By Paul Wehman, Lauren Avellone, and Cynthia Young
Polytrauma Traumatic Brain Injury: Vocational Rehabilitation Supports for Service Members and Veterans within the Polytrauma System of Care
Return to work is an important part of recovery for Service Members and Veterans sustaining a polytrauma injury. Polytrauma refers to injuries affecting more than one external body part or internal system (U.S. Department of Veterans Affairs, 2019). Due to heightened safety risks associated with deployment, military members often experience polytrauma injuries on-the-job (Wyse et al., 2018). Polytrauma injuries are frequently the result of combat-related explosive events but can also occur due to other causes such as falls or motor vehicle accidents (Ropacki et al., 2018; Wyse et al., 2018). Commonly, polytrauma injury involves a traumatic brain injury (TBI). To illustrate, a study of 16,590 Polytrauma System of Care users through the U.S. Department of Veterans Affairs (VA) found that nearly half (48.6%) had a TBI diagnosis (Adams et al., 2019).
Polytrauma TBI occurs along with one or more other traumas such as amputation, damage to sensory modalities, spinal cord injury, or serious mental health conditions (e.g., post-traumatic stress disorder, anxiety, depression, substance disorder) that impair daily functioning (Adams et al., 2019; U.S. Department of Veterans Affairs, 2019). Due to the complex nature of TBI, particularly with polytrauma injuries, Service Members and Veterans often encounter difficulties with returning to major life areas such as independent residential living, social activities, and employment. For example, approximately 60.4% of individuals with TBI are unemployed compared to a 3.5% national unemployment average (Cuthbert et al., 2015). Individuals with polytrauma TBI are likely to need specialized employment services to aid in successful return to work (Wehman et al., 2019). In this article, a review of the vocational rehabilitation procedures implemented at nationwide Polytrauma System of Care sites throughout the U.S. Department of Veterans Affairs is discussed in order to provide information on how Service Members and Veterans with polytrauma TBI are supported during work re-entry. Example services from one site, the Polytrauma Transitional Center (PTC) Service Member Transitional Advanced Rehabilitation (STAR) program in Richmond, Virginia are described.
Polytrauma System of Care
To assist with successful return to major life activities such as employment, the Department of Veterans Affairs developed a nationwide treatment model in 2005 known as the Polytrauma System of Care (PSC) which provides rehabilitative support for Service Members and Veterans who have experienced any level of polytrauma/TBI (Armstrong et al., 2019; Wyse et al., 2018). The PSC is a network of tiered levels of support offering inter-disciplinary services that help individuals with polytrauma injuries return to independent activities (Pogoda et al., 2018). A set of services is individualized based on each Service Member and Veteran’s needs but may include assessment and evaluation, treatment planning, case management, rehabilitation technology, employment services, family training, and social support (U.S. Department of Veterans Affairs, 2019).
The PSC comprises four component sites ranging from most to least levels of support. First, Polytrauma Rehabilitation Centers (PRCs) are intensive inpatient facilities which provide acute care for those with the most significant needs. Service Members and Veteran’s with polytrauma TBI typically travel to one of the five PRC locations in Virginia, Texas, Florida, Minnesota, and California (Armstrong, 2019). Once able to transition to a least intensive setting, the individual often begins receiving care from a Polytrauma Network Site (PNS) closer to their home using in-patient or out-patient services (U.S. Department of Veterans Affairs, 2019). Like PRCs and PNSs, the third tier of service offers a wide range of comprehensive supports except on an outpatient basis from a Polytrauma Support Clinic Team (PSCT). Lastly, more limited services are available from a Polytrauma Point of Contact (PCC) accessible through VA facilities (U.S. Department of Veterans Affairs, 2019). At each level, an interdisciplinary treatment team will work with the Service Member or Veteran to determine treatment goals related to independent living, community participation and re-entry to employment.
Addressing Employment through the Polytrauma System of Care
Compensated Work Therapy (CWT) is a national vocational rehabilitation (VR) program operated by the Department of Veterans’ Affairs that partners with businesses and government agencies to support Service Members and Veterans during return to work (Pogoda et al., 2018). Each VA medical center across the U.S. has a CWT program (U.S. Department of Veterans Affairs, 2020). As many as 65,000 veterans with a variety of mental and physical conditions participated in CWT across the U.S. in 2017 (Ottomanelli et al., 2019). To ensure quality services and outcomes, most are recognized by the Commission on Accreditation of Rehabilitation Facilities (CARF), an international health and human services agency (Ottomanelli et al., 2019). Participants in the CWT program are eligible for healthcare services from the VA, have a desire to return to work, and experience barriers that hinder obtaining and retaining employment through traditional avenues (U.S. Department of Veterans Affairs, 2020), such as those with polytrauma TBI injuries.
