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Development, Implementation, and Outcomes of a Residential Vocational Rehabilitation Program for Injured Service Members and Veterans <In Press, Journal of Vocational Rehabilitation>

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BACKGROUND: The Service member Transitional Advanced Rehabilitation Program (STAR) is a novel model designed to promote interdisciplinary collaboration while delivering comprehensive physical, psychosocial and vocational rehabilitation services. The STAR program was established as a pilot program in 2011 and is now approved for permanent continuation. It is housed in the Polytrauma Transitional Rehabilitation Center at Hunter Holmes McGuire VA Medical Center in Richmond, Virginia. OBJECTIVE: The present study introduces the development, implementation, participant characteristics and five-year program outcomes of the STAR program. METHODS: A paired sample t-test was employed to compare pre and posttest functioning in the following areas: physical, mental and emotional, vocational, and community integration. Mixed analysis of variance was further employed to determine the impact of demographic variables such as age, gender, race/ethnicity and marriage status on recovery. RESULTS: Statistically significant improvements in physical, mental and emotional, and vocational functioning were found in participants after completion of the STAR program. Regarding demographic variables, only marital status appeared to impact PTSD recovery. CONCLUSIONS: The STAR program’s vocational rehabilitation and community reintegration services, as well as efforts to improve physical and psychological functioning, have demonstrated positive outcomes. Overall, the development and implementation of the program has been highly successful.
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Journal of Vocational Rehabilitation 48 (2018) 111–126
DOI:10.3233/JVR-170919
IOS Press
111
Development, implementation,
and outcomes of a residential vocational
rehabilitation program for injured
Service members and Veterans
Joseph Webstera,, Jeong Han Kimb, Carolyn Hawleyb, Lara Barbirc, Sharon Bartona
and Cynthia Younga
aService member Transitional Advanced Rehabilitation Program (STAR) Program, Hunter Holmes
McGuire VA Medical Center, Richmond, VA, USA
bDepartment of Rehabilitation Counseling, Virginia Commonwealth University, Richmond, VA, USA
cDepartment of of Counseling Psychology, Radford University, USA
Revised/Accepted July 2017
Abstract.
BACKGROUND: The Service member Transitional Advanced Rehabilitation Program (STAR) is a novel model designed to
promote interdisciplinary collaboration while delivering comprehensive physical, psychosocial and vocational rehabilitation
services. The STAR program was established as a pilot program in 2011 and is now approved for permanent continuation. It
is housed in the Polytrauma Transitional Rehabilitation Center at Hunter Holmes McGuire VA Medical Center in Richmond,
Virginia.
OBJECTIVE: The present study introduces the development, implementation, participant characteristics and five-year
program outcomes of the STAR program.
METHODS: A paired sample t-test was employed to compare pre and posttest functioning in the following areas: physical,
mental and emotional, vocational, and community integration. Mixed analysis of variance was further employed to determine
the impact of demographic variables such as age, gender, race/ethnicity and marriage status on recovery.
RESULTS: Statistically significant improvements in physical, mental and emotional, and vocational functioning was found
in participants after completion of the STAR program. Regarding demographic variables, only marital status appeared to
impact PTSD recovery.
CONCLUSIONS: The STAR program’s vocational rehabilitation and community reintegration services, as well as efforts
to improve physical and psychological functioning, have demonstrated positive outcomes. Overall, the development and
implementation of the program has been highly successful.
Keywords: Vocational rehabilitation, Veterans, VA, community reintegration
1. Introduction
Military conflicts in Iraq and Afghanistan since
2001 are resulting in a large number of U.S. Service
Address for correspondence: Joseph Webster, M. D., Director,
Service member Transitional Advanced Rehabilitation Program,
Hunter Holmes McGuire VA Medical Center, Richmond, VA,
USA. Tel.: +1 804 675 5000; E-mail: joseph.webster@va.gov.
members sustaining traumatic brain injuries (TBI)
and posttraumatic stress disorder diagnoses (PTSD;
Burke, Olney, & Degeneffe, 2009); the two most
common factors that interfere with successfully tran-
sitioning back into the workforce (Gaiter, 2015).
According to the Bureau of Labor Statistics, the
unemployment rate for Iraq and Afghanistan War
Veterans increased from 7.3 percent in 2008 to 11.5
1052-2263/18/$35.00 © 2018 – IOS Press and the authors. All rights reserved
112 J. Webster et al. / VR for injured Service members and Veterans
percent in 2011. The Veterans Employment Chal-
lenges survey conducted by Prudential (2012), found
a 30.2 percent unemployment rate in the Veteran
population, compared to 16.1 percent for civilians
in the same age range. Furthermore, 98 percent of
survey participants reported at least one service-
related challenge to entering or re-entering the work
force; two-thirds reported three or more obstacles to
employment. In 2013, the rate was 5.5% compared
to nonveterans (6.4%), however the unemployment
rate for OEF/OIF Veterans is still much higher (7.3%;
Roberts, 2016, p. 121).
Issues that Service members and Veterans strug-
gle with are broad-ranged and include a host of
health-related, physical, and psychological disorders.
For instance, the Institute of Medicine (IOM; 2012)
cited three categories of conditions that frequently
co-occur with PTSD in military populations: psychi-
atric (e.g., depression and substance use disorders);
medical (e.g., chronic pain, TBI, and spinal cord
injury); and psychosocial (e.g., relationship prob-
lems, difficulties in social settings, intimate partner
violence, child maltreatment, unemployment or lack
of employment, homelessness, and incarceration).
This wide range of co-occurring conditions indicates
the need for population-specific comprehensive reha-
bilitation and support services.
In October 2010, a joint Veterans
Affairs/Department of Defense (VA/DoD) Task
Force met at Walter Reed Army Medical Center
(WRAMC) to address coordinated efforts on behalf
of wounded warriors. The findings of this task
force identified a need for improved comprehensive
transitional rehabilitation support and recommended
a program be developed to address all aspects of
the physical, psychological and vocational needs for
injured and ill Service members. The Department of
Veterans Affairs responded to this recommendation
by launching the Service member Transitional
Advanced Rehabilitation (STAR) program at Hunter
Holmes McGuire VA Medical Center in Richmond,
Virginia.
The purpose of this study was two-fold. First, the
present study provided a description of the devel-
opment and implementation of the STAR program
as a novel model for the provision of vocational
rehabilitation services within a comprehensive, resi-
dential rehabilitation setting. The second purpose was
to report the characteristics of program participants
and a summary of STAR program outcomes includ-
ing, sample characteristics that differentiate STAR
program outcomes.
