Mid Sweden University

The objective of this study was to better understand the long-term effects of an improved model for cooperation on employment between rehabilitation professionals in vocational rehabilitation (VR). To compare these effects with those associated with the traditional model of cooperation. The study featured a group of patients who participated in a developmental project. All of the patients had some degree of restricted work capacity, which was evidenced somatically as well as mentally/socially. They had all experienced long periods of unemployment during the 2-year period before the intervention. A 'natural experiment study design' that relied on database records was used. Using matching criteria, we identified 'social twins' from a government register to create comparison groups at the local, county and national levels (n=4×51 patients). Repeated-measures analysis of variance and logistic regression were used to analyse the data. The majority (59%) of the study group was employed 3 years after the intervention compared with 39 and 41% in the two matched control groups, respectively. The corresponding figures after 6 years were 51 versus 39 and 37%. An individual with a somatically restricted work capacity was about twice as likely to secure gainful employment following VR as compared with an individual with a mentally/socially restricted work capacity. In conclusion, the study focused on an improved method of cooperation between rehabilitation actors in the context of VR programmes. A model that included systematic multiprofessional cross-sector group meetings was explored, and we concluded that a substantial percentage of the enrolled patients successfully secured employment over a 6-year period. This percentage exceeded that of matched pairs in a county and national group; we presume that these groups represented 'the usual form of cooperation'.

The overall aim of the thesis was to acquire an increased knowledge of co-operation between different rehabilitation actors in the provision of vocational rehabilitation (VR). One aim was to investigate the differences in effects on employment between clients rehabilitated according to a systematic multi-professional cross-sector co-operation model (SMCVR) and clients subjected to conventional co-operation. A second aim was to investigate the communicative process in the rehabilitation group meetings and female clients’ experiences during the VR process.

The studies used material collected from two intervention projects, enabling natural experimental designs. Fifty-one unemployed clients with various work limitations, who underwent intervention with SMCVR I model during a period of 18 months, were individually matched into pairs using records from the Swedish Public Employment Service. Three matched comparison groups, representing the conventional way of co-operation between VR actors, were formed at local, county, and national levels. A distinctive feature of the SMCVR I model was that the client’s rehabilitation was planned by multi-professional cross-sector rehabilitation groups consisting of the client, a rehabilitation official from the social insurance office, an occupational therapist from a primary care unit, an employment counsellor from the county employment office and a social worker from the municipal social administration office. The main effect variable was the number of persons in employment. ANOVA for repeated measures for binary responses and a logistic regression model was used. The VR actors involved in the SMCVR II model were a public employer (a municipality), the social insurance office and an occupational health service. The material consisted of 22 systematic multi-professional cross-sector rehabilitation group meetings with clients who underwent intervention (20 women, 2 men). An observer attended each meeting to observe communication; each meeting was tape-recorded and subsequently transcribed. The analysis was based upon these transcriptions, using content analysis.

A larger proportion of clients subjected to this particular form of developed co-operation studied (SMCVR I) became employed during the first 2 years compared with similar clients in neighboring municipalities or among those in a national register; the higher employment rate showed a peak two years after closure of the intervention; the chance of becoming employed after rehabilitation in the 2-year follow-up was roughly twice as high as that in both comparison groups with conventional co-operation. There was a difference between the study group, the national and county comparison groups on 6 measuring occasions over the period from 1 year following closure of the intervention to the 6th year after. The logistic regression model showed that the clients with mental/social work limitations were at a greater risk of being unemployed after VR than clients with somatic work limitations. In the SMCVR II model the topics discussed primarily concerned the client’s situation regarding the field of medical and health care, previous and new work, and social insurance and none of the professionals dominated the meetings. The clients had the highest percentage of utterances. Clients were allowed ample scope to address their own requirements, thoughts and feelings. ‘Adaptation’ was a pervading theme in the discussions during the observations. The ‘importance of work’ for the clients emerged as a sub-theme; positive and neutral aspects occurred. The conflict between health and work was an ever-present theme of substantial importance for VR. Support from the employer and fellow workers during the client’s return to work was important. This support appeared as both a positive and a negative force in the VR.

In conclusion, systematic multi-professional cross-sector co-operation – which can be performed without any changes in law – leads to seeing a greater proportion of clients in employment over a long period of time compared with “co-operation as usual”. It is possible to achieve a creative communicative climate in multi-professional cross-sector rehabilitation group meetings, which can favor good results in VR.

Many women require vocational rehabilitation before they can return to work. The objective with the present study was to describe female clients' situation during the rehabilitation process, as it became apparent during the rehabilitation meetings with the various actors involved. The clients' diagnoses varied, but the majority was affected with musculoskeletal disorders. The meetings were audio-taped and transcribed verbatim, after which they were analysed by qualitative content analysis. The following themes emerged: Adaptation to the rehabilitation group; client's health status; the workplace's significance for rehabilitation; and the client's decision-point. Conflict between health and work was immensely important for rehabilitation. Differences in attitude were apparent during the rehabilitation meetings, as some clients were passive and exercised less influence on the planning, than the other more active clients did.

Objective: To evaluate the effects of systematic co-operation among municipal employees on the number of sick-leave days per month and the type of benefit granted by the Social Insurance Office. A further aim was to evaluate the economic consequences for society.Design: A 6-year follow-up study with a matched-pairs design.Methods: Days on sick-leave were calculated for each subject one year before the intervention started and yearly for the following 6-year period. Statistical mixed-model analysis was used. The economic benefit of the intervention was estimated as the increased production stemming from fewer days on sick-leave.Subjects: Sixty-four employees on long-term sick-leave were individually matched with controls from another Social Insurance Office in a county with a socioeconomic structure similar to that of the study group.Results: The study group had 5.7 fewer days on sick-leave per month and person over the 6-year period (p=0.003). The estimated average economic benefit of the intervention was (sic)36,600 per person over the 6-year period. In conclusion, those who received systematic co-operation in vocational rehabilitation had fewer days on sick-leave than their "treatment-as-usual" peers. This effect persisted over 6 years, generating substantial net economic gains for society.

