Vocational outcomes after brain injury in a patient population evaluated for Life Care Plan reliability

Abstract

This retrospective cohort study examined the vocational outcomes in forty-four traumatically brain injured patients. Patient files selected were limited to those who were seen for the development of an original Life Care Plan and were subsequently seen at least once for a complete update of that plan. Patients who were retired at the time of the brain injury were excluded. Each participant was actively involved in litigation at the time of the initial evaluation as well as at the time of his or her update evaluation. Traumatic brain injury resulted from various etiologies. Vocational outcomes were analyzed in relation to severity of injury, age at onset, gender and education. Vocational outcome was reported as a return to work, supported employment, return to school or training or permanent total disability. Twenty-one patients were classified as permanent-total disabilities. Twenty-three returned to work, supported employment, or were successfully in school and expected to return to work. This 52% rate of vocational or school participation is particularly noteworthy since all cases were actively in litigation. A significant trend was found for severity of injury, and level of education, but not for age at onset or gender. These factors are discussed in relation to the subjects' participation in third party civil litigation and implications for Life Care Planning.

Full text

NeuroRehabilitation 21 (2006) 305–314 305
IOS Press
Vocational outcomes after brain injury in a
patient population evaluated for Life Care
Plan reliability
Paul M. Deutscha,∗, Sherie L. Kendallb,c, Carrie Daninhirscha, Sara Cimino-Fergusonaand
Patricia McCollomd
aPaul M. Deutsch & Associates, P.A., 10 Windsormere Way, Suite 400, Oviedo, FL 32765, USA
bDepartment of Behavioral Science, University of Kentucky, Lexington, KY, USA
cBiological Sciences, Division of Nursing, Midway College, Midway, KY, USA
dManagement Consulting and Rehabilitation Service Inc. and LifeCare Economics, Ltd., Alkeny, IA, USA
Abstract. This retrospective cohort study examined the vocational outcomes in forty-four traumatically brain injured patients.
Patient files selected were limited to those who were seen for the development of an original Life Care Plan and were subsequently
seen at least once for a complete update of that plan. Patients who were retired at the time of the brain injury were excluded.
Each participant was actively involved in litigation at the time of the initial evaluation as well as at the time of his or her update
evaluation. Traumatic brain injury resulted from various etiologies. Vocational outcomes were analyzed in relation to severity
of injury, age at onset, gender and education. Vocational outcome was reported as a return to work, supported employment,
return to school or training or permanent total disability. Twenty-one patients were classified as permanent-total disabilities.
Twenty-three returned to work, supported employment, or were successfully in school and expected to return to work. This 52%
rate of vocational or school participation is particularly noteworthy since all cases were actively in litigation. A significant trend
was found for severity of injury, and level of education, but not for age at onset or gender. These factors are discussed in relation
to the subjects’ participation in third party civil litigation and implications for Life Care Planning.
Keywords: Return to work, traumatic brain injury, vocation, life care plan, disability, rehabilitation
1. Introduction
Return to work subsequent to the occurrence of trau-
matic brain injury (TBI) has been identified as a crit-
ical component of the rehabilitation process for many
individuals who have incurred such trauma. Research
literature related to the area of TBI has spent consider-
able time and effort to identify and predict vocational
outcomes for these individuals. While the methodol-
ogy and purpose of the studies may vary, similarity ex-
ists in the intent of each to offer supplementary infor-
mation to assist researchers and practitioners alike in
∗Corresponding author. Tel.: +1 407 977 3223; Fax: +1 407 977
0311; E-mail: pdeut18893@mac.com.
better understanding and supporting this population of
individuals as it relates to their occupational re-entry.
The purpose of this literature review will be to provide
a summary of the existing research in the field of TBI
and return to work. Areas considered include the iden-
tified predictors of successful return to work, stability
of employment, the use of qualitative reviews and case
studies to understand the individual perspective as well
as the impact that litigation and compensation have on
return to work status.
