Vocational and Life Care Planning Fundamentals in Traumatic Brain Injury

Cases – A Current Review

Robert T. Fraser, PhD

Associates in Rehabilitation and Neuropsychology (ARN)Seattle, Washington

206-386-3860Professor, University of Washington

Department of NeurologySeattle, Washington

206-341-4545rfraser@u.washington.edu

TBI Categories Mild head injury

– 85% of all cases– Brief or no loss of consciousness– Glasgow Coma Scale 13-15

Moderate head injury– 10% of all cases– Post-traumatic amnesia 1 to 24 hours– Glasgow Coma Scale 9-12

Severe head injury– 5% of all cases– Post-traumatic amnesia > 8 days– Glasgow Coma Scale < 8

Natural Course of Work Return in TBI – 2 Years Post-Injury

Severe 38%

Moderate 66%

Mild > 80%

Relative and excess risk values [Doctor et al, 2005]

N

Actual unemployment

(%)

Expected unemployment

(%)

Relative risk (95% CI)

Education:

Less than HS 111 54.0% 14.3% 3.77 (3.09, 4.43)

High school 254 40.6% 8.1% 5.02 (4.26, 5.80)

College 53 20.7% 4.3% 4.87 (2.54, 8.00)

Glasgow Coma score:

13 to 15 228 31.1% 8.8% 3.46 (2.87, 4.28)

9 to 12 84 46.4% 9.6% 4.85 (3.71, 6.02)

3 to 8 87 62.1% 10.4% 5.98 (4.92, 6.96)

Glasgow Outcome score (at 1 month):

Good 109 15.6% 8.5% 1.83 (1.10, 2.79)

Moderate 93 39.8% 8.3% 4.81 (3.60, 6.10)

Severe 129 66.7% 9.8% 6.79 (5.89, 7.61)

Differences Between Vocational Assessment and Loss of

Earnings Potential

Loss of Earnings Potential Does Not Review All Specific

Options/Employment Supports

Vocational assessment – Does not always consider dollar loss, while addressing other vocational options/retraining needs

Who Do You Choose as a Vocational Consultant?

Minimally, a Masters degree in rehabilitation counseling or vocational evaluation and a CRC/CVE certification

Significant experience in vocational rehabilitation planning/ report writing synthesizing neuropsychological information

Experience in working with the rehabilitation team

Significant/current experience in rehabilitation job placement and loss of earnings potential assessment

Core Team for Establishing Earnings Loss

Neuropsychologist

Vocational Rehabilitation Counselor

Economist

Consultant Team Neuropsychologist

– Establishes pre- and post-morbid levels of functioning

Vocational expert– Verifies the U.S.D.O.L. cognitive and/or physical limitations– Establishes the scope of job consideration– Assesses work life participation

Economist– Reviews benefits value, interest or discount rate over work

life, etc.

Core Team in Establishing Earnings Loss Physical

Physiatrist/physical capacities evaluator

Vocational rehabilitation counselor

Economist

Earnings Capacity is Affected by:

Cognitive and other impairments

Disability status– Work life participation– Level of earnings

Caveats in TBI Vocational Status

IQ does not fully assess cognitive functioning

School performance does not reflect “real world” demands

Work return does not equal normal career path or work

Intelligence Level Can Remain the Same WHILE:

Overall cognitive functioning is reduced– Attention – Memory– Problem solving– Executive functioning

DOL Job Physical Requirements

Lifting demands

Vision needed

Hearing needed

Walking

Climbing and balancing

Stooping, kneeling, crouching, crawling

Handling, fingering, feeling, reaching

Mild-to-Moderate TBI

Injury severity and no marked substantial neuropsychological deficits

Are the vocational underpinnings of the case missing?

If the Cognitive Issues are Confusing, Remember the Big Picture

The specific symptoms presenting the salient work barrier (e.g., headaches or other physical)

The constellation or additive nature of the neuropsychological/other symptoms

Consider a closed period of vocational loss, symptoms affecting reduced work, life participation or loss of contribution to household tasks

Other Symptoms Can Involve:

Difficulties with certain environments

Balance, dizziness

PTSD and other emotional disorders

Adjustment issues within the family

Computerized Job Search Software

VALE

NOC*

OASYS

Life Step

Labor Market Access* Specific to Canadian labor market

Monthly Earnings of Working Adults With and Without Disabilities, 1994-95

Male– No disability $2,190– Non-severe disability $1,857– Severe disability $1,262

Female– No disability $1,470– Non-severe disability $1,200– Severe disability $1,000

Source: McNeil, J.; US Census Bureau, 1997

Severe Injury: Joe

IQ 114 (Level 2)

IQ 80 (Level 4)

