Article

Pathways to Vocational Services: Factors Affecting Entry by Veterans Enrolled in Veterans Health Administration Mental Health Services

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Abstract

The current study provides naturalistic data documenting the pathways-to-care to vocational services for 155 veterans who were receiving some form of mental health care from the Veterans Health Administration and had a vocational need but were not currently enrolled in vocational services. Of the participants, 94.2% had recognized their vocational need, 80.6% reported that they or someone else had sought help to alleviate the need, and 77.4% had previously received some form of vocational services. The median length of the participants' vocational need was more than 4.2 years. Delays associated with recognition, help-seeking, and treatment entry all contributed to the overall delay in entering appropriate care. Filtering factors associated with quicker recognition, seeking help, and receiving services included diagnosis, level of disability, type of vocational need, and support from primary providers, family, and friends. The results provide information for designing interventions to improve service entry by adults with mental health problems and vocational needs.

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... Prior analyses identified the number of Veterans who participated in employment services relative to the total number of VHA users with psychiatric diagnoses in fiscal year (FY) 2009 and found that only 3.5 percent of Veterans with a psychiatric diagnosis received employment services [17][18][19]. Although it cannot be assumed that all Veterans with psychiatric diagnoses who use the VHA have a need for employment services, a recent independent multimethod evaluation suggested a substantial unmet need for employment services among VHA users with psychiatric diagnoses. ...
... This study sought to describe the reach of employment services to the population of VHA users with psychiatric diagnoses. Overall, findings suggest that only a small percentage of VHA users with psychiatric diagnoses access employment services in a given year-a finding that is consistent with a prior report [17][18][19]. In this representative sample, VHA users with psychiatric diagnoses of schizophrenia had higher odds of accessing any employment services relative to VHA users with other psychiatric diagnoses, including PTSD, depression, and other anxiety disorders, but did not differ in their odds of accessing employment services as compared with VHA users with bipolar disorder. ...
... Reliance on administrative data limited the present analyses in that we were unable to ascertain VHA users' current employment status and their desire for employment or employment services [17] and their utilization of non-VHA employment services (including employment services or referrals provided through the Veterans Benefits Administration), which, along with other individuallevel factors, would likely influence whether or not a Veteran attempted to access VHA employment services. Although prior research suggests psychiatric diagnosis can be validly ascertained from administrative data [26], it is possible that our use of administrative data to identify diagnosis resulted in an underdetection of psychiatric conditions. ...
Article
This study examined the population-based reach of Veterans Health Administration (VHA) employment services to VHA patients with psychiatric diagnoses. Reach of services includes the percentage and characteristics of people who accessed services compared with those who did not. Using clinical administrative data, we identified patients with a psychiatric diagnosis among a random sample of all patients who received VHA services in 1 yr. Among VHA patients with psychiatric diagnoses, we examined their likelihood of receiving any VHA employment services and specific types of employment services, including supported employment, transitional work, incentive therapy, and vocational assistance. We identified clinical and demographic characteristics associated with receiving employment services. Results indicated that 4.2% of VHA patients with a psychiatric diagnosis received employment services. After adjusting for clinical and demographic characteristics, VHA patients with schizophrenia and bipolar disorder were more likely to receive any employment services and to receive supported employment than were patients with depression, PTSD, or other anxiety disorders. VHA patients with depression and PTSD were more likely to receive transitional work and vocational assistance than patients with schizophrenia. Future studies should examine system-level barriers to receiving employment services and identify types of employment services most appropriate for Veterans with different psychiatric diagnoses.
... Unfortunately, despite the many benefits of employment, Veterans and civilians who experience mTBI and/ or have MI often have significant difficulty getting their vocational needs met [10,[21][22][23][24]. Work plays a significant role in how people identify themselves and how they are described by their families, communities, and society. ...
... SE emphasizes engaging an individual in competitive work and then providing the training and support required to remain employed in the specific work setting or the "place then train" approach [36][37]. In TWE programs, temporary jobs are provided for the Veteran on a time-limited basis while staff assist the Veteran to address issues that hinder competitive employment (lack of job search skills, interpersonal skill development, etc.) and provide assistance with the competitive job search [21,38]. SE and TWE are national Department of Veterans Affairs (VA) vocational rehabilitation models that share the goal of helping Veterans overcome barriers to successful return to competitive employment. ...
... Despite the promise and availability of vocational rehabilitation for Veterans, not all individuals benefit, with many dropping out or being unable to obtain and retain competitive employment over the course of a year [21,31,39]. These findings suggest that efforts to enhance the outcome of vocational services for Veterans are needed. ...
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Work plays a significant role in how people identify themselves, and successful return to work is associated with significant psychological and rehabilitative benefits. Unfortunately, despite the many benefits of employment, Veterans who experience mild traumatic brain injury and have mental health issues often have significant difficulty getting their vocational needs met. Considering that a consistent relationship between cognitive dysfunction and difficulties with employability has been firmly established, cognitive rehabilitation may enhance engagement in vocational rehabilitation and return to work outcomes. In this pilot study, we evaluated a 12 wk cognitive rehabilitation intervention embedded within vocational rehabilitation services. Eighteen Veterans were randomly assigned to receive either the embedded cognitive rehabilitation intervention (n = 10) or a control condition offering supportive client-centered therapy that did not focus on employment or cognitive rehabilitation (n = 8); all Veterans (intervention and control groups) received vocational rehabilitation services. This pilot feasibility study demonstrated efficient implementation of an embedded cognitive rehabilitation intervention within vocational rehabilitation. The current pilot data revealed small to moderate effect sizes on employment outcomes. Given these preliminary findings, a larger outcome study is warranted. © 2016, Rehabilitation Research and Development Service. All rights reserved.