PURPOSE: The purpose of this research was to investigate the views of sick-listed employees' immediate superiors on co-operation in vocational rehabilitation before and during a systematic, multi-professional, client-centred, solution-oriented co-operation project in vocational rehabilitation (SMVR intervention). METHOD: A same-subject study with a questionnaire was used, with 95 immediate superiors giving their views on co-operation both before and during the SMVR intervention. RESULTS AND CONCLUSIONS: The immediate superiors felt that the SMVR intervention was successful in promoting co-operation, and reported a significant decrease in referrals of employees from one organisation to another without the problem being resolved. Hence SMVR co-operation was experienced positively by the immediate superiors and in fact led to a joint responsibility in finding solutions. The immediate superiors saw greater possibilities than before for employees to resume regular or other jobs during the SMVR intervention. A more elaborate co-operation model such as the SMVR intervention increased the immediate superiors' experience of successful vocational rehabilitation. Organizations seeking to increase efficiency in vocational rehabilitation might well analyse their work methods and improve their forms of co-operation.

PURPOSE: The present aim was to evaluate the effect of systematic multi-professional co-ordinated rehabilitation (the Stockholm Co-operation Project) on the number of days' sick leave during the first and second half-years after the rehabilitation co-ordination period, compared to the year before. Another aim was to evaluate the economic effects at national level. METHOD: A matched-pairs design was used. The study group was based on 64 rehabilitees employed by a public employer in Stockholm, who took part in a systematic multi-professional co-operation project. To obtain pairs, the 64 individuals were individually matched with 64 people who received conventionally organised rehabilitation. Thus, there were 128 subjects altogether. RESULTS: The study group had substantially less sick leave days per month than the comparison group during the second half-year after the rehabilitation co-ordination period. The effect was even greater in a subgroup with more previous sick leave. During the first half-year after the intervention the comparison group had relatively more sick leave. No effect was found for a subgroup with less previous sick leave. The economic benefit of the intervention was estimated to 1,278 euros per month and person based on the whole group, and to 2,405 euros per month and person based on those with more sick leave. CONCLUSIONS: People who undergo co-ordinated rehabilitation have more working days after the intervention period than those with conventional rehabilitation. This way for rehabilitation actors to co-operate gives better outcomes for rehabilitation cases with long previous sick leave, but not for cases with less previous sick leave. It also generates economic gains at several levels.

PURPOSE: The aim of the present study was to investigate differences in the effects on employment between clients whose rehabilitation was coordinated in systematic multiprofessional rehabilitation group meetings and clients whose rehabilitation was coordinated in the "conventional" way. METHOD: The study was based on a sample of 51 individuals who received systematic group meeting coordination. All individuals in the study group were unemployed before the rehabilitation intervention. Two different comparison groups were chosen: one at a local level and another at a national level. The groups were matched on an individual level based on records obtained from The National Labour Market Board (AMS) and The National Social Insurance Board (RFV). The data were analysed by an analysis of variance (ANOVA) for repeated measures for binary responses. RESULTS: 68.6% in the study group and 49% in both the local comparison group and national group had some form of employment 24 months after rehabilitation. The ANOVA analyses (in terms of odds ratio) found that when all measurement points (6, 12 and 24 months after the rehabilitation) were included in the calculations that there was twice as high a chance of becoming employed after having received rehabilitation services through the multiprofessional group than for both comparison groups. The majority of employment in all the groups was associated with some form of subsidy or sheltered employment.

ABSTRACT Vocational rehabilitation is a complex process. As well as the client, it often involves the employer, medical professionals, national-insurance officials, employment counsellors from the employment office and social services officials. In complex cases, it is customary to arrange specific meetings between the officials from the different authorities. The overall aim of the work presented in this thesis was to increase knowledge of co-operation between different public instances in the provision of vocational rehabilitation. The main question was whether, and if so how, a group involving a client and different rehabilitation workers can improve the client�s prospects. Regarding employment outcome, a larger proportion of clients exposed to the the particular form of cooperation become employed than those in either comparison group. The higher employment rate persisted two years after the end of rehabilitation and the chance of becoming employed after rehabilitation was about twice that of people in either group of conventional rehabilitation.

Syftet med föreliggande rapport är att undersöka den fortsatta utvecklingen av arbetsmetoden; systematiserade flerpartssamtal och att studera effekterna av rehabiliteringsarbetet i Betagruppen. Den föregående utvärderingen av Betaprojektet hade en före- och efterdesign och det var inte så lätt att ställa resultaten av utvärderingen i relation till mera �konventionell� handläggning av rehabiliteringsärenden. För att få en uppfattning om effekterna av Betas arbetssätt jämförs i denna studie Betas arbetssätt med effekter av att arbeta mera �konventionellt�. I studien matchas Betagruppen med individer från andra kommuner i närområdet som har en liknande struktur som Kungsbacka kommun. Dessutom görs också en jämförelse med en riksgrupp. För att få fram effekter av de båda arbetssätten används registerstudier och för att få fram kunskaper om Betagruppens utveckling av samverkan mellan rehabiliteringsaktörerna och eventuella förändringar används gruppintervjuer och enkät.