1.1. Program description
The STAR program was established as a pilot
program designed specifically for injured Service
members and Veterans who require a comprehensive
residential rehabilitation program in order to success-
fully return to work and integrate into the community.
Following the disability conceptualization model of
the International Classification of Function, Disabil-
ity and Health (ICF), the STAR program includes
various services to optimize health, mental, and
vocational functioning, as well as opportunities
for enhanced transition in returning to work and
community.
As part of the mission to provide a comprehen-
sive transition program for injured Service members
and Veterans that would facilitate successful return
to military, federal or civilian employment, the
STAR program was established in the Polytrauma
Transitional Rehabilitation Center on the Hunter
Holmes McGuire VA Medical Center campus in
Richmond, Virginia. This ten-bed residential pro-
gram is co-located with the Polytrauma Transitional
Rehabilitation Program and the Polytrauma Assistive
Technology Center of Excellence.
The STAR program provides a comprehensive
treatment setting for the acquisition of new knowl-
edge, enhancement of resiliency skills, improvement
in physical functioning, and increasing the likeli-
hood of transfer of training to the community setting.
These services are provided at a single site with an
interdisciplinary team of physicians, psychologists,
physical and occupational therapists, speech and
language pathologists, recreation therapists, social
workers, and vocational rehabilitation counselors
to enhance the efficiency and standardization of
treatments.
The Vocational Rehabilitation component of the
program includes a comprehensive vocational intake
assessment following by a graduated program of
worksite skills assessments, work readiness and work
hardening training, work re-entry, and support for
reintegrating the individual into an appropriate occu-
pational role. The comprehensive functional capacity
evaluation and work hardening activities facilitate
successful return to work. Integration with the Dis-
ability Evaluation System allows for more rapid
assessment and transition through the medical board
process if required as part of the military transition
process. Using an interdisciplinary team approach
to provide high-quality care, the STAR Program
provides state-of-the-art medical and vocational reha-
J. Webster et al. / VR for injured Service members and Veterans 113
Table 1
STAR program medical and vocational services
Type of Service Description
Therapeutic
Environment
The STAR program is housed in the Polytrauma Transitional Rehabilitation Center, which provides
comprehensive services in a home-like residential setting. This setting includes individual apavartment-style
rooms with private bathrooms. The living environment includes several common living areas, a full kitchen,
laundry facilities, dining and recreation areas.
Medical Care The STAR program is staffed by a PM&R physician medical director and patients are seen by a physician on a
weekly basis. Medical services and specialty consultative services are available 24/7 for any urgent or emergent
issues. Comprehensive medical management and supervision are provided for issues related to disabling
condition as well as general medical conditions.
Comprehensive
Rehabilitation
Therapy
Rehabilitation services include physical therapy, progressive exercise programs, and occupational therapy for
maximizing activities of daily living (ADL), and cognitive training as well as community re-integration.
Assistive technology and speech therapy services are provided including cognitive assistive devices and
compensatory strategies. Recreational therapy activities are also incorporated and focused on community
reintegration as well as leisure and adaptive sports participation.
Structured Mental
Health Support and
Services
Mental health services are provided by Psychologists and Neuropsychologists. Psychiatry services are available
on a consultative basis. Services include psychological counseling services, psychiatric medication management,
and neuropsychological testing.
Intensive Vocational
Rehabilitation
Services
Services are provided by two certified vocational rehabilitation counselors. Vocational rehabilitation services are
provided 3–5 days per week and include comprehensive assessment, vocational exploration, vocational training,
work readiness and work hardening.
Nursing Care Services Nursing care services are provided 24 hours per day and 7 days per week. Services include the spectrum of
nursing care including medication management.
Social Work Services Services are provided by a licensed clinical social worker and patients are seen for services on a weekly basis
and as needed.
Nurse Case
Management
Case Management is provided on an ongoing basis while the patient is enrolled in the STAR program. Case
management services are also provided to coordinate both program admission and follow-up services at the time
of discharge from the program.
bilitation in a residential setting; Table 1 provides a
brief summary of each service.
2. Methods
2.1. Participants
Injured or ill Service members and Veterans with
associated functional limitations were recruited and
referred from various sources (see Table 2). Among
the total of 102 injured Service members and Veter-
ans who were admitted to the program, the majority
were males (95%). Regarding age, the majority were
in their 20 s (43%), followed by 30 s (32%) and
40 s (20%) ranges. Most participants were either sin-
gle (46%) or married (30%). Racial/ethnic groups
of participants included: Caucasian (64%), African-
American (26%), Hispanic/Latino (9%), and Asian
(1%). At the time of the participants’ admission to
the program, the majority were active duty Service
members (72%), with 40% of participants reporting
that their injuries were sustained during deployment
related activities in either Iraq or Afghanistan. The
majority of participants stayed two to four months
(68%) with 100 days being the average length of
stay (median = 93 days). Descriptive characteristics
of participants are summarized in Table 2.
