FACILITATING RETURN TO WORK THROUGH EARLY SPECIALIST HEALTH-BASED INTERVENTIONS (FRESH)
Study ISRCTN No: 38581822
Background
Traumatic brain injury (TBI) affects more than 1,000,000 people each year in the UK. It can have profound effects on many areas of human functioning, including participation in work. There is limited evidence of the effectiveness of vocational rehabilitation (VR) after injury to promote early return to work following TBI.
Despite the fact that vocational rehabilitation (VR) is a Government priority, VR services supporting people with TBI in returning to work or education are rare in the UK. However, a pilot study in Nottingham demonstrated that people who have access to early specialist traumatic brain injury vocational rehabilitation (ESTVR) returned to and remained in work 12 months.
Aims
FRESH aimed to develop a treatment manual, training package and mentoring model, based on the Nottingham ESTVR model. Feasibility and cost effectiveness was evaluated in three NHS sites in a multi-centre feasibility RCT. The study focusessed on patients with a new TBI, admitted to hospital for ≥48 hours, over 16 years of age, who were working or in full time education at the time of injury and intending to return.
Methods
78 TBI patients were recruited from multiple sites across the UK and were randomly allocated to receive either ESTVR in addition to usual NHS rehabilitation (intervention group) or usual NHS rehabilitation only (control group).
Participants were followed up at 3, 6 and 12 months. A nested qualitative study investigated participants’ (service users and employers) and staff beliefs about important outcomes following vocational rehabilitation, perceptions of acceptability and usefulness of the ESTVR training and intervention, changes in practice resulting from training, the effects (including costs) of implementation on supporting services and longer term sustainability.
The ESTVR Intervention
The intervention, targeted at preventing job loss, was delivered ‘one-to-one’ by an occupational therapist, supported by a TBI case manager with an average of 10 sessions over 12 months. Intervention was tailored to the individuals’ needs and delivered in addition to usual care.
Findings from the Nottingham pilot
In the Nottinghman pilot study (Radford et al, 2013) more people who received early vocational rehabilitation from an NHS based occupational therapist, specialising in traumatic brain injury (TBI) returned to work and were in work at 12 months post injury than those who received usual NHS Rehabilitation.
- Those with moderate or severe TBI appeared to benefit most
- 13% fewer people in receipt of the early VR were claiming benefits at one year
- TBI survivors who received the support were nearly £2,000 better off at 12 months than those in usual care - a difference resulting mainly from lost wages in usual care
- People who were working were significantly less anxious and depressed and had significantly better health-related quality of life
- From a health and social care perspective, which includes the intervention costs plus the cost of appointments with consultants, GPs, therapists, and social workers and medication in the 12 months following hospital discharge, the mean cost difference was £75 (95% CI -£1200.00, £1350.00) per person -about the cost of one therapy session.
Results from FRESH
The FRESH study concluded in 2016. Findings included the following:
- TBI patients recruited to the study who received the ESTVR services found the intervention useful. They particularly valued the practical nature of the support.
- Employers valued timely communication and appreciated the therapist acting as an advocate for the employee.
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The study showed that NHS occupational therapists can be trained and mentored to deliver an early vocational rehabilitation intervention, with high levels of fidelity, for people with TBI. Upskilling community OTs with specialist VR experience is considered the best way of delivering the intervention.
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Return to work for study participants was most strongly related to social participation and work self-efficacy, with a weaker relationship with impairment and, for competitive work or full-time study, with depression.
The trial demonstrated the feasibility of a larger RCT and made a number of recommendations as to how this could be designed and strengthened. Interview findings suggested that an outcome measure relating more broadly to participation in work or other activities might offer a better and potentially more sensitive outcome than return to work measures.
