EL PRIMER GRAN AVANCE

The purpose of intervening early is to ensure advice (1) not to make premature decisions about

relinquishing work and (2) to maintain contact with the employer is given to patients, family members and other key NHS service providers involved in the person’s care.

The assessment involves:

l asking questions about occupational status and vocational aspirations and needs

l responding to the person with TBI’s questions and concerns about return to work, education or training. It sometimes involves input from other relevant stakeholders who form part of a wider multidisciplinary team co-ordinated by the VR therapist or CM including NHS HCPs such as medical consultant, clinical psychologists and physiotherapists and external agencies (e.g. Jobcentre Plus, occupational health).

The rehabilitation involves:

l providing interventions (directly related to the person’s work or study) that promote optimal recovery and management of difficulties, including one or more of the following–

¢ developing skills or behaviours necessary for work or study

¢ restoring work-related routines

¢ activities to improve attention, work/study tolerance and stamina

¢ extending coping strategies (e.g. fatigue management) for use in the workplace or for study.

l planning a return to work/study with relevant agreed accommodations, such as equipment, graded return, voluntary trial, restricted hours/duties, advice/support in the workplace, job coaching, support from work colleagues, off-site support (e.g. from the OT or other relevant agencies). In the case of study return, these may include adjustments to course, learning-support equipment, individual learning support, examination support and personal support (e.g. personal tutor). These plans take account of family and personal circumstances and the required motor sensory and cognitive–behavioural and emotional skills necessary to a return to work/education.

Education involves:

l advising the person with TBI not to return to work too soon (i.e. until the impact of the TBI is understood and coping strategies formulated)

l educating the person, family and employer about difficulties likely to affect work/study (e.g. functional ability, insight and ability to work or return to work/study)

l developing strategies for the person to explain the effects of their TBI to others

l providing written information for participants and employers (e.g. about managing fatigue, job accommodations and informing the Driver and Vehicle Licensing Agency about driving) (seeReport Supplementary Material 4).

Communication and co-ordination includes:

l establishing which other community services [e.g. ABI team, speech and language therapy (SALT)] are involved and communicating with them

l supporting the person prior to, and during, meetings with employers and other stakeholders (including clarifying what was said and agreed in meetings)

l seeking the person’s consent to contact the employer, education provider and/or training provider to discuss needs

l establishing and maintaining communication with employer and informing them of rehabilitation goals

l consulting with occupational health, DEA, Jobcentre Plus occupational psychologist or other VR service providers to discuss relevant action if there is doubt about a client’s ability to cope with a supervised and graded RTW

l providing clear written and verbal advice about appropriate timing, and gradual increases in hours and responsibilities

l liaison with the relevant occupational health department for advice or, when unavailable, consulting the NHSPlus website

l agreeing and discussing the disclosure of information to an employer or occupational health provider (providing clients with draft submissions for comment prior to disclosure)

l agreeing and discussing the RTW plans with the client and a family member (when possible)

l negotiating and agreeing workplace accommodations, such as equipment, graded return, voluntary trial, restricted hours/duties, advice/support in the workplace, job coaching, support from work

colleagues, off-site support (e.g. from the OT or other relevant agencies) with the employer. In the case of study return, these may include adjustments to course, learning-support equipment, individual learning support, examination support and personal support (e.g. personal tutor).

Monitoring involves:

l reviewing progress with ongoing advice, support and feedback for person and employer (supervisor and work colleagues, as appropriate) and obtaining feedback from family members about the impact of work on personal life, family life and relationships

l liaising with DEAs when long-term adjustment and support are needed (e.g. major adjustments to work duties, specialist equipment or help with travel to work).

The intervention is individually tailored and delivered in the community, clinic or workplace over weeks or months based on participants’individual needs. In our earlier cohort comparison,85_{participants had a} mean of 6.5 sessions of occupational therapy and 4.7 1-hour-long sessions of case management over the 12-month intervention period. Half of the sessions were delivered in person and half by telephone or e-mail. This‘direct’contact with the person accounts for about two-thirds of the therapist’s overall time. The rest is spent in administration and travel.

In the single-centre cohort study, ESTVR was delivered by a single experienced OT trained in VR. ESTVR was developed based on best practice recommendations64_{over a number of years and evaluated pragmatically} in the context in which it was developed. What remained unclear was whether or not OTs in other contexts could be trained to deliver it so that its effectiveness could be tested in a RCT. The intervention needed to be described such that the key intervention components were clear before an intervention training manual could be developed. Therefore, the starting point for this study was to manualise the intervention and train OTs in the three sites to deliver it.