1.1. Relationship of severity of injury to return to
work outcomes
For many, work is a part of the individual’s definition
of self. While the importance or role of work may be
ISSN 1053-8135/06/$17.00 2006 – IOS Press and the authors. All rights reserved

306 P.M. Deutsch et al. / Vocational outcomes after brain injury
characterized differently, it has long been recognized as
a factor related to an individual’sperception of quality
of life. Due to the multitude of physical, cognitive and
behavioral factors related to TBI, and the various levels
of severity that affect overall functioning,the return to
work for individuals who have experienced a TBI has
been a prevailing topic of research in the literature. A
primary area of that focus has been on identifying fac-
tors used to predict the likelihood an individual will be
capable of attaining employment post-injury. Studies
have indicated that the more severe the initial injury
and greater the length of posttraumatic amnesia, the
more likely the individual is to experience poor return
to work outcomes [4]. In fact, Cattelani et al. [4] found
that these factors were the strongest predictors differ-
entiating those individuals who would be capable of
returning to their pre-injury levels of work from those
whose needs would require more adaptiveand support
service accommodations. The Cattelani study [4] also
suggests the importance of evaluating cognitive and
behavioral strengths and weaknesses of the individual
following a TBI at various stages of recovery to better
understand what elements need to be considered in the
environment in orderto best facilitate successful return
not only to work but additionally to social, family and
community integration.
In contrast, others have reported less significant find-
ings between the relationship of injury severity and fu-
ture outcomes [6,14]. Results from these studies in-
dicate that the severity of injury was not significant in
the prediction of poorer outcome one and two years
post injury. Dawson et al. [5] reported similar results
finding that at four years post injury, the severity of the
initial injury was not a strong predictor of vocational
outcome; however, the length of rehabilitation stay was
a significant predictor (the longer the stay the poorer
the outcome). The Dawson study also investigated the
use of the Galviston Orientation and Amnesia Test to
determine if level of attention and memory recall mea-
sured at two different times post-injury could be use-
ful in predicting future outcomes. A significant rela-
tionship was found between attained score and return
to work. Additionally, the Dawson sample indicated
that at one year post-injury 66% of subjects returned
to work or school and at four year follow-up 80% had
returned to work or school.
1.2. Relationship of other variables to return to work
outcomes
Other variables associated with return to work out-
comes include the age at which the injury occurred,
marital status and pre-injury level of education. It ap-
pears that the older the individual at the time of injury,
the more negative the outcome for return to work [17].
In addition, Ip et al. [9] found higher rates of unemploy-
ment post-injury for both unmarried individuals and
those with fewer years of pre-injury education.
The stability of employment over time has been an-
other area of focus in the literature. While re-entry into
employment is often a goal of the rehabilitation process
for individuals who have sustained a head injury, it is
important to understand how well individuals are able
to maintain employment over time. Various studies
have considered the employment status of individuals
at various time frames following injury. Some have in-
dicated that employment at one or two years post injury
is predictive of employmentat three and four years post
injury [17]. Kreutzer et al. [11] looked at employment
over a period of one, two and three or four years post
injury of 186 subjects with TBI to determine stability
of employment at three different intervals. Subjects
were categorized as being stably employed, unstably
employed or unemployed. Analysis showed that 34%
were stably employed, that is employed at all three
follow-up intervals, 27% were unstably employed, or
employed at one or two of all follow-up intervals, and
39% were unemployed at all follow-up intervals. Pre-
diction of job stability was indicated by variables in-
cluding job status at one year follow-up. Those who
reported working at this interval were more likely to be
working at the two and three year intervals. Age, length
of unconsciousness and measures on the Disability Rat-
ing Scale one year post injury were also predictive of
future job stability. In addition a relationship was found
between driving independence and employment stabil-
ity [11]. Those individuals independently capable of
transporting themselves to work were four times more
likely to have established stable employment.
1.3. The effect of the definition of success on return to
work outcomes
A shift in focus of the return to work research has
occurred by considering the individual’s perspective of
the definition of success as it relates return to work. In
quantitative literature, predicting return to work from
the pre and post injury percentages can be a complex
task if one is not careful to differentiate amongst the
ways these percentages are presented. With respect
to unemployment rates and TBI, some studies report
pre-injury unemployment at 14% with post injury un-
employment at 71% for a single group of subjects [3].

