return to work after brain injury jeffrey s. kreutzer, ph.d. virginia commonwealth university...
TRANSCRIPT
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Return to Work After Brain Injury
Jeffrey S. Kreutzer, Ph.D.
Virginia Commonwealth University
Medical Center
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Pre- and Postinjury Work Statusof Patients Working Postinjury
Brooks, Glasgow
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Proportion of Employed Patientsat Varying Times Postinjury
Brooks, Glasgow
Months Postinjury
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Return to Work and Job Stability after TBIA TBI Model System Multicenter Analysis
J. Kreutzer, J. Marwitz, W. Walker,et al.Virginia Commonwealth University
Medical Center
Job Stability after TBI
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Job Stability after TBI Primary Outcome Measure
Job Stability – operational definition Stably Employed - employed at
all three follow-up intervals (n=44)
Unstably Employed - employed at 1 or 2 of 3 follow-up intervals (n=35)
Unemployed - unemployed at all 3 follow-up intervals (n=50)
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Employment and Productivity Status
Job Stability after TBI
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Employment and Productivity Status
Job Stability after TBI
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TBIMS Employment Rates 1996 and 2002 Comparisons
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Perception of Problems Impeding Return to Work
no transportation bad temper no motivation can’t walk or climb
stairs depression poor vision trouble using limbs
can’t speak properly can't understand
speech memory problems seizures medical illness thinking problems
n=443
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Perceived Employment Impediments
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Key PointSuccessful Return to Work
holistic approaches work
best
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Neurobehavioral ProblemsMost Commonly Reported 5 - 10 Years
Postinjury1. Bored2. Moves slowly3. Frustrated4. Difficulty lifting5. Writes slowly6. Reads slowly7. Poor concentration8. Trouble making
decisions
9. Tired10. Thinks slowly11. Loses train
of thought12. Easily distracted13. Impatient14. Loses balance15. Misunderstood by
othersWitol, Sander, Seel, & Kreutzer
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Neurobehavioral ProblemsMost Commonly Reported More Than 10 Years
Postinjury
1. Frustrated2. Forgets reading3. Impatient4. Misunderstood5. Bored6. Loses train of thought7. Reads slowly8. Writes slowly9. Moves slowly
10. Tired11. Thinks slowly12. Thinking of the right
word13. Restless14. Trouble making
decisions15. Trouble following
directions16. Learns slowlyWitol, Sander, Seel, & Kreutzer
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Most Commonly Reported Mood Problems*
Symptom 5- 10 yrs 10+ yrsbored 2.57 2.28frustrated 2.40 2.44impatient 2.20 2.33misunderstood 2.14 2.33
*among 15 most commonly reported n=97
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Most Commonly Reported Slowness Problems*
*among 15 most commonly reported
Symptom 5-10 yrs 10+ yrsmoving 2.54 2.22writing 2.30 2.24reading 2.34 2.27thinking 2.27 2.19learning 2.11
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Employee EvaluationSupervision Issues
Rating
1. Performs routine tasks with little or alwaysno guidance
2. Requires little supervision to alwayscomplete complex tasks
3. Willingly accepts and carries out alwaysassignments
Position Title: Executive Secretary I
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Employee EvaluationTime Utilization Issues
Rating1. Able to work effectively against always
tight deadlines2. Performs effectively in pressured always
and tense situations3. Uses time in an efficient and always
productive manner4. Uses the organization’s resources always
effectively to meet deadlines
Position Title: Executive Secretary I
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Employee EvaluationTime Utilization Issues
Rating5. Sets priorities and revises work always
plans to meet deadlines6. Works overtime to make certain always
that deadlines are met7. Punctual always8. Coordinates time away from the always
office in accordance with guidelines
Possible Ratings: Always, Usually, Rarely
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Employee EvaluationKnowledge and Creativity
Rating
1. Demonstrates thorough knowledge alwaysand applies to assignments
2. Maintains conscientious effort usuallyto enhance knowledge
3. Provides and applies creative usuallysolutions to assignments
Position Title: Executive Secretary I
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Employee EvaluationPerformance Quality Issues
Rating1. Thorough and accurate in
usuallycompleting assignments
2. Attentive to detailusually
3. Maintains acceptable production usuallyrate without sacrificing quality
4. Reliablealways
Possible Ratings: Always, Usually, Rarely
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Employee EvaluationPerformance Quality Issues
Rating5. Answers calls promptly and takes always accurate messages6. Demonstrates good follow-through always
on assignments7. Adapts and copes well with always
changing situations8. Written communication is organized, always
grammatical, and accurate
Position Title: Executive Secretary I
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Rating1. Active in providing phone coverage always
to the team2. Offers assistance to team members always
and supports “team concept”3. Resolves conflict in a professional usually
manner
Performance EvaluationProfessionalism
Position Title: Executive Secretary I
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Key PointSuccessful Return to Work
Recognize that employee evaluations often emphasize performance speed
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Key PointSuccessful Return to Work
Some jobs and work environments are more disability-friendly than others
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Vocational
Demands and
OutcomeSuccess in higher status occupations is more difficult because of lower error tolerances
Key Point
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Vocational Tasks for Persons with Severe Disabilities
Typing & word processing
Computer data entry Photocopying Phone answering Collating & stapling Mail preparation Filing
Packaging & unpacking
Pricing Delivery Light assembly Light cleaning Microfilming Food preparation
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Experience tells us that people with even the most severe disabilities can succeed at working -
The personal qualities of successful workers are well known.