Each veteran with a polytrauma TBI will require different vocational services. Therefore, an important aspect of CWT is determining the correct employment components. Additionally, due to resources and demand, different components of CWT are offered at different VA medical centers (U.S. Department of Veterans Affairs, 2020). Examples include vocational support services, supported employment, supported self-employment, transitional work, supported education, and community-based employment services (Ottomanelli et al., 2019). Service Members and Veterans with polytrauma TBI work with a Vocational Rehabilitation Counselor (VRC) to create and accomplish employment goals. The unique role of the VRC is described below.
Vocational Rehabilitation Counselors at Polytrauma Centers
At polytrauma centers, VRCs are considered a core therapy, and VRCs are active members of the medical/therapeutic Interdisciplinary Team (IDT). The IDT is comprised of medical professionals including Physiatrists, Nurses, Physical, Occupational, and Speech therapists, Psychologists, Social Workers, Recreational Therapists, Vision Specialists, Health Coaches, program managers, hospital staff, and military liaisons (Wehman et al., 2019). During the weekly IDT meetings, VRCs communicate the patient’s vocational goals, and the therapy team targets their medical and therapeutic strategies in support of the patient’s vocational goals. From a patient care perspective, the VRCs provide case management and work with every patient who participates in the program. The VRCs are given a medical consult to treat each patient, and then schedule an initial intake meeting with the patient to develop an individualized strategic employment plan with goals, followed by providing daily vocational services throughout the participant’s time in the program.
The VRCs administer assessments to determine vocational interests and abilities including work aptitude, achievement, and values. After that, the VRC’s services involve contacting businesses and arranging informational interviews, networking opportunities, job shadowing experiences, on-the-job assessments, providing transportation to these events, and using the results of these community interactions to further develop individualized vocational goals. In-clinic VR sessions center around assisting the Service Member or Veteran with developing a professional portfolio with documents outlining his or her professional skills and work history. It includes identifying and researching careers, job leads or education programs in line with identified career goals. The VRCs also teach and arrange community partners to teach weekly classes on job-related skills including topics such as effective interviewing and assessment skills; developing tools for job searches; translating military job roles into civilian equivalents; creating targeted resumes; labor market research; and identifying barriers to employment and strategies to overcome these barriers. Importantly, the VRCs provide patients with personal adjustment counseling about work-related stress, disability issues, utilizing job accommodations, assistive technology, and other compensatory strategies to facilitate a successful employment experience. These services successfully assist Service Members with returning to active duty, and successful transition out of the military into civilian employment and education.
Planning for Employment Retention of after Exiting a Polytrauma Center: Site Example
As a Service Member or Veteran with polytrauma TBI returns to work, it is important to ensure that the supports and services needed to successfully retain employment are put in place. Procedures for promoting employment retention vary by center. Here is one example of processes utilized by the Polytrauma Transitional Center (PTC) Service Member Transitional Advanced Rehabilitation (STAR) program in Richmond, Virginia describing “check-ins” with veterans after they leave the program, and resources and organizations to which they are directed to at exit.
In 2018, The STAR program initiated a program follow-up survey to check-in with former patients. At program discharge, the patient is administered the follow-up survey as a baseline and informed that in 6 months, and a year, they will be contacted again to complete the survey. The survey asks the Service Member or Veteran to rate their level of satisfaction with the program and also asks if they are currently employed, seeking employment, or attending an education or training program. While the Service Member or Veteran is in the STAR program, efforts to establish business connections and employment supports are made. Patients often choose to join Veteran non-profit organizations who provide mentoring, support and activities within the person’s home community. A few that have been found to be very supportive include the Wounded Warrior Project (WWP) and American Corporate Partners (ACP) mentorship program (a non-profit organization engaged in national corporate career counseling for military personnel). Transition services through the Transition Center on the military base are excellent resources as well for both active duty Service Members and Veterans. In addition, the Marine for Life and Soldier for Life programs are very helpful with mentoring, networking, and connecting Veterans to employment opportunities. For those with entrepreneurship goals, SCORE at www.score.org is recommended because it is large network of volunteers and expert business mentors. Each patient also connects to industry-specific resources based on his or her career goals. Lastly, it is also recommended that patients develop a LinkedIn profile, and the STAR program assists them with accessing LinkedIn tools and using this resource for continued networking.