P.M. Deutsch et al. / Vocational outcomes after brain injury 307
Given the reported percentages of return to work or
the stability of work, different conclusions about how
successful employment is defined may be inferred. An
alternative way to measuresuccess as it relates to return
to work has been found through the use of qualitative
studies. These investigations seek to understand the
perspective, meaning making and values those individ-
uals who have sustained a brain injury attribute to what
they identify constitutes successful return to work.
In a study by Levack et al. [12] seven individuals di-
agnosed with moderate to severe TBI were interviewed
to uncover themes associated with successful returnto
work. While support was indicated for the idea that
paid work can be related to feelings of success, three
additional themes about return to work and individual’s
feelings of success or failure were uncovered. These
themesincludedtheideathatreturntoworkcouldbeas-
sociated with highly negative and catastrophic personal
consequences, feelings of success could be achieved
without the presence of full-time or paid employment
and success at work could be associated with factors
other than the number of hours worked or the amount
of pay received [12].
Using a small cohort of individual subjects, Opper-
mann [15] interviewed subjects to gain an understand-
ing of the meaning they ascribed to work following a
TBI. These interviews were subsequently analyzed for
the presence of explicit themes and data analysis re-
vealed three specific return to work themes. According
to the participants, return to work was defined by their
experiences of finding work post-injury, maintaining
work post-injury and the feelings of independence re-
lated to work following injury [15]. Descriptive anal-
ysis was detailed in uncovering individual experience
in these areas and giving rise to information about per-
sonal challenges and struggles of the individualsnot or-
dinarily described or highlighted in quantitative studies
that focus on measurement of factors or percentages.
Descriptive studies can be a valuable tool in helping
practitioners and professionals working with individ-
uals who have experienced a TBI establish more ap-
propriate or functional ways of restructuring the work
environment to facilitate a more successful re-entry
into work. Through the use of individual case studies
Kowalske et al. [10] reported the individual circum-
stances of three subject’s experiences with return to
work following TBI. Using the Enablement Model of
treatment [8], accommodations were made to the work
environment for each individual based on determined
strengths and weaknesses. These accommodations in-
cluded changes to the structure of the work environ-
ment as well as decreases in the level of distractions
as a means of creating an optimal work environmentto
meet the individual’s needs.
1.4. The effect of compensation seeking on return to
work outcomes
The impact of compensation seeking and litigation
on the outcome of successful or timely return to work is
another area that has received attention in the literature.
In a study by Reynolds et al. [16] it was indicated that
return to work outcomes were slower for individuals
with mild TBI seeking financial compensation than for
those who were not seeking any financial compensa-
tion for their injury. Return to work for those not seek-
ing compensation averaged four to seven days from the
time of injury while those involved in a litigation pro-
cedure averaged three to seven months to return to prior
work status. These results are similar to earlier find-
ings by Binder and Rohling [1] that found individuals
seeking financial incentives as a result of their injury
performed more poorly than their non compensation
seeking counterparts on outcomes measures of symp-
tom reports, neuropsychological testing and return to
work status.
It is important to consider that the aforementioned
findings are for those individuals who have experienced
a mild rather than severe incident of TBI. Other studies
have considered the clinical differences in testing and
symptomology between mild and severe cases of TBI
in the presence of pending litigation. Millis [13] used
the Warrington Recognition Memory Test [18] to asses
the memory and motivation of two groups of subjects
who had experienced a brain injury. Findings indicated
that subjects identified as having mild TBI and seek-
ing financial compensation scored significantly lower
on subtests of forced choice word and facial recogni-
tion than both individuals identified with mild TBI who
had returned to work as well as a group identifiedwith
moderate to severe TBI. Green et al. [7] used the Word
Memory Test to measure performance differences be-
tween subjects with mild head injuries to those with
moderate or severe head injuries. In the absence of any
significant between group differences in years of edu-
cation or IQ, it was found that the subjects with more
severe injuries scored significantly higher on measures
of effort than did their less severely injured counter-
parts [7]. The notion that substandard effort and or
malingering in more mild cases of TBI in the presence
of litigation has been considered as a factor in cases
where financial compensation is pending [2].