2.2. Measures
The STAR program employed various instruments
to assess patient functioning and program outcomes
in a variety of domains. Mobility functioning was
measured using the 2 Minute Walk Test (2MWT),
Dynamic Gait Index (DGI), Berg Balance Scale
(BBS), and 10 Meter Walk Test (10MWT). To mea-
sure psychological functioning, the PTSD Checklist –
Specific (PCL-S), Beck Depression Inventory II
(BDI-II), and World Health Organization Quality
of Life – Brief Version (WHOQOL-BREF) were
used. Regarding vocational functioning, the newly
developed Work Perception Scale (WPS) and Job
Readiness Scale (JRS), were used. Finally, the Cana-
dian Occupational Performance Measure (COMP)
and Community Reintegration for Service members
114 J. Webster et al. / VR for injured Service members and Veterans
Table 2
Characteristics of STAR program participants. NA – Not
Applicable
Gender
Male 97 95%
Female 5 5%
Total 102 100%
Marital Status
Single 47 46%
Married 31 30%
Married, Separated 10 10%
Divorced 14 14%
Total 102 100%
Referral Source
Military Treatment Facility (MTF) and other MTF 52 51%
VA 48 47%
Home 2 2%
Total 102 100%
Military Branch for Active-Duty[1]
Air Force 1 1%
Army 50 67%
Army National Guard 1 1%
Marine Corps 13 18%
Marine Corps Reserve 1 1%
Navy 9 12%
Total 75 100%
Mechanism of Injury
Blast wi Fragment 5 5%
Blas wo Fragment 26 25%
Bullet 1 1%
Fall 6 6%
Vehicle 26 26%
Assault 3 3%
Other 34 34%
Missing 1 1%
Total 102 100%
Secondary Polytrauma Injury Structures
Not Applicable 6 6%
Nervous System/Brain 6 6%
Soft Tissue 7 7%
PTSD 39 37%
Ortho-Fracture 14 14%
MSK 23 23%
Headache Pain 3 3%
Missing 4 4%
Total 102 199%
Length of Stay[3]
01–30 days 2 2%
31–60 days 8 9%
61–90 days 31 35%
91–120 days 29 33%
121–150 days 10 11%
151–180 days 7 9%
181 more 1 1%
Total 88 100%
Age
10 s 3 3%
20 s 44 43%
30 s 33 32%
40 s 20 20%
50 s 2 2%
Total 102 100%
(Continued)
Table 2
(Continued)
Race/Ethnicity
Asian 1 1%
African American 27 26%
Hispanic/Latino 9 9%
Caucasian 65 64%
Total 102 100%
Military Status at Admission
Active Duty 75 74%
Veteran 27 26%
Total 102 100%
Where Injured[2]
Iraq 14 14%
Afghanistan 26 26%
Other Foreign 5 5%
Stateside 54 55%
Total 99 100%
Primary Polytrauma Injury Structures
Not Applicable 1 1%
Nervous System/Brain 84 82%
Soft Tissue 3 3%
PTSD 1 1%
Ortho-Amputation 4 4%
Ortho-Fracture 5 5%
MSK 2 2%
Missing 2 2%
Total 102 100%
Tertiary Polytrauma Injury Structures
Not Applicable 26 25%
Nervous System/Brain 2 2%
Soft Tissue 10 10%
PTSD 6 6%
Ortho-Amputation 1 1%
MSK 42 41%
Headache Pain 6 6%
Missing 9 9%
Total 102 100%
[1]Only for the 75 participants who were active-duty at the time
of admission were included in this category; [2]Three participants
who did not completed program were excluded from the total;
[3]Participants who did not complete or are still in the program
were not included in the total.
(CRIS) were used to measure community integra-
tion. At the time of program completion, participants
also completed the Vocational Preparation Effec-
tiveness Survey (VPES), a self-reported descriptive
assessment on the effectiveness of vocational reha-
bilitation services provided in the STAR program.
For WPS and JRS, preliminary analysis (i.e., item-
total correlation) was conducted and deviated items
were removed from statistical analyses to improve
measurement reliability.
2.2.1. 2 Minute Walk Test (2MWT)
The 2MWT assesses the distance walked in
two minutes and has been validated for people
with various disabilities including cardiac surgery,
J. Webster et al. / VR for injured Service members and Veterans 115
lower extremity amputation, multiple sclerosis, neu-
rologic impairment such as stroke, head injury and
tumor, older adults/geriatric, and spinal cord injury
(Connelly, Thomas, Cliffe, Perry, & Smith, 2009).
Test-retest reliability tested across various sample
populations revealed coefficients over 0.80 (e.g., 0.83
for lower extremity amputation, 0.97 for neurologic
impairment, 0.95 for older adult, 0.98 for stroke),
indicating good reliability. There is no cut-off score
established for 2MWT.
2.2.2. Dynamic Gait Index (DGI)
The DGI (Shumway-Cook & Woollacott, 2001)
assesses gait, balance, and fall risk to mea-
sure not only steady walking, but also walking
in more challenging situations. The DGI uses a
four-point ordinal scale (0 = severe impairment to
3=normal), and obtains scores ranging from 0 to 24;
lower scores indicate greater impairment. Previous
researches (Jonsdottir & Cattaneo, 2007; Herman,
Inbar-Borovsky, Brozgol, Giladi, & Hausdorff, 2009)
indicates that the DGI is a reliable and valid measure;
it has been shown to yield ratios of subject variability
to total variability with excellent interrater reliability
(0.96) and test-retest reliability (0.98) when rated by
physical therapists (Shumway-Cook, Gruber, Bald-
win, & Liao, 1997).
2.2.3. Berg Balance Scale (BBS)
The BBS (Berg, Wood-Dauphinee, Williams, &
Gayton, 1989) is comprised of 14 balance-related
tasks, ranging from standing up from a sitting position
to standing on one foot. The BBS uses a five-point
rating scale (0 = unable to 4 = independent) designed
to measure static and dynamic standing balance. The
total score range is 0 to 56, and the sum of all
obtained scores on each task is used as the final
measure, with higher total scores indicating better
balance. The BBS is a popular measure used with
traumatic brain injuries, community dwelling geri-
atric patients, multiple sclerosis, orthopedic surgery
recovery, osteoarthritis, Parkinson’s disease, spinal
cord injury, stroke and vestibular dysfunction. The
internal consistency of the BBS reported in existing
literature ranges from 0.85 to 0.98 (Berg, Wood-
Dauphinee, & Williams, 1995; Brusse, Zimdars,
Zalewski, & Steffen, 2005). Additionally, the BBS
has demonstrated excellent test re-test reliability
(0.94) and has been recommended for use in reha-
bilitation and wellness programs for determining
whether change during or after intervention is clini-
cally significant (Steffen & Seney, 2008).
2.2.4. Timed Ten-Meter Walk Test (10MWT)
The unique aspect of the 10MWT (Collen, Wade,
& Bradshaw, 1991) compared to other mobility mea-
sures is that it assesses gait speed; an essential
mobility function necessary for safely navigating
within the community (e.g., crossing a street before
the light changes). The 10MWT has shown excel-
lent test-retest reliability, interrater reliability, and
construct and predictive validity across various medi-
cal populations including: healthy adults (Bohannon,
1997; Watson, 2002) and patients with hip frac-
tures (Hollman et al., 2008), spinal cord injuries
(Bowden & Berman, 2007; Burns, Delparte, Patrick,
Marino, & Ditunno, 2011; Lam, Noonan, Eng, &
SCIRE Research Team, 2007), stroke (Collen, Wade,
& Bradshaw, 1990; Flansbjer, Holmback, Down-
ham, Pattern, & Lexell, 2005), multiple sclerosis
(Paltamaa, Sarasoja, Leskinen, Wikstrom, & Malkia,
2007), Parkinson’s disease (Steffen & Seney, 2008),
and TBI (vanLoo, Moseley, Bosman, de Bie, & Has-
sett, 2004). Overall changes in total score between
pre- and post-test assessment were used in the present
study.
