Early focus on work

🚧 Challenge: it is important to focus on work at the (sub)acute phase of recovery when the person  is medically stable. 

In this way, you give the person the perspective that work will be included as part of the rehabilitation process.

There is an important difference between an early 'focus on work' and 'effectively returning to work': 

• an early focus on work means that you give the person the opportunity to ask questions and make 'work' a topic for discussion.
  • You inform the person about their legal rights, benefit entitlements and obligations.
  • You prepare the person for a subsequent return to work.
• effectively returning to work means that the person actually returns to work.

💪 Opportunity: rehabilitation can differ in terms of content, intensity and follow-up. It is important to focus on work in all people with mild injuries and those with severe injuries.

• for people with a mild brain injury, who often spend only a short time in hospital, an early focus on work means that the topic is already discussed.
• for people with a moderate to severe brain injury, who might require long-term rehabilitation, an early focus on work means that the topic can be a rehabilitation goal.

🔀 An early focus on work has several goals:

• To inform the person with ABI  and their friends and family  about ABI and its impact on how the person functions in general and more specifically at work. It is important to inform the person so that they can acknowledge the consequences.
• To form a holistic, overall picture of the person : addressing not only challenges and symptoms, but also focusing on activities, participation and context.
  • For instance, ask what the person's work status was before ABI and explore the importance of working for the person’s identity. 
  • The person's need for help guides the rehabilitation process.
• Get an initial assessment of their work status before the ABI,  the importance of work for that particular person and their vocational need for help. The person's need for help guides the rehabilitation.
• Offer the person a perspective: discuss that (returning to) work can be part of the recovery process and that it can be complex after ABI, taking into account e.g. the severity of the ABI and the expectations at work. The person can follow vocational rehabilitation with a focus on increasing workload.

🤝Together: refer to different parties who can support the person in returning to employment.

💡Tips & tricks:

• The person does not have to be fully recovered to focus on returning to work.
• Discuss a timeline with the person.
• Even for people with a severe brain injury, where a return to work is not yet an issue or might be doubtful, it is important to focus on work.
• Sometimes the person has practical concerns, such as how to report the sick leave to the health insurance company. 
• Consider the person’s level of self-awareness. Some people may over- or underestimate themselves.

You can inform the person  in detail about:

• the impact of ABI (at work):
  • how can ABI and its associated consequences affect and/or interfere with (work) reintegration?
  • what the impact of visible consequences (such as motor skills) could be?
  • what the impact of less visible/invisible consequences (such as cognition, mood or behaviour) could be?
  • what the opportunities and/or challenges for the person with ABI in the (medium-) long term could be?
• the options regarding a return to work: returning to work after ABI is often not an all-or-nothing story. In an ideal situation the person would gradually build up their workload and working with relevant parties would look for a feasible job.
• the various parties involved in a return to work, such as the advisory doctor for the health insurance company  and/or the occupational doctor .
  • If the person is better informed about these parties and their roles, this can reduce uncertainty and tension for the person  and for their friends and family.

🧰Useful Tools: If you would like the brochure on 'Tips and tricks for people with ABI who want to return to work', please send an e-mail to dorien.vandenborre@thomasmore.be  

💡Tips and tricks: refer the person to the section of this website that gives answers to frequently asked questions tailored to the person.

As a doctor/therapist , you know about ABI and its impact on how a person functions in the workplace.

As a result of the rehabilitation process or the follow-up, you often have a good insight into the person's functions and can identify possible challenges or pitfalls. 

💪Opportunities

• By focusing on work early on, you strengthen the person  and can give them the perspective that a (return to) work may be possible.
• Even if work is not yet an issue, it is important that as a doctor you give sufficient focus to 'work'. 

Yes.

Participation in general is the ultimate aim of the rehabilitation process.

Rehabilitation aims to optimise the person's self-reliance with the ultimate goal of maximum participation in society. What exactly the concept of 'work'  means to someone is personal. Work can help regain an understanding of life (Klepo et al., 2020). It can be a tool for overcoming the brain injury or reducing its place in someone's life. Returning to work can have a beneficial effect on a person's health (van der Noordt et al., 2014).

Huber's (2011) definition of health is in line with this: "the ability to adapt and self-manage in the face of social, physical and emotional challenges". 

Yes.

There are rehabilitation centres that specialise in vocational rehabilitation (VR).

• The ICF-based definition of vocational rehabilitation reads as follows: "a multidisciplinary and evidence-based strategy available in different settings and services that offers activities to persons of working age with health-related difficulties in work-related functioning with the main goal of promoting work participation".  

💪Opportunity: a reintegration coach (also called case manager, reintegration coordinator or vocational coordinator) is part of the rehabilitation team  and is an expert:

• on acquired brain injury and its consequences at work.
• on the legislative framework for returning to work. 
• on suitable work for people with ABI, i.e. work in which the person's capacity matches the workload.

🚧Challenge: in Belgium, there is no separate code for vocational rehabilitation and consequently, this occurs within existing rehabilitation agreements. In Belgium, vocational rehabilitation focuses on the 'first train, then place' principle.

💡Tips & tricks: it is important to formulate the (vocational) need to help the person with ABI on intake.

In this road map, we describe the 'first train then place' methodology.

• The focus is on regaining specific and generic work skills, practising strategies to reduce challenges and psycho-education (informing and coaching, individually or in groups) in a healthcare setting (Murray et al., 2021).

🔀 Several treatment options are described within this methodology, such as 

• The 'case coordination model' (Early Vocational Rehabilitation, van Velzen 2014, 2015, 2016) starts with a reintegration coach who monitors the progress of the individual rehabilitation process of the person with ABI and integrates vocational rehabilitation into this process. A characteristic feature of this methodology is that
  • the focus is on early intervention,
  • the focus is on continuity of care and monitoring the progress of the individual process and
  • opportunities for consultation on vocational rehabilitation with relevant parties are actively addressed.