308 P.M. Deutsch et al. / Vocational outcomes after brain injury
The occurrence of TBI is one that has a considerable
impact on the individual who has sustained this injury.
Mild, moderate or severe, brain injury affects multiple
areas of an individual’s life, not the least of which is the
ability to return to one’s prior level of work. Additional
research into the predictors, outcomes and clinically as
well as individually defined levels of success may assist
in helping professionals identify and improve the sup-
ports needed to facilitate success in the return to work
status of this population. This article seeks primarily
to reassess many of the same predictors previously ex-
amined but within the context of a broad population of
moderate, moderate to severe, and severe brain injury
survivors, all of whom are involved in the State or Fed-
eral Civil Court system over a period of multiple years.
The study reports on supported work programs, tran-
sitional work, return to work attempts and successful
return to work in the open labor market in relation to
various levels of brain injury.
1.5. Design and methodology
Data were collected on forty-four anonymous cases
to examine the rate and influencing variables on return
to work in traumatically brain injured individuals in-
volved in State or Federal Civil Litigation. The patient
litigation originated in various states nationwide. The
diagnosis for all participants was acquired brain injury
although the etiology of the brain injury varied. There
are thirty-one males and thirteen females in the sample
population. All patients were initially seen for a Life
Care Plan (LCP) evaluation and subsequently it was
necessary to accomplish a complete re-evaluation of
the patient status to update the LCP. The LCP’s were
obtained from the data-base of The Foundation for Life
Care Planning Research. Included cases from two ex-
periencedandcertifiedlifecareplannersinprivateprac-
tice, both of whom maintain a policyof strict adherence
to published life care planning processes, procedures,
standards, tenets, methodologies, and principles.
Two studies were being conducted simultaneously.
An analysis of the original and updated LCPs was be-
ing accomplished as part of a study on the reliability
and validity of the Life Care Planning Process while
vocational data from the same files were being used to
complete study reported here. Data were initially col-
lected on 54 patients resulting in 108 Life Care Plans;
however, 10 of these patients were retired from em-
ployment at the time of onset of their brain injury and
were not included in the vocational study reported here.
All patient cases with the necessary vocational data
and LCPs that fit the criteria were included in the study.
To maintain confidentiality of the research, all files
in the Foundation for Life Care Planning Research’s
database are purged of names and replaced with file
identifiers.
1.5.1. Scaling of data: Traumatic brain injury
Patients were categorized based on severity of injury
according to the Traumatic Brain Injury (TBI) Severity
Rating Scale where:
1=Moderate Injury
2=Moderate to Severe Injury: Some supervision
required
3=Severe Injury: Supported apartment/Live-in
care
4=Severe Injury: 24 Hr supervision required
5=Borderline Persistent Vegetative State (PVS)
6=Persistent Vegetative State (PVS).
The determination of level of severity was made at
the time of the evaluation for the initial LCP.
1.5.2. Scaling of data: Return to work
Data were collected on return to various levels of
work, supported employment, school or training ac-
cording to the Return to Work (RTW) Coding Scale
where:
1=Permanent and Total Disability – 24 hour care
required
2=Supported Work
3=Supported/Transitional Employment
4=Return to School or Training with Limitations
5=Return to Work with Loss of Earning Capacity.
For purposes of this study Supported Work (level 2)
is defined as “a unique employment opportunity for in-
dividuals who require ongoing support services while
placed with employers in the competitive labor mar-
ket”. A job coach providing supervision to no less than
three individuals was one criterion that had to be met.
One on one job coaching was not an accepted criterion
for inclusion. The client had to have moved beyond the
point at which they had received initial pre-vocational
trainingorthestageatwhichtraininghadbeenprovided
to the employee and co-worker in working effectively
together.