Personal qualities are different than work skills.
You have the ability to change the kind of person you are, and to succeed at work.
How
so?
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“Am I Ready To Work ?” TestTrue or False?
I know my strengths and limitations.
I have clear goals and focus on making things better.
I keep trying even when things seem difficult.
I try to learn from my mistakes.
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“Am I Ready To Work ?” TestTrue or False?
I am willing to admit when I make a mistake.
I am willing to ask for help.
When people ask if I need help, I respond politely.
When people talk, I make sure to listen.
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“Am I Ready To Work ?” Test True or False?
When I’m not sure how to do something, I ask.
I look for the positive in other people and situations.
I’m polite and respectful to others. I can learn a lot from other people. I’m thankful when people offer me
constructive feedback.
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“Am I Ready To Work ?” Test
True or False? I do my best to be patient with
myself, my goals, and other people.
I pay attention to how I’m feeling. I work hard to control my
discouragement and anger. I think about other people’s
feeling.
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“Am I Ready To Work ?” Test True or False?
I can clearly see the benefits of work.
Outside of work, I try to do things that are good for me.
I choose to spend time with people who can help me reach my goals.
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“Am I Ready To Work ?” Test True or False?
I am an important and responsible member of my treatment team.
I communicate my feelings, needs, concerns, and ideas.
I understand that success at work means more than just doing my job.
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Vocational Planning and Counseling
Jeffrey S. Kreutzer, Ph.D., ABPPVCU Health System
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Case Planning Issues
Should I choose to help this person find and keep a job?
What goals and time frames are practical?
What do I need to be concerned about or sensitive to?
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Client FactorsCharacter, Personality, Intellect,
Skills, and Health
Work ethic, attitude, desire for success Stamina, sleep, pain, and health Transportation independence Stress and frustration tolerance Control of sexual and aggressive impulses Ability to accept diminished skills and
potential
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Client FactorsCharacter, Personality, Intellect,
Skills, and Health
Interpersonal and negotiation skills Responsiveness to feedback Neuropsychological functioning Adaptability Loyalty to employer
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Client FactorsSituational
Immediate and long-term financial needs
Expense of working Accumulated benefits and
other pressures to remain Consistency between career
plans, hopes, and available options
Retirement plans
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Work Responsibilities and Environmental Factors
Dangers Cost of making mistakes Job complexity and demand on
workers Flexibility in scheduling and
assigning responsibilities Organizational stability Noise, distractions, and ambience
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Colleague and Supervisor Factors
Presence and level of supervision Morale Attitude toward people with
disabilities and willingness to be supportive
Employee evaluation and feedback system
Competitiveness Tolerance of individual differences
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Community Factors Demand for workers Accessibility Presence and types of local
businesses Availability of medical and
rehabilitation resources Cost of living and average wages
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Return to WorkAssessment
Jeffrey S. Kreutzer, Ph.D., ABPPVCU Health System
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Assessment ComponentsInterview or Questionnaire Format
conditions for return to work
responsibilities schedule safety issues
work environment
relationship with your supervisor
goals and job security
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Conditions for Return to Work
Has your doctor or employer set any conditions for your return to work?
If yes, describe conditions……. How long do you feel that you need
before you can return to work part-time? How long do you feel that you need
before you can return to work full-time?
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Responsibilities What is your job title? Do you have a
written job description? If yes, please provide a copy.
