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Comorbid Traumatic Brain Injury and Visual Impairment: Vocational Rehabilitation Service Provision and Agency-Level Outcomes
Research Takeaway: Some people with a traumatic brain injury (TBI) also experience visual impairment (VI). We wanted to know how many consumers with both TBI and VI are served by vocational rehabilitation (VR) agencies, how agencies provide services to these consumers, and how likely consumers are to find employment.
A TBI is an injury to the head that damages the brain. People who experience a TBI may also experience some level of VI, and some people with a pre-existing VI experience a TBI. Rehabilitation can be hard for these individuals due to issues like short-term memory loss or physical limitations.
Almost no research exists on the experiences and outcomes of VR consumers with combined TBI and VI. This study looked at how many consumers with combined TBI and VI are served by VR agencies, how agencies provide services to them, and their employment outcomes. We wanted to know if any VR agency service-provision factors are linked to the number of consumers with combined TBI and VI served and their employment outcomes.
Most VR agencies serve very few people with combined TBI and VI. The average percentage of consumers with combined TBI and VI served by an agency was just 2%. The average employment rate for these consumers was 43%. The proportion of consumers with combined TBI and VI who were served and their competitive employment rates varied a lot by agency.
When working with consumers with combined TBI and VI, VR agencies reported using the following strategies:
- Collaboration between counselors: Administrators at 45% of agencies said they used either between-agency or within-agency collaboration to serve consumers with combined TBI and VI. Separate agencies for the blind collaborated with their state’s general VR agency. Combined agencies that serve all disability types used within-agency collaboration. In both types of collaboration, a counselor with expertise in TBI and one with expertise in VI worked together to provide services.
- Involvement of external organizations: Use of external organizations, like hospitals or rehabilitation centers, was reported by 45% of VR agencies. Some VR agencies used these outside organizations as vendors or contractors, while other agencies reported a deeper level of partnership with outside groups to help them serve consumers with TBI and VI.
- Specialized TBI units or caseloads: Some combined agencies (18%) said their agencies had specialized TBI units, programs, or service providers. In some agencies, these personnel worked directly with consumers. In others, they served as resources for direct-service staff.
- Staff training in TBI: Twelve percent of administrators said that staff members who served consumers with VI also received training about TBI.
- Personnel with experience in both TBI and VI: Just 6% of administrators (representing three agencies) reported having a person on staff with expertise in both TBI and VI.
Over one-third of VR agency administrators (35%) said they did not do anything special or different to serve consumers with combined TBI and VI. No agencies reported having a unique service-delivery program to serve this population.
Only one service approach was linked to both serving more consumers with combined TBI and VI and better employment outcomes for these individuals. Employing staff with dual expertise in TBI and VI was associated with serving more of these consumers and closing a higher percentage of them as competitively employed.
- Provide more training for VR counselors about combined TBI and VI. All counselors and staff who work with consumers with VI can benefit from TBI-related training and certification. Certifications are offered by the Brain Injury Association of America and the Academy of Certified Brain Injury Specialists. In addition, the National Technical Assistance Center on Blindness and Visual Impairment offers a free, online continuing education course about combined TBI and VI.
- Seek out staff with expertise in both TBI and VI. Employing staff with this dual expertise was linked to serving more consumers with combined TBI and VI and with better employment outcomes for these consumers. Staff with dual expertise may better understand the needs of this population and encourage the appropriate provision of services.
- Plan for the unique challenges of serving consumers with combined TBI and VI. More than a third of agencies reported that service provision for this population was the same as service provision for all other consumers with VI. However, TBI can require specialized intervention, and VR agencies should have a plan for serving these unique consumers.
We analyzed data on 914 consumers with combined TBI and VI from the Rehabilitation Services Administration Case Service Report (RSA-911) from fiscal years 2013-2015.
We also interviewed administrators at 51 VR agencies, representing all 50 U.S. states and the District of Columbia. Twenty-seven of these states had one VR agency that served all consumers with disabilities (combined), while 24 had two VR agencies, one for consumers who are blind (separate) and one for consumers with all other disabilities (general).
Findings taken from the following article: McDonnall, M. C., Cmar, J. L., & Lund, E. M. (In press). Comorbid traumatic brain injury and visual impairment: Vocational rehabilitation service provision and agency-level outcomes. Journal of Visual Impairment & Blindness.