To meet the criteria for Supported/Transitional Em-
ployment (level 3), “the client had to have moved
through level 2 and transitioned into competitive em-
ployment without the need for a job coach”. This

P.M. Deutsch et al. / Vocational outcomes after brain injury 309
Fig. 1. Histogram of number of subjects per category of the Trau-
matic Brain Injury Rating (TBI) scale where 1 =Moderate Injury,
2=Moderate to Severe Injury: Some supervision required, 3 =
Severe Injury: Supported apartment/Live-in care, 4 =Severe Injury:
24 Hr supervision required, 5 =Borderline Persistent Vegetative
State (PVS) and 6 =Persistent Vegetative State (PVS).
required stabilization on the job with support only
through the routine, on site supervision available within
that employment setting. This employment or employ-
ment of a similar nature would have to have been main-
tained consistently from the initial evaluation through
to the update. Should a job change have been required,
only a brief break for a job search and interviews would
have been allotted for consistent employment to have
been considered. In relatively small sample of this
study, no breaks in employment occurred, so determin-
ing a reasonable time break was not necessary.
Return to School or Training with Limitations (level
4) is defined as “a return to a full time elementary,
high school or vocational school program”. In each
instance a determination was made as to the success of
the individual’s efforts. Success was defined in terms of
passing grades and progress on to the level. Successful
return to school or training was only considered in the
instance in which the program led to a diploma or a
vocational certificate.
Finally Return to Work with Loss of Earning Capac-
ity (level 5) is defined as “a return to the competitive
labor market without support on the job”. No consid-
eration was given to whether the individual had voca-
tional rehabilitation assistance in placement. If the pa-
tient demonstrated supported work (RTW level 2) or
greater level of success in the first interview, this had
to be demonstrated in the updated LCP for inclusion
in the study. If RTW was not achieved until the LCP
update, but was stable at the time of the update the case
was included in the study.
Fig. 2. Histogram of number of subjects per category of the Return to
Workcoding scale where 1=Permanent and Total Disability-24 hour
care required, 2 =Supported Work, 3 =Supported/Transitional
Employment, 4 =Return to School or Training with Limitations and
5=Return to Workwith Loss of Earning Capacity.
1.5.3. Demographic data collected
Also collected on each patient was the following
data:
1). Sex.
2). Age at onset of injury.
3). Time between initial LCP and update LCP eval-
uations (in months).
4). Number of years of education attained before
TBI.
1.5.4. Statistical analyses
This study analyzes various factors that impact pa-
tient outcomes as measured on the RTW scale. Be-
cause the data are therefore scaled, statistical tests are
nonparametric where a choice between parametric and
nonparametric testing is made, specifically, the data
comparing RTW scores for males and females were
analyzed using the Mann Whitney U test for unpaired,
nonparametric data. Where more than three or more
group means were compared, the one-way Analysis of
Variance (ANOVA) test was employed. If the ANOVA
was significant, a post test for linear trend and in one
instance (RTW by level of TBI), the Newman-Keuls
Multiple Comparison Test was applied.
All group comparisons were made for a two-tailed p
value. An αlevel of p<0.05 was considered signifi-
cant for all statistical tests employed. The data are ex-
pressed as means plus and minus (±)the standard error
of the mean (SEM). Computer assisted analyses uti-
lized GraphPad Prism version 4, GraphPad Software,
Inc., San Diego, CA (2003) and the Statistical Package
for the Social Sciences, (SPSS).

310 P.M. Deutsch et al. / Vocational outcomes after brain injury
Fig. 3. Vocational outcomes (RTW score) by severity of injury (TBI score) showing significant ANOVA (F =21.01; p<0.0001); significant
linear trend (R squared =0.35; slope =−0.42; p<0.0001); and Newman-Keuls post hoc test significant for categories 1, 2, and 4 (∗p<0.05
in every case).
Fig. 4. Vocational outcomes (RTW score) by level of premorbid education showing significant ANOVA(F =3.74; p<0.05); significant linear
trend (R squared =0.13; slope =−0.78; p<0.05).
2. Results
2.1. Demographics
The study’s sample population is comprised of 31
males and 13 females. Except for the specific compar-
ison of gender differences, the analyses are conducted
on the entire group including both males and females.