Is driving required for you to perform your job? Will transportation be an issue if you return to work? How will you get to work?
Describe job responsibilities and indicate most important.
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Responsibilities Do you have contact with customers? If
yes, please describe. Do you have contact with other workers?
If yes, please describe. Do you supervise other workers? If yes,
please describe? What equipment do you use on your job?
Describe any training or qualifications to use equipment.
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Schedule How many hour per week
are you required to work? Are you required to work overtime? Would you be allowed to work part-time? Are you required to work swing-shifts? How much flexibility would you be allowed
in your schedule to accommodate breaks, doctors appointments, not feeling well?
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Safety Concerns Is your job dangerous? If yes, how? Do you use dangerous equipment on
the job? If yes, describe. Do other employees use dangerous
equipment? If yes, describe. Have you or others been injury at work?
If yes, please explain (e.g., how often).
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Work Environment Are there other people in the
workplace who have had serious injuries and return to work? If yes, how have they been treated?
Do you have concerns about how you would be received by co-workers if you returned to your previous position? If yes, explain.
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Relationship with Your Supervisor
How frequently have you had contact with your supervisor since your injury?
What does your supervisor know about the injury?
What was your relationship with your supervisor like before the injury?
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Relationship with Your Supervisor
What feedback has your supervisor given you since your injury?
Has your supervisor offered to change your responsibilities or position so that you can do your job? If yes, how?
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Goals and Job Security
What do you see as your biggest challenges in return to work?
Describe your career goals and whether they have changed since the injury.
Do you feel that you will have a secure job if you return to work? If not, why not?
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The Potential Family Role
They can ...facilitat
eignoreimpedesabotag
e
The process of ... job
developmentjob matchingplacementmaintenance
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Family members often need help understanding the demands of a job ...
I know he can’t remember what day it is
Still, why couldn’t he run a nuclear plant?
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Employment Can Increase Family Employment Can Increase Family Members’ Stress LevelsMembers’ Stress Levels
need for transportation assistance
caretaker’s resumption of former work responsibilities
redistribution of injured person’s responsibilities
daily apprehensions about client’s failures or termination
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Employment Interference by Family Members
Communicating and emphasizing personal fears about failure
Over-protectiveness - calling employer, following patient, questioning
Telling client he’s too good for the job Demanding better performance Failing to acknowledge client’s gains and
hardships
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Skepticism about the value of intervention often increases as a function of time post-injury
Gain an understanding of the family’s
past experiences with rehabilitation professionals
personal expectations for the process and outcome of intervention
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Leave the family out ...
When intervention fails and when
the personal problems of the personal problems of family members exceed their family members exceed their potential contribution orpotential contribution or
family members clearly family members clearly indicate a desire to sabotageindicate a desire to sabotage
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Employment Enhancement by Family Members
Acknowledging and emphasizing client’s efforts and successes
Encouraging communication Promoting in-home generalization of
cognitive and behavioral interventions
Encouraging abstinence from alcohol
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Employment Enhancement by Family Members
Acknowledging personal impact of employment process
Understanding interactions between client, family, and personal goals
Moderating feedback and offers of assistance
Aiding participation in alcohol-free social and recreational opportunities
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Building Family Trust Set realistic goals and expectations Acknowledge potential benefits and
limits of intervention Maintain ongoing communication Follow through with agreements
A written program description and contract helps establish and document agreements
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Supported Employment Methods
and Models
Jeffrey S. Kreutzer, Ph.D., ABPPVirginia Commonwealth
University Medical Center
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Attributes of Employment Models
employees’ level and type of disability nature of supervision and support resources work responsibilities for workers and
supervisors level of compensation and benefits workers’ relationship to host company number of work sites level of community integration and visibility
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SupportedEmployment Models
enclave mobile work crew small business sheltered workshop co-worker training center based training individualized supported
employment
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Enclave Characteristics
Structure - special training group, 3 - 8 persons working in community based industry
Supervision - permanent, full-time, on site Incentives - pay and benefits based on
productivity; commensurate with other workers Workers - paid by host or support company Supervisor - paid by support company
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Enclave Advantages intensive supervision allows hiring persons with
very severe disabilities employee improvement and supervisor fading
not required greater likelihood of co-worker stability and
support supervisor can oversee more than one worker potential for good pay and benefits especially