For more information about this project, visit the project overview page: Exploration of Secondary Data to Increase Our Knowledge About Subpopulations of Individuals who are Blind or Visually Impaired and WIOA Impacts..
Losing Employment: At-Risk Employed Vocational Rehabilitation Applicants With Vision Loss
Research Takeaway: Many applicants to vocational rehabilitation (VR) services who are blind or visually impaired (B/VI) are already employed. Our study explored the risk factors that make these consumers more likely to lose their jobs.
Many consumers who are B/VI enter the VR system employed. Often, they are looking for help to keep their jobs or advance in their careers. Recent federal legislation emphasizes helping these consumers maintain employment.
However, there is very little research available on the characteristics and outcomes of employed VR consumers. We wanted to understand the characteristics and VR services that are linked to higher odds that employed B/VI consumers will lose their jobs.
Most consumers in our study (84%) maintained employment during their time in VR. However, among those who did not maintain employment, we found some characteristics that make it more likely an employed B/VI consumer will lose their job:
- being female,
- having a secondary disability,
- working fewer hours at the time of application,
- having less education, or
- having a previous unsuccessful VR employment outcome.
In addition, we found that the longer consumers were served by VR, the more likely they were to lose their job, especially for older consumers.
Consumers who were more likely to keep their jobs also tended to share some traits, including:
- having at least an undergraduate degree,
- being Business Enterprise Program vendor, or
- having a previous VR closure with a competitive outcome.
Receipt of a few VR services were also linked to higher odds of maintaining employment for VR consumers who are B/VI:
- on-the-job supports (short-term),
- diagnosis and treatment of impairments, and
- rehabilitation technology services.
- Assess employed VR consumers for risk factors. As employed consumers open cases with VR, counselors should check if the consumer has any risk factors that make them more likely to lose their job. Some of these risk factors, like part-time employment, can be addressed to improve the odds of maintaining employment.
- Fast service delivery matters when it comes to job retention. The likelihood of losing employment increased with VR case length. VR agencies should make job-retention cases a high priority and expedite services for consumers who are trying to maintain employment.
- Improve data sharing to make it easier to keep track of consumers. Almost one-third of consumers in our study who did not maintain employment had their cases closed due to difficulty contacting them. VR agencies should share data with other workforce partners to maintain current contact information. This helps counselors stay in touch with consumers and hopefully keep them motivated to continue the VR process.
We analyzed data from the fiscal year 2015 Rehabilitation Services Administration Case Service Report (RSA-911 data) on 4,499 competitively employed VR applicants who are B/VI.
Findings taken from the following article: Crudden, A., McDonnall, M. C., & Sui, Z. (2018). Losing employment: At-risk employed vocational rehabilitation applicants with vision loss. Journal of Visual Impairment & Blindness, 112(4), 461-474.
For more information about this project, visit the project overview page: Job Retention and Advancement: A Mixed Methods Investigation.
For more information on the Journal of Visual Impairment & Blindness, please visit www.afb.org/jvib
How Do VR Services Received by Consumers who are SSDI Recipients Impact Their Employment Outcomes?
Research Takeaway: The vocational rehabilitation (VR) services received by Social Security Disability Insurance (SSDI) recipients with blindness or visual impairments (BVI) can have a significant impact on the likelihood that these individuals will secure competitive employment. Receipt of some VR services increases the odds of finding employment, while others are associated with decreased odds. The services needed and received by an individual may serve as a signal to their VR counselors about where they are in the process of becoming job-ready and the level of effort that may be required to help that consumer successfully re-enter the workforce.
One-third of the individuals with BVI who enter the VR system are SSDI recipients. SSDI payments are provided to individuals with disabilities who are unable to work; in order to qualify, an individual must have substantial work experience. Traditionally, SSDI recipients have been viewed as less likely to become employed, due to the assumption that individuals who are receiving government benefits will be reluctant to give those up by taking a job.
This study sought to better understand the employment outcomes of individuals who are (a) BVI, (b) in the VR system, and (c) SSDI recipients by exploring whether the services received from VR are linked to whether an individual is more or less likely to find employment. Both the SSDI and VR programs face budgetary constraints, and these findings can be valuable for VR agencies helping individuals leave the benefit rolls to re-enter the workforce.