As a group, the mean age is 33.1 ±2.4 years, with a
range from 10 to 59 years of age at the time of acquiring
the TBI. The mean time between the initial and the up-
dated patient LCP evaluations was 22.9 ±2.3 months
with a range between 5 months, and (in only one case),
84 months. The level of education acquired prior to the
onset of TBI is reported in number of completed years
of schooling or training. The mean level of education
is 12.3 ±0.5 years with a range between 2.5 and 18
years. These data are not shown.
2.2. Scaled TBI and RTW data
Thehistogramofthenumberofsubjectspercategory
of TBI is shown in Fig. 1. The number of subjects
per category is: n1=9, n2=11, n3=3, n4=19,
n5=1, n6=1 and Ntotal =44. The mean TBI score
is 2.9 ±0.2 with a range that spans the scale values
from 1 through 6; however, with 3 or fewer subjects in
categories 3, 5, and 6, some analysis are not possible
and other interpretations are difficult.
Thehistogramofthenumberofsubjectspercategory
of RTW is shown in Fig. 2. The number of subjects
per category is: n1=21, n2=11, n3=1, n4=2,
n5=9, and Ntotal =44. The mean RTW score is

P.M. Deutsch et al. / Vocational outcomes after brain injury 311
Fig. 5. Vocational outcomes (RTW score) by age group showing non-significant ANOVA (F =2.11; p>0.05).
2.2 ±0.2 with a range that spans the scale values from
1 through 5; however, with fewer than 3 subjects in
categories 3, and 4, some analysis are not possible and
other interpretations are difficult.
2.2.1. Analysis of factors’ relationship to vocational
outcomes
The relationship of level of TBI and RTW score is
graphically displayed in Fig. 3. The one-way ANOVA
indicates the means are significantly different (F =
21.01; p<0.0001); furthermore, the post test for lin-
ear trend is also significant (R squared =0.35; slope
=−0.42; p<0.0001). The Newman-Keuls Multiple
Comparison post hoc test shows TBI categories 1, 2,
and 4 differ from one another (∗p<0.05 in every case).
Conclusions cannot be made about categories 5 and 6
because too few subjects are included. Similarly, cate-
gory 3 is difficult to interpret due to the high variability
occasioned by the low number of subjects.
Figure 4 displays the relationship of level of educa-
tion acquired prior to TBI and vocational outcomes as
measured on the RTW scale. For this analysis the levels
of education are grouped as less that a high school de-
gree (<12 years education) (n=9, mean RTW score
=3.1 ±0.61), attainment of the high school diploma
(12 years of education) (n=17, mean RTW score =
2.5 ±0.42), or some education beyond highschool (>
12 years education) (n=18, mean RTW score =1.6
±0.23). The one-way ANOVA indicates the means
are significantly different (F=3.74; p<0.05); fur-
thermore, the post test for linear trend is significant (R
squared =0.13; slope =−0.78; p<0.05).
The relationship of level of age at the time the TBI
was acquired and vocational outcomes as measured on
the RTW scale is graphically displayed in Fig. 5. For
Fig. 6. Vocational outcomes (RTW score) by gender showing
non-significant Mann Whitney U test (p>0.05).
this analysis the ages of the subjects at the time of TBI
are grouped as under 18 years of age (n=4, mean
RTW score =3.5 ±0.86), ages 18 through 30 years
(n=17, mean RTW score =5.0 ±2.76), ages 31
through 40 (n=8, mean RTW score =3.0 ±1.50),
ages 41 through 50 (n=8, mean RTW score =5.0 ±
1.75), ages 51 through 60 (n=7, mean RTW score =
5.0 ±1.71).The one-way ANOVA indicates the means
of the age groups are not significantly different (F =
2.11; p>0.05), and therefore, there is no linear trend
between the age groups.
Figure 6 graphically displays the results of the anal-
ysis of vocational outcomes as measured by the RTW
scale by sex of the patient. The mean RTW score of
males (n=31) is 2.4 ±0.29. The mean RTW score
of females (n=13) is 1.8 ±0.41. The Mann Whitney
test for unpaired nonparametric (scaled) data are not
significant (p>0.05).