2.2.5. PTSD Checklist – Specific (PCL-S)
Using a five-point Likert scale (1 = not at
all, 5 = extremely), the PCL-S (Conybeare, Behar,
Solomon, Newman, & Borkovec, 2012) is a 17-item
self-report measure designed to assess the extent and
degree of DSM-IV symptoms of PTSD experienced
in the past month. Generally, the cut-point scores
of 36–44 are used for VA primary care or special-
ized medical clinics (e.g., TBI or pain population),
45–50 for VA mental health clinics, and 30–35 for
civilian primary care. In terms of measuring pre and
post interventions, 5–10 point changes are considered
reliable (i.e., not due to chance) and a 10-point thresh-
old is used to determine clinical meaningfulness
(Monson et al., 2008). The PCL-S has demonstrated
sufficient internal consistency (= 0.94; Blanchard,
Jones-Alexander, Buckley, & Forneris, 1996; Rug-
giero, Del Ben, Scotti, & Rabalais, 2003) as well
as test-retest reliability (r= 0.88; Ruggiero et al.,
2003), and has been used in both general psychi-
atric (e.g., Sampson, Kinderman, Watt, & Sembi,
2003) and military (e.g., Barrett et al., 2002; Sutker,
Corrigan, Sundgaard-Riise, Uddo, & Allain, 2002)
research.
2.2.6. Beck Depression Inventory II (BDI-II)
The BDI-II (Beck, Steer, & Brown, 1996) includes
21 items measuring behavioral and affective symp-
116 J. Webster et al. / VR for injured Service members and Veterans
toms of depression using a four-point rating scale
(0 = symptom not present to 3 = symptom very
intense). Scores range from 0 to 63, with higher
scores indicating greater depressive symptom sever-
ity. The BDI-II has been widely used to assess
depression in a variety of populations, including
Veterans (e.g., Chard, Schumm, Owns, & Cotting-
ham, 2010; Nelligan et al., 2008), and demonstrates
adequate convergent validity, discriminant validity,
test-retest reliability (r= 0.93), and good inter-
nal consistency (< 0.92; Beck, Steer, & Brown,
1996).
2.2.7. World Health Organization Quality of Life
- Brief (WHOQOL-BREF)
The WHOQOL-BREF (WHOQOL Group, 1998)
includes 26 items that measure quality of life (qol),
which is defined by the WHO as “a person’s per-
ception of his/her position in life within the context
of the culture and value systems in which he/she
lives” (WHOQOL Group, 1994, p. 28). Respondents
rate the intensity, frequency, or evaluation of the
selected attributes of QOL during the previous two
weeks on a five-point Likert scale. The WHOQOL-
BREF produces scores across four domains: physical,
psychological, social relationship and environment.
Each domain has demonstrated sufficient internal
consistency (Cronbach’s alphas ranged from 0.66
to 0.84), test-retest reliability (ranging from 0.66
to 0.87), as well as discriminant and construct
validity in both healthy populations and various
patient groups, including patients with spinal cord
injuries (Jang, Hsieh, Wang, & Wu, 2004; Skeving-
ton, Lotfy, & O’Connell, 2004; WHOQOL Group,
1998). Because the STAR program is designed to
address overall quality of life rather than specific
area of quality of life, the total score was used
in this study. This is supported by the WHOQOL
Group’s (1998) indication that all four domains
should be considered when evaluating overall quality
of life.
2.2.8. Work Perception Scale (WPS)
The WPS is composed of 10 items, measuring par-
ticipants’ work-related motivation, engagement, and
performance. The WPS uses a four-point rating scale
(1=strongly disagree to 4 = strongly agree) to exam-
ine the degree in which one values work, as well as
one’s beliefs about injured Service members’ work
ability and performance. Scores on the WPS range
from 10 to 40, with higher scores indicating more
positive perceptions of the value of working. WPS
was developed for the present study; therefore, an
item-total correlation analysis was completed first to
refine items and improve reliability.
2.2.9. Job Readiness Scale (JRS)
The JRS is a 29-item measure that collects infor-
mation regarding job seeking skills (14 items),
employment attributes (8 items), and career prepa-
ration (7 items). The JRS uses a four-point rating
scale (1 = strongly disagree to 4 = strongly agree) and
yields scores ranging from 10 to 40, with higher
scores indicating greater perceived job readiness.
Items were adapted from existing validated measures
such as the Job Search Knowledge Scale (Lip-
tak, 2009), Job-Seeking Self-Efficacy scale (Barlow,
Wright, & Cullen, 2002), and Self-efficacy of Job-
seeking Skills scale (Hergenrather, Rhodes, Turner,
& Barlow, 2008).
The WPS and JRS are self-report measures that
were developed specifically for STAR program par-
ticipants, and thus construct validity information
for these instruments is not currently available;
however, as stated with the WPS, preliminary
item-total correlation analysis was first employed
to refine items and improve overall reliability. In
the present study, internal consistency alphas in a
given sample examined in both pre and posttest
were 0.860 and 0.963 for the WPS and JRS,
respectively.
2.2.10. Vocational Preparation Effectiveness
Survey (VPES)
Using 14 items and a five-point rating scale, the
VPES is designed to examine the participant’s per-
ceived effectiveness of the STAR program’s various
vocational services (e.g., development of a resume,
participation in an independent job search, etc.). As
the VPES is not designed to measure a psychological
construct, no reliability and validation information is
available for this measure.
2.2.11. Canadian Occupational Performance
Measure (COPM)
The COPM (Law et al., 1998) collects informa-
tion on self-care (personal care, functional mobility,
community management), productivity (paid/unpaid
work, household management, play/school), and
leisure (quiet recreation, active recreation, socializa-
tion) to identify the participants five most important
problems. These problems are rated in terms of
performance and satisfaction. The COPM has demon-
strated strong evidence of divergent and convergent
J. Webster et al. / VR for injured Service members and Veterans 117
validity (Dedding, Cardol, Eyssen, & Beelen, 2004)
as well as test-retest reliability (Law et al., 1998). It
has been used with various general and specialty med-
ical populations, including pain (Carpenter, Baker, &
Tyldesley, 2001), stroke (Cup, op Reimer, Thijssen,
& van Kuyk-Minis, 2003), and neurorehabilitation
(Bodiam, 1999) patients.