Our analysis showed that VR services tend to be provided in four clusters or groupings:
- Special and remedial services : Receiving services in this cluster was associated with lower odds of employment. Receiving more services in this category indicates that anindividual may be facing a substantial barrier to employment which requires intensive efforts to overcome.
Services in this cluster include reader, personal attendant, and interpreter services; basic academic remedial or literacy training (“remedial services”); and college or university training.
- Job-related services : Receiving more services in this cluster was associated with higher odds of employment, especially in states with high unemployment rates. These services are generally given to those who have demonstrated that they are “job-ready.” As a result, it is not surprising that receipt of these services strongly predicts employment success. Services in this cluster include job placement assistance, job search assistance, on-the-job supports, job readiness training, and on-the-job training.
- Evaluation : Receiving more services in this cluster was not associated with employment, one way or another. Services in this cluster include information and referral services, VR counseling and guidance, technical assistance services, and assessment.
- Training and supports : Receiving more services in this cluster was associated with greater odds of employment. This category of services may be used to provide job-seekers with the technology and extra assistance they need to secure a job, thus linking it to positive employment outcomes. Services in this cluster include rehabilitation technology, other services, transportation services, maintenance, occupational/vocational training, miscellaneous training, and disability-related augmentative skills training.
Our analysis also showed that some specific VR services within the four clusters are positively related to employment outcomes for SSDI recipients who are BVI. The following VR services were shown to indicate improved odds of securing competitive employment:
- Job placement, such as a referral for a job interview
- Job search assistance, such as identifying jobs or resume preparation
- On-the-job supports, which are usually services to help an individual already on the job
- On-the-job training, such as paid training in specific job skills
- Counseling and guidance
- Rehabilitation technology, such as assistive technology that can be used on the job
- Other services, which could include a wide range of supports or medical care not included in other categories
- Maintenance, such as monetary support for items related to job-seeking (e.g., clothing, relocation costs).
In the same way, other individual services within the clusters were shown to indicate decreased odds an individual will find competitive employment:
- Reader services, such as reading aloud or transcription into braille
- Interpreter services, which are usually received by individuals who are deaf-blind
- Job readiness training, including basic training on appropriate work behavior, timeliness, and dress and grooming
- Augmentative skills training, including orientation and mobility, braille, and use of low vision aids
- Assessment, which includes determination of eligibility for VR services and/or determining details of which services are needed.
The services that were shown to decrease the odds of employment for SSDI recipients who are BVI can serve as “red flags” for VR service providers. If a consumer requires one or more of these services, it may be an indication that they will need extra time and effort to find employment. However, although receipt of these services may signal a consumer who is “at risk,” they can still achieve success. For example, an analysis of consumers who received job-readiness training found that consumers who were younger or had more work experience were still able to achieve employment at normal rates.
Our analysis found that job-related services are especially meaningful when unemployment (and thus competition for jobs) is high. Service providers in states with tight economies may want to consider boosting provision of job-related services to provide their clients with the extra edge they need to compete successfully in the workforce.
The results of this study also reinforce that idea that, rather than SSDI recipients being unpromising job candidates, they can experience great success on the job market. In our study, SSDI recipients with BVI had an employment rate of 45%, compared to a 52% employment rate for non-SSDI recipients. This demonstrates that, contrary to popular belief, SSDI recipients are able to achieve employment success at rates close to those of their non-recipient peers. Service providers serving clients who are SSDI-recipients should maintain high expectations for their employment success. Staff interactions with employers proved to be far more important for employment outcomes than agency policy or practice. This drives home the point that regular, positive contact with employers is the best way to improve employment outcomes for consumers who are BVI. VR counselors in particular should be encouraged to consider interacting with employers to be an essential part of their job, and VR agency administrators should ensure that counselors have the resources, training, and time they need to make this happen.
We studied 3,610 SSDI recipients with BVI who were closed by a VR agency in FY 2011. Our data came from case service records in the RSA-911 data set. Various analysis techniques were used to determine patterns in service delivery and which services predict employment.