... Participants indicated whether 18 employment barriers discouraged them from working or made employment difficult or not. The majority of barriers included were derived from the Pathways-to-Care study, which assessed vocational needs of Veterans who were receiving mental health care and were not receiving VA vocational services (Drebing et al., 2012). We also created an indicator for total number of barriers. ...
Article
Background: Prior research found lower employment rates among working-aged patients who use the VA than among non-Veterans or Veterans who do not use the VA, with the lowest reported employment rates among VA patients with mental disorders. This study assessed employment status, employment functioning, and barriers to employment among VA patients treated in primary care settings, and examined how depression and anxiety were associated with these outcomes. Methods: The sample included 287 VA patients treated in primary care in a large Midwestern VA Medical Center. Bivariate and multivariable analyses were conducted examining associations between socio-demographic and clinical predictors of six employment domains, including: employment status, job search self-efficacy, work performance, concerns about job loss among employed Veterans, and employment barriers and likelihood of job seeking among not employed Veterans. Results: 54% of respondents were employed, 36% were not employed, and 10% were economically inactive. In adjusted analyses, participants with depression or anxiety (43%) were less likely to be employed, had lower job search self-efficacy, had lower levels of work performance, and reported more employment barriers. Depression and anxiety were not associated with perceived likelihood of job loss among employed or likelihood of job seeking among not employed. Limitations: Single VA primary care clinic; cross-sectional study. Discussion: Employment rates are low among working-aged VA primary care patients, particularly those with mental health conditions. Offering primary care interventions to patients that address mental health issues, job search self-efficacy, and work performance may be important in improving health, work, and economic outcomes.
... This is concerning for NG members who do not receive VA services and for those who are eligible for but are not aware of, or are not able to access, VA vocational services. Veteran recognition of vocational need represents the largest delay in service entry, with many participating in mental health or substance abuse treatment programs to address their vocational needs (39). This finding highlights the need to screen for vocational needs and to increase access to vocational services for veterans prior to developing mental and substance-related issues. ...
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Employment is a vital part of the postdeployment return to civilian life. This study investigated factors associated with employment-related outcomes (employment status, self-reported work performance, and self-reported work satisfaction) among National Guard members returning from Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn deployments. The sample consisted of 1,151 National Guard service members who had returned from overseas deployments approximately six months earlier. Bivariate and multivariable analyses were performed to examine associations between predictors and employment-related outcome variables. Higher-risk alcohol use was associated with reduced odds of being employed as well as with lower ratings of work satisfaction, whereas psychiatric symptom load was associated with lower self-reported work performance and work satisfaction ratings. Perceived social resources were associated with higher self-reported work performance and work satisfaction, whereas better physical functioning was associated with better self-reported work performance. Policy makers and clinicians may need to consider and assess alcohol use among unemployed National Guard members. They may also need to consider psychiatric symptom load and physical functioning among employed service members who perceive poor work performance and have low work satisfaction. Further research is needed on causal links between these predictors and employment outcomes.
... Thus, understanding the conditions under which physical disabilities can detract from self-efficacy in SCCT is particularly important to understanding a variety of distal outcomes. This research question is increasingly important, given a critical need for vocational rehabilitation and counseling for physically disabled war veterans, particularly in the United States (Drebing et al., 2012). Advances in medical practices have saved the lives of many veterans wounded in combat, who subsequently need additional supports to readjust to civilian work with a disability (Hendricks & Amara, 2008). ...
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In this study, the authors focused on the context of physical disabilities (i.e., one’s age when a disability manifests and the severity with which it impacts major life activities) to better understand how disabilities influence vocational self-efficacies. Consistent with Social Cognitive Career Theory, age of onset moderated the relationship between disability severity and self-efficacies in the Realistic, Artistic, Social, and Conventional vocational domains. Specifically, disability severity had a strong, negative impact on self-efficacies for people who became physically disabled later in life. In contrast, the relationship between disability severity and self-efficacy was nonsignificant for people who became disabled in early childhood. These findings held across Holland’s Realistic, Investigative, Artistic, Social, Enterprising, and Conventional domains when controlling for a variety of other person inputs and domain-specific learning experiences.
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Chapter
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Ware JE, Jr.: SF-36 Health Survey Update, in Maruish M (ed): The Use of Psychological Testing for Treatment Planning and Outcome Assessment, Volume 3. Mahwah, New Jersey: Lawrence Erlbaum Associates; 2004, pages 693-718. ISBN 0805843310, 9780805843316.
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