65

18

$27,000

$9,600

30 yrs

18 yrs

Pre-injury = $810,000

Post-injury = $172,800

$638,000

Intelligence % of Jobs Earnings Work Life

Case of Jim, 23 y.o. Truck DriverMild/Moderate TBI

Pre-injury 98 4

Post-injury 95 2

IQ Reasoning Level

Jim is Back at Work, Earning Less Due Overtime Loss

Pre-injury 63% $21,554.20 35.1 yrs

Post-injury 15% $15,537.60 14.8 yrs

WorkAccess Salary Work Life

Case of Jack

45 y.o. construction business owner/lead worker

His attorney is focused on the cognitive deficits – complaints of attention and memory difficulties

Cognitive testing is conflicted– No significant attention problems/mixed

memory findings (27th to 99th %ile)

Jack Does However Have a Symptom Pattern

Headache

Conversion reaction on the MMPI

Some aggravated disc degeneration with lessened lifting capacity (light to medium)

Jack’s $ Compensatory Issues

Restricted to light to medium work vs. no restrictions (Loss of $32,000 annually - $250,000)

Closed period of total loss ($248,000)

A 0.5 loss of work life participation due to the history of aggravated cervical disc degeneration, depression – conversion reaction, and headaches - $250.000

Case of Sally

Age 46 at time of accident

Objective cognitive memory deficit

Persistent headaches

Subjective complaints of back and neck pain, organization difficulties, irritability

Depression, alleviating

Case of Sally

Key to vocational loss was persistent headaches

If retires at age 59, loss = $418,000

If retires at age 65, loss = $612,000

What if Your Client is Still Working and Working Well?

Are the computerized programs always definitive?

Case of Professor Conwell

Three years ago injury, post-concussive symptoms

Mild NP difficulties, contradictory findings

Marked emotional response

“Back-to-work”

Excellent academic reviews

Basis of Professor Conwell’s Loss

Critical functional impact the first two years

Loss of local consulting – 2 years

Loss of national consulting contract – 20 years ($80,000)

Loss of two books’ royalties, had established stream

Attorney McMahon

49 years old

State attorney

Extensive insurance claim’s management work pre-law

Back-to-work for State – good proficiency reviews

Symptoms of Attorney McMahon

PTSD symptoms, subtle cognitive loss

Subtle visual difficulties

Emotional concerns (somatic, mood alteration)

Physical concerns (cervical tightness, movement limitations)

Basis of Loss: Over 13 Years

State salary $51,000

vs.

Private practice:– Plaintive attorney ($112,000)– Defense attorney ($105,000)

Computerized Searches Can Be Helpful, But “Hands-on” Research

Has Become Even More Important!

Issues in Pediatric/Adolescent TBI Cases

Stability of the impairment(s)

Estimating pre-injury cognitive level (no school records)

Establishing pre-injury cognitive level (school records)

Need for Persistence in Clarifying Case Underpinnings

Clarifying the Case Basis:Use of Interrogatory Protocols

Specific cognitive – e.g., problem solving

Physical impact

Headache issues

The constellation of symptoms

Given the Interrogatory Data, Can Harry Work Full-Time, Part-time, or No. of Hours?

Case is in Medical Flux

We don’t have a magic bullet in terms of establishing loss of earnings potential!

Generally Neglected Issues

Work life expectancy

Dollars related to disability

Loss of contribution to household tasks – Inside/outside home

Maximizing the Consultant’s Courtroom Testimony

Utilize a sequence of questions to establish the consultant’s credibility

Have the rehabilitation counselor provide you with a list of questions and refine together

Sequence the rehabilitation counselor’s testimony after the breadth and severity of impairment is established

All resources referenced in establishing earnings loss – overheads/slides

Final Vocational Recommendations

Early involvement of the vocational consultant

Priority is an experienced/credentiated consultant with other experts

Ensure early vocational consultant-life care planner interaction

Consider the impact of multi-system/ psychosocial residuals of injury

If valid, consider a closed period of loss

Life Care Plans

Have emerged as the standard by which other plans are to be measured on managing catastrophes

Life Care Plan Checklist

Projected evaluations

Projected therapeutic modalities

Diagnostic testing/educational assessment

Wheelchair needs

Orthopedic equipment

Life Care Plan Checklist

Aids for independent living

Orthotics/prosthetics

Home furnishings

Drug/supply needs

Health/strength needs

Recreational needs

Life Care Plan Checklist

Future medical care – both routine/ specialized

Transportation

Architectural renovations

Vocational needs

Potential complications

In LCP, Major Issue is Often?

Home care/facility care and at what level?

Checklist for Selecting a Life Care Planner

Professionals qualifications

Awareness of life care planning

Commitment to the profession

Industry experience

Medical foundation

Weed (1999)

Most Often Missed in LCP

Recreational, educational, and vocational needs