Giesen, J. M., & Hierholzer, A. (in press). Vocational rehabilitation services and employment for SSDI beneficiaries with visual impairments. Journal of Vocational Rehabilitation
Study of Employment Outcomes for SSDI Beneficiaries Reveals Better Employment Outcomes for Consumers Served in Blind Agencies, Importance of Work Experience in Obtaining a Job
Research Takeaway- Employment outcomes were similar across all races and ethnicities for individuals with blindness or low vision who also receive Social Security Disability Insurance (SSDI) benefits. This suggests that prior work experience (which an individual must have in order to receive SSDI benefits) has a positive influence on the chances of getting a job. In addition, some individuals from specific groups were more likely to have competitive employment outcomes when they were served by a blind (rather than a combined) Vocational Rehabilitation (VR) agency. Thus, services oriented specifically for consumers who are blind or visually impaired seem to be most effective for this population.
What are the factors affecting competitive employment outcomes for individuals with blindness and low vision who receive SSDI benefits?
This project used 2010 data from the Rehabilitation Services Administration to track employment outcomes for 4,478 individuals with blindness or low vision who were receiving both vocational rehabilitation services and SSDI benefits.
- Across diverse backgrounds, having prior work experience increases consumers’ chances of finding competitive employment. In contrast to typical findings of race differences in employment outcomes, this study found that SSDI recipients who are African American, Hispanic, white, or multirace had almost identical levels of competitive sector employment after receiving VR services. This surprising finding suggests that no matter an individual’s race or ethnicity, prior work experience can level the playing field and help overcome barriers to employment.
- Higher amounts of SSDI benefits are associated with finding a job. Researchers found that individuals receiving higher amounts of SSDI benefits at the time they applied for VR services had a greater likelihood of finding a job than applicants who were receiving lower amounts of benefits. Because SSDI benefit amounts are based on an individual’s previous earnings, this means that individuals with significant past work experience had better employment outcomes than their peers with lower levels of previous experience on the job.
- Some consumers served in blind agencies had a better chance of a competitive employment outcome than their peers served in combined agencies. Consumers tend to see a decline in competitive employment as they age. However, this study found the decline in employment was much less dramatic and mostly eliminated for older, SSDI recipient consumers who were served by a blind agency. Female and Asian Americans individuals who are blind also had better employment outcomes when served by blind agencies. Blind agencies provide categorical services that are oriented specifically for consumers who are visually impaired, and these services are provided by counselors experienced with and focused on serving consumers who are visually impaired. Thus we expect that categorical blindness services wherever provided—even those provided in agencies other than blind agencies—will be most beneficial to blind consumers receiving SSDI and probably to blind consumers in general.
- Encourage work experience for consumers whenever and wherever you can. Even work experiences such as internships (both paid and unpaid), apprenticeships, and job shadowing can allow individuals to gain some experience in the workplace. A focus on work experience opportunities for transition-age consumers as they enter the VR system, perhaps through partnerships with education agencies or through summer transition programs that include work components, could be particularly beneficial.
- Consumers who receive SSDI make excellent job candidates due to their previous employment experience, but they may need help understanding how returning to work impacts their benefits. Although SSDI benefits may be lost due to employment, there are a number of supports (e.g., Medicaid buy-in programs) in place to help individuals return to work without suffering a large financial blow. When working with a consumer who receives SSDI, try offering benefits planning services to help reduce their uncertainty and fear about returning to work. The many resources available at www.socialsecurity.gov/work/ are a great place to start.
Findings taken from the following article:
Giesen, J. M., & Cavenaugh, B. S. (2013). Disability insurance beneficiaries with visual impairments in vocational rehabilitation: Socio-demographic influences on employment. Journal of Visual Impairment & Blindness, 107(6), 453-467.
Exploring the Most Effective Strategies for Working with Employers to Improve Employment for Consumers with Blindness and Low Vision
Research Takeaway: The way Vocational Rehabilitation (VR) counselors and business relations (BR) staff interact with employers matters. Employment outcomes for individuals who are blind or visually impaired (BVI) are improved when VR counselors treat employers like customers and when BR staff use blindness-specific techniques when working with employers.
Employment rates for individuals who are BVI are currently, and have been historically, much lower than the employment rate for the general population. Therefore, it is essential to understand what people who work with the BVI population can do to more effectively help them find jobs.
