienced injury or pathology need to practice a continuous training in order to recover functional abilities, and the therapist need to monitor the outcomes of such practices. The Virtual Reality exercises are designed on Unity 3D to empower the therapist to set up personalised exercises in a easy way, enabling the patient to receive personalized stimuli, which are crucial for a positive outcome of the practice. Furthermore, the reaction speed of the system is of fundamental importance, as the temporal evolution of the scene must proceed parallel to the patient’s movements, to ensure an effective and efficient therapeutic response. So, we optimized the Virtual Reality application in order to make the loading phase and the startup phase as fast as possible and we have tested the results obtained with many devices: in particular computers and smartphones with different operating systems and hardware. The implemented platform integrates in Nu!Reha system®, a tele-rehabilitation set of services that helps patients to recover cognitive and functional capabilities.
Introduction:
Novel strategies are needed to address barriers to COVID-19 vaccination among people experiencing homelessness, a population that faces increased COVID-19 risk. Although growing evidence suggests that financial incentives for vaccination are acceptable to people experiencing homelessness, their impact on uptake is unknown. This study aimed to assess whether offering $50 gift cards was associated with the uptake of the first doses of COVID-19 vaccine among people experiencing homelessness in Los Angeles County.
Methods:
Vaccination clinics began on March 15, 2021; the financial incentive program was implemented from September 26, 2021 to April 30, 2022. Interrupted time-series analysis with quasi-Poisson regression was used to evaluate the level and slope change in the number of weekly first doses administered. Time-varying confounders included the weekly number of clinics and the weekly number of new cases. Demographic characteristics were compared for people experiencing homelessness vaccinated before and after the implementation of the incentive program using chi-square tests.
Results:
Offering financial incentives was associated with the administration of 2.5 times (95% CI=1.8, 3.1) more first doses than would have been expected without the program. Level (-0.184, 95% CI= -1.166, -0.467) and slope change (0.042, 95% CI=0.031, 0.053) were observed. Individuals who were unsheltered, aged <55 years, and identified as Black or African American accounted for a higher percentage of those vaccinated during the postintervention period than during the preintervention period.
Conclusions:
Financial incentives may be an effective tool for increasing vaccine uptake among people experiencing homelessness, but important ethical considerations must be made to avoid coercion of vulnerable populations.
People experiencing homelessness (PEH) have been disproportionately affected by COVID-19, yet their vaccination coverage is lower than is that of the general population. We implemented a COVID-19 vaccination program that used evidence-based and culturally tailored approaches to promote vaccine uptake and equity for PEH in Los Angeles County, California. From February 2021 through February 2022, 33 977 doses of vaccine were administered at 2658 clinics, and 9275 PEH were fully vaccinated. This program may serve as a model for future service delivery in vulnerable populations. (Am J Public Health. Published online ahead of print December 1, 2022:e1–e5. https://doi.org/10.2105/AJPH.2022.307147 )
Traumatic brain injury (TBI) is one of the most complex diseases. Since the advent of imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI), there has been a quest to develop complementary diagnostic tools to provide more accurate assessment of injury severity and to improve outcome prediction. The progress has been slow. Because of this shortcoming, the treatment of TBI remains largely symptomatic and reactive rather than proactive.
Historically, persons with disabilities have been viewed differently within a society. Improved awareness across different cultures, along with economic and scientific advances in the field of medicine, the views of society towards disability have changed in the last three decades. Rehabilitation is the process of facilitating the recovery of patients following their traumatic brain injury. It aims to maximise the quality of life, improve functional outcome where able and ensure maximal participation in activities of daily living, work and leisure. A multidisciplinary team is critical to any successful rehabilitation programme and relies on coherent and effective team working, with no one clinical discipline able to meet a patient’s needs solely. Goals should be specific and measurable, with the time period for achievement identified. The majority of the goals should be written concerning the activities/participation level of the International Classification of Functioning, Disability and Health framework.
The article was invited for a Special issue of Generations: American Society on Aging on Disability and Aging. Authored by leaders at the Rehabilitation Research and Training Center (RRTC) on Community Integration in Syracuse, New York and RRTC on Independent Living and Public Policy in Berkeley, California, the article was influential in framing the agenda across diverse disability groups, aging, and interested constituencies on personal assistance and community services. The article is part of a book edited by Edward Ansello and Nancy Eustis, and available at http://www.amazon.com/Aging-Disabilities-Seeking-Common-Ground
Presents the empowerment rehabilitation model, which was developed to assist traumatic brain injury (TBI) survivors, families, and treatment providers in addressing unmet needs and to enhance the enablement, armament, and empowerment process of persons with TBI. The model's 5 components (structure, motivation, information, acceptance, and skills) address the physical, cognitive, emotional, and behavioral needs of persons who have sustained a TBI as they emerge through the rehabilitation process. Each of the 5 components are defined, and examples of their application in meeting the needs of survivors, families, and treatment providers are illustrated. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Investigated whether traumatic brain injury patients (TBIPs) with persistent cognitive deficits could achieve successful community readaptation following outpatient retraining or residential treatment. 18 TBIPs (aged 16–53 yrs) were assigned to cognitive retraining, and a control group of 9 TBIPs received no intervention. 14 male TBIPs (aged 18–52 yrs) also completed residential treatment. Ss completed a disability rating scale and a psychosocial rating scale. All TBIPs achieved a reduction in disability related to cognitive deficits, although some did not benefit sufficiently from either readaptation approach. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Interviewed 37 severely head-injured patients (aged 12–60 yrs), divided into early and late recovery groups, and 39 of the Ss' significant others (aged 21–64 yrs) regarding social support systems. Data indicate that patients' household social standing decreased significantly from preinjury to postinjury but leveled off over time. After the initial phase of recovery, when family and friends offered help, patients were dependent on primary kin for financial, emotional, and task-oriented support. Findings suggest that head-injured patients and their families may become socially isolated. It is argued that community service programs should be aware of the benefits of social support for these patients and their families. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
A survey of independent living centers (ILCs) and medical rehabilitation programs (MRPs) with cooperative relationships was conducted to (1) document the extent and kinds of relationships that exist and (2) identify factors that are reported to impede or facilitate those relationships. A questionnaire was mailed to 83 ILCs that are listed in the ILRU Registry of Independent Living Programs and that reported having a relationship with one or more MRPs. Subsequently, another questionnaire was sent to the MRPs with which each ILC reported having a relationship. Usable questionnaires were received from 46 ILCs. In descending order, the most frequently reported relationships were (1) making referrals to or supplying information about MRPs, (2) providing peer counseling services, and (3) conducting training in daily living skills for medical rehabilitation patients. Mean ratings of satisfaction with the various kinds of relationships were relatively high. The three most frequently endorsed barriers to stronger relationships were conflicting approaches or styles of service delivery, funding of services, and conflicting program philosophies. Using information from a database describing ILCs, it was found that ILCs with MRP relationships served significantly more consumers than centers not having such relationships. According to results provided by 25 MRPs, patients with spinal cord injury most frequently received services by staff members of ILCs, with peer counseling being the most frequently provided service.