2.2.12. Community Reintegration for Service
members (CRIS)
Measuring an injured individual’s adjustment to
life at home and in the community through the assess-
ment of participation in life roles, the CRIS (Resnik,
Plow, & Jette, 2009) yields three subscale domains:
Extent of Participation (EP; 50 items); Perceived
Limitations (PL; 54 items); and Satisfaction with Par-
ticipation (SP; 47 items). The EP subscale assesses
how often an individual experiences or participates in
specific activities using seven-point scales indicating
the number of times per week or other frequency of
occurrence (not at all, very often, etc.). The PL sub-
scale uses two different seven-point response scales.
The first indicates the magnitude of perceived limita-
tions and the second asks the degree to which one
agrees or disagrees with specific statements about
the amount of limitation that they have. The SP sub-
scale asks about satisfaction with different aspects
of participation using a seven-point response scale
(1=terrible to 7 = very happy). The CRIS has demon-
strated strong concurrent and known-group validity,
as well as excellent test-retest reliability, with intra-
class correlation coefficients (ICC) of 0.91, 0.90, and
0.90, respectively (Resnik, Gray, & Borgia, 2011).
2.2.13. Exit satisfaction survey
The exit satisfactions survey used in this study uti-
lizes a five-point Likert scale (1 = strongly disagree
to 5 = strongly agree) and is comprised of 12 ques-
tions (e.g., I received accurate information about the
program, I was involved in establishing my treat-
ment goals, the team focus on goals important to
me and my family). This survey was used to eval-
uate participant’s perceived satisfaction of the STAR
program.
3. Results
Paired-sample t-tests were used in the present
study to examine pre- and post-intervention dif-
ferences. Concerning WPS and JRS, preliminary
item-total correlation analyses were conducted as
these were newly developed instruments specifically
for STAR program participants and thus no prior reli-
ability information exists. Results are summarized
below.
3.1. Mobility functioning
Improvements were observed in the areas of overall
walking distance and functional mobility (i.e., ability
to navigate community safely). The results of paired-
sample t-tests indicated that pre- and post-treatment
differences across all measures were statistically sig-
nificant (t(71) = –0.6.115, p< 0.0001 for 2MWT;
t(80) = –6.279, p< 0.0001 for DGI; t(57) = –4.416,
p< 0.0001 for BBS; and t(65) = –4.4108, p< 0.0001
for 10MWT). Results are summarized in Table 3.
3.2. Mental health functioning
STAR program participants’ mental health func-
tioning was assessed using the PCL-S, BDI-II
and WHOQOL-BREF. Statistically, overall improve-
ment was shown on all variables as indicated in
Table 3 below. Particularly for the PCL-S and BDI-
II, clinical improvement was further examined by
using the interpretation manuals’ guidelines regard-
ing interpreting symptom change. The PCL-S views
a 5–10 point reduction in scores as reliable, and
a 10-point threshold is used to determine clin-
ically significant improvement. However, overall
mean differences for the PCL-S were 4.26, indi-
cating statistically significant reductions in PTSD
symptom severity but not reaching clinically sig-
nificant reductions. Regarding changes in BDI-II
scores, as indicated in the frequency table, a large
proportion of participants showed improvement in
their depressive symptoms. Statistically significant
improvement was also identified in WHOQOL after
the STAR program. Results are summarized in
Table 3.
3.3. Vocational functioning
Tools used to measure the impact and effectiveness
of the STAR program’s vocational training included
WPS, JRS and the VPES. While the WPS and JRS
were designed to measure participants’ work percep-
tion and readiness to work, VPES is descriptive in
nature and designed to document participants’ sub-
jective rating on the effectiveness of various aspects
of STAR’s vocational training such as portfolio and
resume development. Therefore, paired sample t-tests
118 J. Webster et al. / VR for injured Service members and Veterans
Table 3
Pre- and posttest score comparison
Variables nMean Mean Differences tdf Sig
Mobility Functioning
2MWT (Pre) 72 470.56ft
2MWT (Post) 72 538.29ft 67.73ft –6.115 71 0.000∗∗
DGI (Pre) 81 20.21
DGI (Post) 81 22.59 2.38 –6.279 80 0.000∗∗
BBS (Pre) 58 51.16
BBS (Post) 58 54.26 3.10 –4.736 57 0.000∗∗
10MWT (Pre) 66 1.06[1]
10MWT (Post) 66 1.21[1] 0.15 –4.108 65 0.000∗∗
Vocational Functioning
WPS (Pre) 77 34.70
WPS (Post) 77 36.30 1.6 –2.701 76 0.009∗∗
JRS (Pre) 45 62.76
JRS (Post) 45 84.29 21.53 –11.722 40 0.000∗∗
Community Integration
COMP Performance Pre 38 4.04
COMP Performance Post 38 6.21 –2.17 –8.501 37 0.000∗∗
COMP Satisfaction Pre 38 3.49
COMP Satisfaction Post 38 6.05 –2.56 –8.639 37 0.000∗∗
CRIS EP Pre 35 40.58
CRIS EP Post 35 42.51 –1.93 –1.824 34 0.077
CRIS PL Pre 36 42.81
CRIS PL Post 36 43.60 –0.79 –0.839 35 0.407
CRIS SP Pre 36 42.46
CRIS SP Post 36 45.63 –3.17 –2.681 35 0.011
Mental Health Functioning
PCL-S Pre 65 45.20
PCL-S Post 65 40.94–4.26 3.284 64 0.002∗∗
BDI-II Pre 69 15.99
BDI-II Post 69 13.12–2.87 4.058 68 0.000∗∗
WHOQOL-BREF Pre 66 85.61
WHOQOL-BREF Post 66 92.50 6.89 –4.283 65 0.000∗∗
Clinical Comparison of BDI
Pretest Posttest
BDI-II n%n%
0–10 (Normal) 27 37.5% 36 52.2%
11–16 (Mild mood disturbance) 14 19.4% 11 16.0%
17–20 (Borderline clinical depression) 5 7% 10 14.5%
21–30 (Moderate depression) 16 22.2% 4 5.8%
31–40 (Severe depression) 10 13.9% 5 7.2%
Over 40 (Extreme depression) 3 4.3%
Total 72 100% 66 100%
[1]walking distance/second, lower scores indicate improved symptoms, ∗∗p= 0.01. CRIS EP = CRIS Extent of
Participation; CRIS PL =CRIS Perceived Limitation; CRIS SP = CRIS Satisfaction with Participation.
were only used to compare pre and post-intervention
differences in the WPS and JRS, while a descrip-
tive analysis was employed to examine participants’
subjective rating on the effectiveness of various voca-
tional training of VPES.