312 P.M. Deutsch et al. / Vocational outcomes after brain injury
3. Discussion
The data which were extracted and analyzed for this
study are noteworthy in relationship to the outcomes
found on employment post traumatic brain injury in
other studies noted in the literature search. Kreutzer et
al. [11] reported finding a 34% rate of stable employ-
ment and another 27%, unstably employed. Brooks
et al. [3] reported a post injury employment rate of
29%. Among the forty-four participants in this study
11, or 25%, are in supported employment post in-
jury while twelve, or 27%, are working, in transitional
employment settings leading to work or are in stable
school/training programs likely to lead to work.
Particularly of interest is that each member of the
study population had an active case in litigation dur-
ing the course of the initial evaluation and the update
evaluation. Forty-three of the forty-four members of
the study population had litigation limited to State or
Federal Tort Claims with no Worker’s Compensation
claim. Although no specific data are analyzed to com-
pare one type of litigation to another, it is notewor-
thy that this study demonstrates findings different from
those whose participants are primarily drawn from a
population of worker’s compensation claimants. The
worker’s compensation process brings with it a differ-
ent set of variables with influences that need to be re-
searched separately from those whose litigation is out-
side this process. Assumptions cannot be extrapolated
from that population to other types of litigation groups
and the outcomes in this study helps to affirm that point.
Participation in supported work, transitional employ-
ment, formal school, vocational training programs or
employment was not impeded by the litigation process.
There are no data that would allow for a determination
of any delay in the rehabilitation process secondary to
litigation, but since all proceeded to these steps prior
to an end in litigation there also is no basis to suggest
such a delay took place. All participants ranged from
moderate traumatic brain injuries to those in a persis-
tent vegetative state. Even those in at the moderate
level were sufficiently severe that they were not living
entirely independent lives post injury. They required
casemanagement,andassistanceinarrangingforapart-
ment leases, major purchases, and coordination of a
daily structured routine. Most required a supervised
apartment program or similar arrangementsin a private
home setting.
The data suggest a number of clear trends that have
important implications for Life Care Planners. Cer-
tainly, as one might expect, the less severe injuries
have the greatest probability of return to work. What
is equally important is the number of individuals with
more severe injuries with success in transitional em-
ployment and training programs. With 7% of the study
population in this category and 25% in supportedwork
there are clear implications for Life Care Planners not
to forget their commitment to vocational rehabilitation
in plan development. Overall 52% of the study popu-
lation is involved in supported work, transitional em-
ployment, school, training or direct employment with
20.5% falling in the stably employed category.
Age of onset is the next data set that demonstrates a
significant trend. The younger patients to tend to show
a greater probability of a return to supported work, tran-
sitional employment, school/training or employment.
It is important to recognize this as a trend with partic-
ipation in these programs still spread across age cate-
gories.
Pre-morbid educational development is a variable
thathadacounterintuitiveoutcomeinthisstudy. Based
onresultsseenintheliteratureresultsandbasedonintu-
itive expectations as a Vocational Rehabilitation Coun-
selor, the anticipation wouldbe that the higher the pre-
morbid educational level, the greater the probability of
return to work. In the data analysis in this study, the
results showed an inverse relationship between the var-
ious categories of return to work and education. This
may, in part, be explainedby the relatively low numbers
in the sample population. It is more probably explained
by the greater severity of injury found in the individuals
with the higher levels of education. This artifact may
have been factored out had the study populations been
larger, but in this instance it significantly impacted the
results. Nevertheless, for Life Care Planners this again
is an important consideration. Certainly vocational re-
habilitation counselors are well aware that lower edu-
cational levels prior to the onset of an injury negatively
influence transferable skills. Planning for their clients
will often include post injury training to improve voca-
tional participation. Again the Life Care Planner, when
not coming from a vocational background, should con-
sult with a vocational rehabilitation counselor and con-
sider training or supported to transitional employment
settings to improve potential for the traumatically brain
injured.