Barriers to Return to Work for Service Members and Veterans with Polytrauma TBI
During recovery, Service Members and Veterans with polytrauma TBI are faced with adjusting to many life circumstances all at once. In addition to following intensive treatment regimens for their injuries, they are often adapting to other changes such as needing assistance from others while healing, making difficult choices about their future, and deciding when and how to pursue different levels of community integration. Those sustaining injuries during deployment may also find the transition back to civilian life difficult and foreign (Demers, 2011). Here, a brief review of recognized barriers is presented.
Barriers to work re-entry for Service Members and Veterans are often unique to the demographics of the population. For example, consider the STAR program in Richmond, VA where 75%-80% of patients are active duty military Service Members in medical recovery while in the program (Service Member Transitional Advanced Rehabilitation Program. FY17 annual outcomes report; 2017). This impacts return to work in several ways including determining fitness for duty, possible exaggeration of conditions, and unrealistic expectations. For example, when a Service Member develops a medical condition, it may render him or her “Unfit for Duty.” In the STAR program, vocational rehabilitation efforts are then targeted toward work assessments that replicate job tasks to provide recommendations for return to duty.
On the other hand, assessments and therapies may reveal that the Service Member is not likely going to be able to return to duty The STAR program has assisted several Service Members with adjustment to disability after assessments demonstrated that the Service Member was not likely fit for duty, and would not likely be able to return to duty. In these cases, the vocational services shift to planning for military transition and determining viable civilian career goals. In several cases, the Service Member was not ready to acknowledge issues related to injury, nor consider transition to civilian employment. The goal of the STAR program is not to convince the patient of his deficits, but rather, provide assessment data as an indicator of the person’s actual current performance and provide vocational recommendations based on his strengths. In a few cases, the person was not ready to consider new employment options until after leaving the program.
Another barrier is when the person is waiting for surgery or to recover from orthopedic injuries and their employment transition is on hold. The STAR program addresses this barrier by offering career exploration that takes into account current and future career options. The biggest barrier to return to work tends to occur when an active duty patient is recovering from injury and enters the Integrated Disability Evaluation System (IDES) process because the Service Member may want to appear to be as “disabled” as possible while being examined by medical personnel in order to obtain a higher disability rating. For this reason, the Service Member may not fully engage in vocational services because he does not want to appear as if he is capable of working.
If the transition is from active duty to civilian employment, there are other barriers to consider as well. For example, many Veterans may feel unsure of where they fit within the climate of a business, or feel misunderstood since many civilians do not understand military culture (Demers, 2011). Many veterans with polytrauma TBI will have entered the military at a young age and therefore have limited civilian work experience (Wehman et al., 2019) which is problematic because there is often a lack of parallel positions between military and civilian jobs in terms of duties, industry, authority, salary, and training requirement (Wehman et al., 2019). Veterans may also have trouble adjusting to the differences in hierarchy and greater pressure to make decisions alone associated with civilian work compared to military work (Wehman et al., 2019). They may also hold themselves to a higher standard and have difficulty adjusting to decreased shows of respect in civilian jobs (Demers, 2011). As mentioned, barriers will differ across Service Members and Veterans so assessing these challenges prior to work re-entry is essential in promoting successful transition back to work.
Return to work for Service Members and Veterans with polytrauma TBI is a complex process that requires a treatment team who works collaboratively to establish and accomplish vocational goals. The PSC provides vocational rehabilitation services at VA medical centers nationwide which includes the provision of VRC services. The VRC works with the Service Member or Veteran to complete a myriad of critical work re-entry activities such as completion of vocational assessments, arrangement of work experiences, counseling for work-related stress, and education on work skills and job securement. Services extend beyond program enrollment as efforts are made to assist the Service Member or Veteran in obtaining long term supports and connections to community agencies that will aid in employment retention. While each individual experiences different types of barriers and varying levels of motivation and certainty regarding the work re-entry process, the PSC provides an array of services to overcome these barriers and help Service Members and Veterans with polytrauma TBI successfully return to work.