As indicated above, prior to the analyses for WPS
and JRS, item-total correlation analyses were com-
pleted. Item-total correlation analysis identified items
that significantly deviate from other items in terms
of measuring the purported constructs. Concerning
general decision guidelines, any item with a negative
item-total correlation coefficient is removed unless a
case for theoretical justification can be made. Because
there were two data sets (i.e., pre- & posttest) and
the numbers of each data set were not identical due
to drop-out, the data set with the highest sample
size and fewest missing cases was chosen for the
analysis.
Regarding the WPS, there were no items with item-
total correlations below 0.3, and thus no effect on the
alpha coefficient (= 0.908) was identified; however,
seven items on the JRS had item-total correlations
below 0.3. Once these items were removed (JRS items
2, 3, 6, 13, 14, 23 and 24), the original alpha coef-
J. Webster et al. / VR for injured Service members and Veterans 119
Table 4
Summary of VPES
Employment Preparation Tasks 1 2 3 4 5 6 7
Very Ineffective Neither Effective Very Not Not
Ineffective Ineffective Effective Applicable Answered
or Effective
Development of Professional Portfolio. 2 (1.8%) 27 (23.9%) 66 (58.4%) 3 (2.7%) 15 (13.3%)
Completion of a master employment
Application.
10 (8.8%) 22 (19.5%) 49 (43.4%) 16 (14.2%) 16 (14.2%)
Development of Resume. 5 (4.4%) 20 (17.7%) 67 (59.3%) 7 (6.2%) 14 (12.4%)
Identification of at least 3 employment
references.
1 (0.9%) 2 (3.5%) 21 (18.6%) 68 (60.2%) 5 (4.4%) 14 (12.4%)
Development of a sample cover letter 1 (0.9%) 4 (3.5%) 23 (20.4%) 64 (56.6%) 7 (6.2%) 14 (12.4%)
Successful location and application for
appropriate job leads.
5 (4.4%) 22 (19.5%) 66 (58.4%) 5 (4.4%) 15 (13.3%)
Ability to effectively communicate my skills
and abilities.
3 (2.7%) 25 (22.1%) 67 (59.3%) 18 (15.9%)
Successful preparation for a job Interview. 4 (3.5%) 27 (23.9%) 63 (55.8%) 5 (4.4%) 14 (12.4%)
Location of community resource that will
facilitate my education and employment
goals.
5 (4.4%) 24 (21.2%) 69 (61.1%) 15 (13.3%)
Identify my optimal career path including
additional educational requirements.
1 (0.9%) 2 (1.8%) 25 (22.1%) 67 (59.3%) 18 (15.9%)
Obtained or know how to obtain the
certification(s)/license(s) I need for the
type of work I want.
1 (0.9%) 4 (3.5%) 24 (21.2%) 66 (58.4%) 18 (15.9%)
Successful plan, organize and schedule my
future work or school activities
8 (7.1%) 27 (23.9%) 62 (54.9%) 16 (14.2%)
Understand potential work stressors and
identification of effective coping strategies
13 (11.5%) 27 (23.9%) 52 (46.0%) 14 (12.4%)
Overall effectiveness of STAR VR Services 3 (2.7%) 21 (18.6%) 72 (63.7%) 17 (15.0%)
ficient (= 0.860) was improved (= 0.881). These
seven items were also removed from further anal-
yses to compare pre- and posttest outcomes. Both
were designed as single-factor measures, thus total
scores were used for the statistical analyses; results
are summarized in Table 3.
Concerning the VPES, utilizing five-point rating
scale with an additional column in which one may
answer “not applicable,” participants were asked
to rate the effectiveness of the STAR program in
assisting them to accomplish thirteen aspects of job
preparation, and one additional item asking over-
all perception on the effectiveness of STAR. As the
VPES is not a psychological instrument to measure a
certain construct, descriptive analysis was performed.
Most participants rated the service effectiveness on
each of the 13 areas positively and the results are
summarized in Table 4 above.
3.4. Community integration
The COMP and CRIS were used to examine func-
tional improvement from a community integration
perspective. COMP consists of two subscales (per-
formance and satisfaction) and CRIS includes three
subscales (extent of participation, perceived limita-
tion, and satisfaction with participation). The results
are summarized in Table 3.
3.5. Pre- and posttest difference depending on
sample characteristics
Pre- and posttest differences were paired and com-
pared based on four sample characteristics (i.e.,
gender, marital status, age, and race/ethnicity). Mixed
analysis of variance was employed and no significant
effects on gender, age, and race/ethnicity were found;
however, marital status appeared to have an impact on
recovery for both PTSD, F(3,61) = 5.539, p= 0.002,
partial eta2= 0.214, and depression, F(3,65) = 6.134,
p= 0.001, partial eta2= 0.221.
3.6. Exit survey
Information regarding participant satisfaction on
various aspects of the STAR program was collected
utilizing twelve questions. Results indicated a high
level of satisfaction from majority of participants and
are summarized in Table 5 below.
120 J. Webster et al. / VR for injured Service members and Veterans
Table 5
Exit survey
2013 2014 2015
N=21 N=24 N=24
Total %= Strongly Agree + Agree
I received accurate information about the program. 100% 100% 97%
I was involved in establishing my treatment goals. 100% 96% 91%
The team focused on goals important to me and my family. 90% 100% 100%
Team members helped me to reach my goals. 100% 100% 90%
I am pleased with my progress toward my goals. 90% 100% 91%
I was adequately prepared for discharge. 90% 91% 94%
I was treated with respect. 100% 100% 91%
My questions and concerns were addressed. 100% 91% 91%
The rehabilitation staff was sensitive and responsive 100% 96% 88%
to my rights, needs, and preference.
I felt safe and comfortable in the residence. 100% 100% 97%
Overall, I was satisfied with the program. 100% 100% 91%
I would recommend this program to someone else. 100% 100% 91%
4. Discussion
As previously stated, the purpose of this study was
two-fold. First, the present study provided a descrip-
tion of an innovative pilot program that represents a
unique model of care incorporating vocational reha-
bilitation services into a comprehensive residential
rehabilitation program. The second purpose was to
report the characteristics of program participants and
a summary of STAR program outcomes including
sample characteristics that differentiate STAR pro-
gram outcomes.