A big part a VR counselor’s job is to work with employers, and there is an increased focus on emphasizing employer engagement within the VR system. We wanted to know if the way counselors interact with employers makes a difference in employment rates for VR consumers who are BVI. This study focused on the Business Relations Model (BRM), which posits that counselors should treat employers as customers and consider their unique needs. Although the BRM approach is anecdotally considered to be effective, there is very little research to back up this claim.
We were also interested in the way BR staff work with employers. Some VR agencies employ BR staff to serve as the primary liaisons with local employers. However, many BR staff don’t have specific training in BVI, so we wanted to see how effective they were at helping individuals who are BVI secure employment. We looked to see if employment rates for consumers who are BVI were affected by BR staff use of three blindness-specific techniques:
- Providing education about how individuals who are BVI function on the job
- Exposing businesses to people who are BVI
- Providing referrals to other businesses that employ someone who is BVI
- The approach VR counselors use when working with employers does indeed influence employment rates for consumers who are BVI. Consumers had better employment outcomes when their VR counselors used the BRM approach when working with employers.
- Consumers who are BVI also had better employment outcomes when BR staff used blindness-specific techniques, such as talking about how workers who are BVI complete workplace tasks.
- Agencies that reported creating BRM-inspired policies did not necessarily have better employment outcomes for their consumers. This indicates that the way individual VR counselors and BR staff interact with employers is more important than overall agency policy.
- Many VR counselors report feeling uncomfortable and unsure of themselves when interacting with employers. However, this is one of the most important aspects of their job. Using the BRM approach and treating employers like customers can create positive outcomes for consumers. Counselors may wish to receive training in using BRM from BR staff or from more experienced counselors.
- BR staff might be experts in BRM, but they may not know much about blindness and low vision. Blindness is a unique disability that requires alternative techniques and technology to accommodate it. In order to help them be more effective at creating successful placements for consumers who are BVI, BR staff need training in issues related to blindness, such as blindness-specific technology and the ways employees who are BVI complete workplace tasks. BR staff can then pass this information along to employers, thus improving employment outcomes for BVI individuals.
- This study demonstrated the effectiveness of the BRM approach, and VR agency administrators should strongly consider emphasizing this technique. However, administrators should keep in mind that real change has to happen with individual counselors. Simply setting agency policy or creating new guidelines won’t be enough to boost employment outcomes for consumers who are BVI. Individual counselors need to buy into the changes and modify their approaches to employers.
- In VR agencies that serve consumers with a broad range of disabilities, it may be worthwhile to track employment outcomes for BVI consumers separately. This would allow agencies to determine which counselors and BR staff are most effective at working with this unique population.
- Staff interactions with employers proved to be far more important for employment outcomes than agency policy or practice. This drives home the point that regular, positive contact with employers is the best way to improve employment outcomes for consumers who are BVI. VR counselors in particular should be encouraged to consider interacting with employers to be an essential part of their job, and VR agency administrators should ensure that counselors have the resources, training, and time they need to make this happen.
We surveyed over 200 VR counselors and BR staff across the country about their approaches to interacting with employers. The surveys focused on the BRM approach and blindness-specific approaches. We then linked this data with outcome data (RSA-911 case service) for consumers who are BVI in the VR system in order to determine how approaches to working with employers impacted employment outcomes.
McDonnall, M.C. (2015). The relationship between vocational rehabilitation professionals' interactions with businesses and employment outcomes for consumers who are blind or visually impaired. Rehabilitation Counseling Bulletin. Advance online publication. DOI: 10.1177/0034355215586389
Voice Over Internet Protocol (VoIP) phones are found in many offices but are often inaccessible to individuals with blindness or visual impairments (BVI). If you’re assisting a consumer who is BVI to acquire an accessible VoIP system for their office, and want to make sure that it’s fully accessible, here are the top 10 features to keep in mind.
Keys on VoIP phones that are uniform in shape and texture and are placed close together can be difficult to use for individuals with BVI. A VoIP phone that has well-spaced, prominent keys that are different shapes and textures can make the interface of a physical VoIP phone accessible. Keys with unique textures or shapes provide a point of orientation and make memorizing key locations easier when navigating a phone by touch.
Like most physical phones, VoIP phones usually display caller ID on a digital display that is difficult for someone with BVI to use. A VoIP phone that can connect to an external talking caller ID or has some other way of non-visually communicating caller ID can be used successfully by someone with BVI.