- Adams RS, Larson MJ, Meerwijk EL, et al., Post deployment polytrauma diagnoses among soldiers and veterans using the Veterans Health Affairs Polytrauma System of Care and receipt of opioids, nonpharmacologic, and mental health treatments. Journal of Head Trauma Rehabilitation. 34(3): 167-175, 2019.
- Armstrong M, Champagne J, Mortimer DS. Department of Veterans Affairs Polytrauma Rehabilitation Centers: Inpatient rehabilitation management of combat-related polytrauma. Physical Medicine Rehabilitation Clinics of North America. 30(1): 13-27, 2019.
- Cuthbert JP, Harrison-Felix C, Corrigan JD, et al., Unemployment in the United States after traumatic brain injury for working-age individuals: Prevalence and associated factors 2 years postinjury. Journal of Head Trauma Rehabilitation. 30(3): 160-174, 2015.
- Demers A. When veterans return: The role of community in reintegration. Journal of Loss and Trauma. 16(2): 160-179, 2011.
- Ottomanelli L, Bakken S, Dillahunt-Aspillaga C, et al., Vocational rehabilitation in the Veterans Health Administration Polytrauma system of care: current practices, unique challenges, and future directions. Journal of Head Trauma Rehabilitation. 34(3): 158-166, 2019.
- Pogoda TK, Carlson KF, Gormley, KE, et al., Supported employment for veterans with traumatic brain injury: provider perspectives. Archives of Physical Medicine and Rehabilitation. 99(2): S14-S22, 2018.
- Ropacki S, Nakase-Richardson R, Farrell-Carnahan L, et al., Descriptive findings of the VA polytrauma rehabilitation centers TBI model systems national database. Archives of Physical Medicine and Rehabilitation. 99(5): 952-959, 2018.
- Service Member Transitional Advanced Rehabilitation Program. FY17 annual outcomes report, 2017.
- U.S. Department of Veterans Affairs. Polytrauma/TBI system of care. Published March 7, 2019. Accessed July 9, 2020. https://www.polytrauma.va.gov/understanding-tbi/.
- U.S. Department of Veterans Affairs. Compensated Work Therapy. Published March 3, 2020. Accessed July 9, 2020. https://www.va.gov/HEALTH/cwt/index.asp.
- Wehman P, Avellone L, Pecharka F, et al., Reintegrating Veterans with polytrauma into the community and workplace. Physical Medicine and Rehabilitation Clinics of North America. 30(1): 275-288, 2019.
- Wyse JJ, Pogoda TK, Mastarone GL, et al., Employment and vocational rehabilitation experiences among veterans with polytrauma/traumatic brain injury history. Psychological Services. 17(1): 65-74, 2018.
Paul Wehman, PhD – Dr. Wehman is a VCU Professor in the School of Education’s Counseling and Special Education Department with a longtime appointment in the VCU Health System’s Physical Medicine and Rehabilitation. He is Director of both the VCU Rehabilitation Research and Training Center and the Autism Center for Excellence and Editor-in-Chief of the Journal of Vocational Rehabilitation. Recognized as one of the 50 Most Influential People in Special Education for the millennium by Remedial and Special Education, his highly interdisciplinary background has made him a nationally recognized expert in transition, supported employment, brain injury, physical and developmental disabilities and autism.
Lauren Avellone, PhD – Dr. Avellone is a Board Certified Behavior Analyst (BCBA) with a PhD in Special Education and a MS in clinical psychology. She has broad experience working in both research and clinical settings with individuals with a variety of disabilities including autism, brain injury, psychiatric disorders and developmental disabilities. She has provided behavior analytic services in a variety of settings including hospitals, classrooms, and residential settings. In addition to amassing extensive clinical experience, she has conducted research in a wide range of disciplines including psychology, special education, and rehabilitation counseling.
Cynthia Young, MS, CRC – Cynthia Young is a Vocational Rehabilitation Counselor at the Central Virginia VA Health Care System in Richmond, Virginia. In 2011, she was a part of the team that developed the Servicemember Transitional Advanced Rehabilitation (STAR) Program, a polytrauma rehabilitation program for Service Members and Veterans (SM/V) recovering from injury or illness. She provides individualized vocational services to assist SM/Vs with return to military service and with transition to civilian employment. Cynthia received her Master’s Degree from Virginia Commonwealth University, is a Certified Rehabilitation Counselor (CRC) and the proud daughter of a U.S. Marine Corps Veteran.