4.1. Overall program
STAR has served patients with varying severities
of TBI as well as patients with other brain conditions
such as stroke, anoxia, and encephalitis. The program
has also been able to successfully treat patients with
a host of other neurologic and orthopedic conditions.
Over time, it has evolvedin order to meet the changing
needs of the populations being served. This evolution
in primary population served includes a transition
from combat-related injuries to non-combat related
injuries and illnesses. The program has also expe-
rienced a shift from injuries occurring overseas to
more injuries occurring stateside. Despite this evo-
lution, STAR has maintained high levels of success
in terms of both patient satisfaction and achieving a
92% program completion rate.
It is important to emphasize that the STAR pro-
gram represents a new model of care in several
respects. The residential setting, where patients are
actually living at the program in order to receive
intensive vocational and rehabilitation services, is
unique. Additionally, the program integrates voca-
tional rehabilitation services directly with physical
and cognitive rehabilitation services; Vocational
Rehabilitation Counselors are part of the core inter-
disciplinary team. Another feature is that the program
fully integrates mental health service providers as
part of the treatment team. These services have also
been enhanced over time in order to meet popula-
tion needs. With successful implementation results,
the STAR program, which was initially established
as a pilot program, was approved for permanent
continuation.
4.2. Physical functioning
Program participants had diverse and multiple
injuries occurring both overseas, in conflict zones,
as well as stateside. Of these conditions, TBI was the
most frequently occurring primary injury (80.8%),
and PTSD the most frequently occurring secondary
injury (37.5%). Concerning mobility, improvement
was identified in all mobility measures including
2MWT, DGI, BBS and 10MWT. The goal of rehabil-
itation is to facilitate optimal functioning so that the
individual may return to his/her community and expe-
rience opportunities for participation and inclusion.
Following an injury, the recovery process spans time
and consists of not only medical support, but psy-
chological support to process the injury and develop
positive coping mechanisms towards adjustment and
returning to work. This interplay between physical
and psychological healing is paramount, as research
suggests injured workers need to be equipped both
physically and psychologically prior to entering a job
search (Berglind & Gerner, 2002).
J. Webster et al. / VR for injured Service members and Veterans 121
4.3. Psychosocial and mental health functioning
Program participants also experienced decreased
levels of PTSD and depression symptom severity
along with increased levels of QOL. This outcome is
consistent with previous literature that demonstrated
higher levels of QOL resulted in reduced men-
tal health challenges such as depression (Hegelson,
Reynolds, & Tomich, 2006). This result is not surpris-
ing as previous studies suggest that with increased
self-efficacy and functioning, and decreased anx-
iety and pain, QOL also improves (Kerns, Otis,
Rosenberg, & Reid, 2003; Lorig & Holman, 2003;
Mackenzie & Bosse, 2006).
Although statistically significant reductions were
found in participants’ PTSD symptoms from pre- to
post-program participation, these reductions were not
clinically significant (i.e., they did not reach over a
10-point reduction which has been indicated as nec-
essary for clinically meaningful symptom reduction;
Monson et al., 2008) but participants’ mean score
remained within the suggested range for a probable
diagnosis of PTSD. In light of this finding, several
interpretations are offered below.
First, research indicates that between one third
and one half of patients receiving empirically sup-
ported treatments for PTSD do not fully respond to
treatment, at least on some measures (Schottenbauer,
Glass, Arnkoff, Tendick, & Gray, 2008). As men-
tioned earlier, participants’ average length of stay
in the residential program was between two to four
months, which may not have allowed enough time
for Service members and Veterans to fully engage
in intensive PTSD treatment; it also may not have
allowed enough time for clinical effects of pharma-
cological treatment to begin.
Second, the measure utilized to assess PTSD (i.e.,
PCL-S) asks respondents to report the severity of
symptoms they have experienced within the past
month, which may have also influenced the smaller
reduction in PTSD symptom scores from pre- to
post-program participation given their short dura-
tion of stay. Also, prior trauma was not assessed,
which has been found to influence the severity of
PTSD and responses to subsequent traumas (Ozer,
Best, Lipsey, & Weiss, 2003), and therefore treat-
ment outcomes. Likewise, research reviewing the
relationships between trauma type and treatment out-
comes indicates that treatment for combat-related
PTSD has shown the lowest effect sizes (Bradley,
Greene, Russ, Dutra, & Westen, 2005; Ford, Fisher,
& Larson, 1997), which may possibly be attributed
to the heightened severity of pathology in Veter-
ans seeking care at VA hospitals or malingering
due to secondary gain (i.e., VA disability benefits
may depend on remaining symptomatic; Bradley et
al., 2005). It is likely that this population has dealt
with multiple traumas given the complexity of the
acquired disabilities reported, and that longer-term,
intensive trauma treatment would be most beneficial.
Researchers have indicated that patients with TBI
and co-occurring PTSD require a greater amount of
time to benefit from PTSD interventions (Rettman,
Sigford, & Friedman, 2009), which is particularly
relevant for the present sample given the high rates
of TBI.
Third, many of the patients who complete the
STAR program still face the challenging processes of
going through necessary medical board procedures
and fully transitioning out of the military. This can
be very stressful because as it will undoubtedly
have a significant impact on future benefits and
compensation that they will receive following mil-
itary transition. Regardless, these findings suggest
that the STAR program may benefit from placing a
greater emphasis on PTSD treatment, considering
expanding treatment opportunities to include coping
skills classes and gold standard treatments in both
individual and group therapy modalities (i.e., pro-
longed exposure and cognitive processing therapy).
Mental health professionals working with the STAR
program interdisciplinary team should monitor and
ensure participants’ continuity of care with the VA’s
PTSD clinic following their completion of the STAR
program.
4.4. Vocational rehabilitation and community
integration
The vast majority (95%) of participants were in
their in their 20’s-50’s placing them within the work-
ing age range. The Vocational Rehabilitation Services
provided in the STAR program have proven to be
highly effective as indicated by the WPS, JRS,
and VPES results. Work perceptions encompass an
individual’s meaning of work as well as his/her moti-
vations for doing so. Work perceptions influence an
individual’s beliefs about the outcomes of the return
to work process and contribute to whether an individ-
ual chooses to return or withdraw from the workforce
following an injury or illness (Sampere et al., 2012).
As such, participants’ work perceptions significantly
improved throughout their participation in the STAR
rehabilitation program, potentially increasing their
122 J. Webster et al. / VR for injured Service members and Veterans
motivation for returning to work and/or securing new
employment.