VoIP phones have visual indicators to alert users to new voicemail. Look for systems that present this information in an accessible manner. For example, sending an email to the user upon receipt of a voicemail is an accessible alternative for people with BVI.
The call log of a physical VoIP phone is available on the digital display without an accessible alternative. Currently, an accessible call log can be acquired by connecting a software based VoIP phone (softphone) to the same line as the physical phone so that it can be accessed by a person with BVI using computer access software.
Like the call log, the address book is presented visually on the digital display of a physical VoIP phone. The most accessible way to use the address book is to use a softphone that can make calls on the same line as the physical phone so that the user can use the address book using screen access software on the softphone.
A softkey is a physical button that changes function depending on circumstances. The current function of a softkey is presented visually on a digital display just above the key so that a user knows what the key will do if pressed. Softkeys that have audible or tactile indications that their status has changed are accessible to people with BVI.
In many cases VoIP displays are not backlit and have small fonts and low contrast, making the display very difficult to read for someone with low vision. A VoIP phone is more accessible if the display has high contrast between foreground and background. Large font also makes the display easier to read.
Printed documentation that uses a small font is inaccessible to someone with BVI. The most universally accessible style of documentation will be digital formats such as DOCX or HTML. Digital documents can be enlarged by screen magnifiers, read with screen readers, or printed in braille. (NOTE: PDF documents that contain only images of text are not accessible to screen readers or braille displays.)
In order to be accessible, status changes, such as phone muting and display navigation, should have sounds to signal these changes. Such sounds, commonly called earcons, make navigating VoIP systems easier for a person with BVI. For example, a different tone playing for mute and unmute allows a person with BVI to determine the status of their device.
The display on a physical phone can be used for many functions, from caller ID to settings. Communicating this information using synthetic speech makes a VoIP system more accessible. Currently, the only method for presenting VoIP functions in a completely accessible manner is to use a softphone, because there are no physical VoIP phones that present their information in an accessible manner from the device itself.
For more information about employment
To learn more about research results related to employment, visit our Article Summaries page. That webpage hosts downloadable PDFs that include easy to understand descriptions of research publications that focus on practical takeaways.
Improving Employment Outcomes by Connecting With Businesses
Vocational Rehabilitation (VR) agencies are increasingly focused on building and maintaining employer relationships in order to support the employment of individuals with disabilities. Employers were surveyed about their interactions with VR and their hiring of people who are blind or visually impaired (BVI). Employers who reported contact with VR agencies were more likely to have hired an individual with BVI and to intend to hire from among this population in the future. These results provide empirical support for the importance of VR professionals making and maintaining relationships with employers.
Utilizing Mentors in the Job Placement Process
One strategy for improving the employment success of graduates is connecting them with successful mentors who are blind in their profession of interest.
Mentors can help students with visual impairments develop skills, knowledge, and motivation as they transition from college to employment.
Approximately 40% of high school students who are blind or visually impaired attend a 4-year college—the highest rate of post-secondary school attendance among students with disabilities.* Unfortunately for many of these students, a college degree does not always lead to a rewarding career in their chosen profession. College students with visual impairments may lack a clear understanding of what specific careers require on a day-to-day basis. Students may also lack understanding about how their blindness could impact job seeking activities and on-the-job performance. Students will often graduate from college without having had the chance to get on-the-job experiences. Graduates may have difficulty finding employment or be underemployed.
Learn how to assist consumers transitioning to employment by exploring our resources below.
Download and read our Mentoring Manual to learn:
- About the mentoring relationship
- How job seekers can benefit from a mentoring relationship
- How to set up a mentoring relationship
- Tips for making a mentoring relationship successful
If you’re working with a consumer with blindness or low vision who is looking for employment, our Job Seeker’s Resource Sheet can provide them with information such as:
- Information on the Americans with Disabilities Act, disclosing a disability, and asking for an accommodation at work
- Websites to connect with local job openings and job search tools
- Self-paced classes to improve soft skills and knowledge of job-seeking activities
*Newman, L., Wagner, M., Cameto, R., & Knokey, A. (2009). The post-high school outcomes of youth with disabilities up to 4 years after high school: A report from the National Longitudinal Transition Study-2 (NLTS2). Menlo Park, CA: SRI International.