In summary: variables that significantly interacted
with vocational outcomes in this study included the age
of the patient at the time TBI was acquired, number
of years of pre-morbid education, and severity of brain
injury. Gender, number of months between initial and
update evaluations and the time frame between injury

P.M. Deutsch et al. / Vocational outcomes after brain injury 313
onset and initial evaluation were not found to be influ-
encing variables in this study. The existence of litiga-
tion in each of the study population’scases did not ap-
pear to influence their participation in supported work,
transitional work, school/training, or employment.
Further research needs to be considered regarding
how Life Care Planners are utilizing vocational rehabil-
itation programs for the Traumatically Brain Injuredin
the LCP process specifically to answer these questions:
What is the extent of post planning follow-through with
these plan recommendations? Does the use of the Life
Care Planning Process enhance the vocationaloutcome
in TBI?
4. Conclusions
A number of important implications for Life Care
Planners were identified. The most critical is the impor-
tance for the planner not to simply take the individual
as they are at the time of the evaluation and assume this
will be the long term outcome for final plan recommen-
dations. The Life Care Planner must have a commit-
ment to rehabilitation and the plan should include rea-
sonable and appropriate recommendations to improve
the status of that individual. This research shows the
potential of the individual with a brain injury to par-
ticipate at various levels of employment. It is critical
for the Life Care Planner to take this into consideration
and where necessary to consult with the Vocational Re-
habilitation Counselor with expertise in working with
brain injury. It is also clear that assumptions should not
be made about the status of litigation interfering with
the rehabilitation process. At least outside of work-
er’s compensation, this study suggests good potential
for rehabilitation participation proceeding unimpeded
without regard to litigation.
Acknowledgements
Sherie L. Kendall was supported in part by NIA
(Loan Repayment Program – Clinical Research) and
by the Founders’ Award for Career Development from
The Foundation for Life Care Planning Research.
About the Authors
Paul M. Deutsch Ph.D., CRC, CCM, CLCP, FIALCP
received a Master’s and doctorate from the University
of Florida and is President of the Foundation for Life
Care Planning Research. He maintains a private prac-
tice in Rehabilitation Counseling and Mental Health
Counseling and specializes in Life Care Planning. Dr.
Deutsch is lead faculty at Kaplan Universities Life
Care Planning program and teaches at the University of
Florida/MediPro continuing education program in Life
Care Planning.
Sherie L. Kendall Ph.D. received a BA in Biology
from Indiana University Kokomo, followed by a doc-
torate from Indiana University School of Medicine, In-
dianapolis, IN, in Medical Neurobiology. Dr. Kendall
is Director of Research for the Foundation for Life
Care Planning Research, a postdoctoral scholar at the
University of Kentucky, Department of Behavioral Sci-
ences and Assistant Professor of Biology in the Di-
vision of Nursing at Midway College, Midway, Ken-
tucky.
Carrie Daninhirsch M.A. began working at Paul M.
Deutsch & Associates, P.A., in August 2004. Since
that time she has been involved in research related to
the field of life care planning as well as course and
curriculum development for Kaplan University. Ms.
Daninhirsch received a Bachelor of Science degree in
Psychology from Northeastern University, then earned
a Master’s Degree in Counseling Psychology from Les-
ley College. She is currently a Doctoral Candidate in
the Counselor Education and Supervision program at
Kent State University.
Sara Cimino-Ferguson, MHS, CRC, CLCP earned
a Master of Health Science degree in Rehabilitation
Counseling from the University of Florida. Mrs.
Cimino-Ferguson is currently employed by Paul M.
Deutsch & Associates, P.A. and the Division of Voca-
tional Rehabilitation in the state of Colorado.
Patricia McCollom MS, RN, CRRN, CDMS, CCM,
CLCP received her RN from Iowa Methodist School
of Nursing, her BA in Educationand Psychology from
Drake University and her MS in Rehabilitation also
from Drake University. Patricia serves as an adjunct
faculty member at several Universities and maintains a
private practice as a case manager and Life Care Plan-
ner. Patricia is well respected for her role in founding
the International Academy of Life Care Planners.
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