In addition to enhancing work perceptions, the
STAR program provides vocational rehabilitation to
develop job readiness skills. Job readiness describes
an individual’s skillset and preparation for engag-
ing in the job search process. Edward, Li-Tsang,
Lam, and Chan (2006) described the development of
work readiness as the primary requirement for job
placement. Furthermore, the participation in work
readiness programs has been found to increase worker
motivation and employment readiness. During their
participation in the program, patients increased in
where they were on the job readiness continuum.
These findings are consistent with the participants’
responses to the VPES showing that individuals who
participated in the STAR program felt better pre-
pared to enter the workforce in various domains (see
Table 4).
Providing Vocational Rehabilitation Services
(VRS) in this new model presented a number of
challenges as well as significant advantages. The pro-
gram has found that VRS can be greatly enhanced
through an interdisciplinary approach where infor-
mational interviews and worksite assessments are
performed with a collaborative team approach. In
the STAR program, physical therapists, occupational
therapists, and speech-language pathologists often
directly participate in these assessments with the
vocational rehabilitation counselors. This approach
has been able to more rapidly address essential
worksite accommodations as well as facilitate more
specific work hardening and training activities. This
type of collaboration was essential in order to com-
press the entire vocational rehabilitation process into
a 3-month time period.
Community integration was also assessed on a
continuum of vocational rehabilitation as fostering
work perception, job readiness and vocational prepa-
ration to facilitate patient employability upon their
return to the community. However, the results were
mixed in that participants showed improvement on
both of COMP Performance and Satisfaction indicat-
ing improvement in occupational performance and
participants’ level of satisfaction on their perfor-
mance. Concerning CRIS, only the Satisfaction with
Participation domain showed improvement, and no
improvement was observed in the areas of Extent of
Participation and Perceived Limitation. This result
indicates that the STAR program improves partici-
pants’ ability to re-join the community, but is not
indicative of ensuring that it is actually happen-
ing (i.e., no improvement in the area of extent
of participation and perceived limitation). This can
be explained in terms of sample characteristics of
STAR program participants. In the STAR program,
most of the individuals completing the program
are Active Duty Service member (74%) who had
limited prior work experience and education out-
side of the military. Thus, they do not transition
directly into employment. This is typically because
they are either still active duty at the time of pro-
gram discharge and/or their transition out of the
military is delayed by the medical board. Because
of this, the desired focus and primary outcome for
the program is vocational preparation rather than
employment. However, community integration ser-
vices can be further tailored to better address the
needs of participants with the future growth of the
program.
4.5. Marriage factor in mental health
functioning
Relationship status was also found to influence
indices of mental health. When compared to sin-
gle or divorced participants, individuals who were
married had significantly fewer PTSD and depres-
sive symptoms. Social support is paramount for
psychological adaptation to disability and is associ-
ated with perceptions of growth (Livneh & Martz,
2016). Furthermore, research indicates that social
support following trauma exposure is a signifi-
cant predictor of PTSD (Ozer et al., 2003) as
well as posttraumatic growth in Veteran populations
(Tsai, El-Gabalawy, Sledge, Southwick, & Pietrzak,
2015).
Although we do not know how supportive these
relationships are, it is presumed participants of this
study have probably benefitted from a primary rela-
tionship in which psychological and physical support
may have been available during the recovery pro-
cess. Family members, particularly spouses, are often
involved in the processing of a traumatic event and
deeper interpersonal relationships could be a result
of these efforts (Barskova & Oesterreich, 2009; Haw-
ley et al., 2017), which may further mitigate distress
and augment QOL. Particularly considering that most
Veterans have expressed interest in greater family
involvement in their treatment (Batten et al., 2009),
findings in the present study highlight the utility of
involving Service members’ identified support net-
works in the rehabilitation process for improving
mental health outcomes.
J. Webster et al. / VR for injured Service members and Veterans 123
5. Limitation of study
There are several limitations to consider in
reviewing the research findings. First, although the
predominance of males in the present study is char-
acteristic of the military population, findings related
to outcomes are limited in their generalizability to the
female Veteran population. For instance, the preva-
lence of combat-related PTSD is greater in males
than females, although female Veterans are signifi-
cantly more likely to be diagnosed with depression
(Maguen et al., 2010) and are much more likely to
experience sexual assault during their military service
(IOM, 2012).
Second, beyond injury type and severity, psycho-
logical factors can either facilitate or inhibit the
return to work process (Gustafsson et al., 2013). For
instance, individual perceptions of work and per-
ceived readiness to return are among the key factors
associated with employment following an injury or
illness (Reiso et al., 2003; Shultz et al., 2004). Both
of these aspects significantly increased upon patients’
completion of the STAR program.
Of note, however, findings related to participants’
improved work perceptions and perceived job readi-
ness may be limited in the present study; this is
primarily due to the instruments used to assess these
constructs (i.e., the WPS and JRS), as they were
developed specifically for the STAR program and
therefore relatively less psychometric information of
those measures exists. Nonetheless, STAR program
outcomes suggest that the services were beneficial
to Service members and Veterans with regards to
vocational outcomes. Work perception and job readi-
ness are complex constructs to measure, thus not
many validated tools exist; however, strong results of
item-total correlation analyses of WPS and JRS indi-
cated that further development and validation of these
tools would deliver an important contribution to the
field.
Third, this is a study of the outcomes of a pilot reha-
bilitation program. Future studies would benefit from
the inclusion of a comparison group to assess group
differences and overall effectiveness of the STAR
program, beyond that of treatment-as-usual, across
a multitude of outcomes. The current study also
has not collected follow-up data on participants’ job
obtainment and retention following discharge from
the program. As employment stability is a key factor
in determining the long-term efficacy of vocational
interventions (Kreutzer et al., 2003), it would be ben-
eficial to conduct further research on job acquisition
and the job stability of those exiting the program into
paid employment.
6. Conclusion
The STAR program represents a novel model for
the provision of vocational rehabilitation services
within a comprehensive, residential rehabilitation
setting for injured Service members and Veterans.
The development and implementation of the STAR
program has been highly successful and has demon-
strated positive outcomes in relation to the program’s
vocational rehabilitation and community reintegra-
tion services as well as in the domains of physical and
psychological functioning. The program has evolved
over time to meet the changing needs of the pop-
ulation served and it is likely that this continued
evolution will be required in the future.
Conflict of interest
None to report.
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