when host is larger company
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Crew - one or two supervisors, 3- 8 persons with disabilities
Operate from a van, frequent traveling to provide contract services at many different sites
Common services - grounds keeping, landscaping, custodial, painting, farm labor, snow removal
Model works well in rural areas and small communities
Mobile Work Crew Characteristics
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Mobile Work Crew Characteristics
Some workers not fully productive; increasing supervision and public funding needs
Business status typically “not for profit”
Successful marketing and contract negotiation required
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Mobile Work Crew Advantages
Contracting allows flexibility based on community needs
Community travel stops facilitate integration
Public work allows citizens to see persons with disabilities working productively
Cost efficient after start up because of low overhead
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Small Business or Entrepreneurial Option
Characteristics Workers - eight or less; having most
severe disabilities Supervision, very close with ongoing
behavioral programming Business type - manufacturing or
contractual Single business may be constituted of
several linked sites
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Small Business or Entrepreneurial Option
Characteristics Business plan addressees marketing, sales,
production, documentation, quality control Social integration by setting site nearby
other businesses, restaurants, stores, recreation sites
Cost comparable to day treatment or day rehabilitation program
Compared to sheltered workshop - smaller number of employees with greater disabilities
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Sheltered Workshop
Workers with severe and varied disabilities Supervisors - usually more than one Close supervision includes behavior
management Work type - light assembly, printing and
duplication, mailing, clerical Incentives - pay less than minimum wage
based on productivity, few benefits if any
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Sheltered Workshop
Management - one or more staff may focus entirely on business operations
Single site usually zoned for business or light industry
Common complaints -– workers feel “unproductive” – extreme segregation – limited options for work responsibilities– concerns about poor models for behavior
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Co-Worker Training Employment Model
Experienced employees become primary providers of on the job training and support
Employment specialists train experienced employees
Employment specialists serve as consultants, mediators, and data collectors
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Center Based Rehabilitation
ReferralReferral
Extensive Assessme
nt
Extensive Assessme
nt
PlacementPlacement
6 – 12 week follow-up
6 – 12 week follow-up
Eliminate Poor Risks
Eliminate Poor Risks
Extensive Vocation
al Training
Extensive Vocation
al Training
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Supported Employment
ReferralReferralBrief Holistic
Assessment
Brief Holistic
Assessment
Follow-along long-term
Follow-along long-term
Job Analysis, Matching,
Development
Job Analysis, Matching,
Development
Placement
Placement
interdisciplinary rehabilitation
counseling and behavioral services
case coordination
recreational programs
social programs
substance abuse treatment
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Disincentives
Loss of disability income Loss of medical
insurance Fear of stress or failure Loss of “helpless role” Lower pay rate and job
status
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Job Analysis Required cognitive, academic, technical,
interpersonal skills Transportation needs and skills Stamina and endurance requirements Health code requirements Level of independence and available
supervision Environment - noise and safety issues
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Principles of Shared Responsibility
Include persons with brain injury and their families as equal partners
Develop services by preparing supports not people
Establish and maintain relationships with funding and service agencies
Efforts toward improved quality of life
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Job Development Seek available jobs
Contact past and new potential employers
Observation and analysis of job site
Ongoing communication with client, family, and rehabilitation providers
Job matching employers needs with client’s skills and interests
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Vocational Tasks for Persons with Severe Disabilities
Typing & word processing
Computer data entry Photocopying Phone answering Collating & stapling Mail preparation Filing
Packaging & unpacking
Pricing Delivery Light assembly Light cleaning Microfilming
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New Employer Contacts
Job hotlines Help wanted ads Personal contacts Government vacancy listings Referrals from other employers College career planning and
placement offices
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Research indicates that persons with disabilities are
more ...
highly motivated
dependable likely to stay in
their positions longer
than persons without disabilities
Why hire ‘em?
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On-Site Intervention Unobtrusive involvement in
training work-related skills Compensatory strategies development Promoting positive collegial and supervisor
relationships Stress inoculation Problem solving interactions
emphasizing positive feedback Phase-out with mastery
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Job Adaptation and Support Methods
use assistive devices develop or enhance cues rearrange work environment change task sequence or eliminate
difficult steps arrange for co-worker to complete task
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Job Site Enabling
if a work skill or task can be taught - teach it
if it can’t be taught, adapt it if neither teaching nor
adapting are successful, support it
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Box 980542, Richmond, VA 23298-0542USA PH 804 828-9055
Jeff Kreutzer [email protected]
Virginia Commonwealth UniversityMedical Center
The National Resource Center for Traumatic Brain Injury www.neuro.pmr.vcu.edu