• The 'programme-based model' (e.g.: Brain Integration Programme: Geurtsen, 2012), as its name suggests, is a modular programme focused on work-related skills. It consists of
  • intensive and individual rehabilitation focused on work skills and interventions in a structured work environment;
  • supervised work exercises and testing situations;
  • supervised employment placement with transitional counselling.

You can also train the person with ABI directly in the workplace ('first place then train') (Murray et al., 2021). Guidance then starts with the workplace itself, where the person with ABI is trained, coached (on the job coaching) and followed up sustainably (Howe et al., 2017).  

• How is the return to work progressing?
• How stable is the return to work?
• How motivated is the person with ABI to perform that work?
• One example is the supported employment model of Individual Placement and Support (e.g. roundtable methodology: van Dongen, 2018). In this methodology, the person with ABI returns to the workplace as soon as possible. Individual coaching takes place until the person with ABI, as an employee, can (re)perform the work. Individual Placement and Support consists of five steps:
  • is the person with ABI sufficiently involved to return to work (involvement)?
  • to which kind of work does/can the person with ABI want to return (employment profiling)?
  • where can the person with ABI start to work (finding employment)?
  • is the employer sufficiently involved?
  • is the person with ABI getting the right support at/alongside work?

Research shows that the three treatment methods (case coordination model, programme-based model and supported employment model) are effective for work reintegration, but there is not (yet) enough evidence to designate one of the treatment methods as the most effective. Important ingredients of the treatment method are training in work skills on functional, physical, cognitive, communicative, psychosocial and emotional levels with an eye on the mental well-being of the person and their friends and family. 

It is important that the person  is well informed about:

• the severity, extent and location of the acquired brain injury: a brain injury varies from mild to severe.
  • A moderate to severe brain injury may immediately involve an extended period of disability and a greater need for rehabilitation in a hospital or rehabilitation centre.
  • A mild brain injury often involves a short hospital stay. Nevertheless, individuals with a mild brain injury also often need support to return to work.
• the job the person did before the brain injury and the expectations and requirements they have to meet before being able to return to work.
• the impact on the personal life, such as personality, family situation and work-life balance.

Certainly, it is possible.

Not every individual with ABI requires recognition of a work-related disability.

The necessity is contingent upon the severity of the brain injury and its impact on workplace functionality.

• You can request employment assistance by submitting a form as a treating physician (general practitioner or specialist).
• This form includes inquiries such as "what challenges do you encounter in your job?", "are you capable of working within the regular job market?", and "how is the impairment assessed?".
• As a specialist, ensure to include supporting documentation with your responses. If you are a general practitioner, refer to reports from specialist physicians when completing the form.Based on the provided information,
  • VDAB's employment support team evaluates whether the individual with ABI requires interventions to facilitate their return to work.
  • The VDAB acknowledges a brain injury as a form of occupational disability, granting the individual access to employment support initiatives.
  • One such measure is the Flemish Support Premium (VOP), which can offset any decrease in efficiency, such as reduced work pace or increased need for assistance, experienced by individuals with ABI.
  • Additionally, adjustments to the workplace or tools can be arranged.

🤝Collaboratively: Engage in a discussion with the individual with ABI about the option to seek work recognition and its implications.

💡Tip: Work recognition can be pursued at any stage of the work reintegration process.

• This can be initiated when the individual is considering returning to work or even later if they are already employed but facing challenges that may lead to discontinuation.
• Recognition can help restore equilibrium in the workplace by addressing the specific needs of individuals with ABI.

⚖️ Legal Update: Effective July 1, 2023, a new measure called Individual Customization (IMW) will replace VOP. Applications for this new measure can be submitted starting from July 1, 2023.

Depending on the severity of the ABI and its impact on functioning at work, it may be sufficient for you, as doctor,

• to support the person in returning to work.
• to discuss a suitable approach and follow-up on a return to work, if the person wants to return to work with their previous employer. 

🤝Together: with the person's consent, you can liaise with the occupational doctor  about the rehabilitation process, further planning, challenges and ways to make the return to work sustainable. The occupational doctor can support the patient .  

🚧Challenge: if the person is unwilling or unable to return to the previous employer, support by employment services  may be appropriate.

• This might require permission from the advisory doctor of the health insurance company .
• The person can also contact the occupational doctor  for advice and support.

💪Opportunity: with ABI, it can be important to monitor the progress of the reintegration process and make agreements about this with the other relevant parties. It is useful to review these agreements regularly.   

If the person  has already returned to work and is at risk of leaving, specialised job coaching  can be started.

🔀 There are several options for a sustainable return to work: 

• the person with ABI  can return to their previous employment with their former employer .
• the person with ABI can return to their previous role with a new employer.
• the person with ABI can take up adapted employment with their former employer: working with the employer, the occupational doctor  and the person , you  can explore whether there are other possibilities for the person within the same company.
• the person with ABI can look for an adapted position with another employer.
• the person with ABI can start voluntary work.
  • This can help them (re)discover possibilities and their abilities.
  • It can be a valuable use of free time and part of the search for paid work.
  • It can be a starting point when exploring alternative occupational or educational opportunities (e.g. voluntary work, permitted work, sheltered workshop, further education or other occupational provision).

You can consult with the occupational doctor  to check the options for returning to work and discuss what might be suitable work for the person with ABI .

🤝Together: always ask for the person’s consent before you contact other relevant parties. 

•  The occupational doctor has no treatment relationship with the client.
• This doctor decides on medical fitness for a particular job.

🤝Together: with the person, discuss how information about how they are functioning enables the occupational doctor to give an opinion on their return to work.

Yes, with the patient's consent. 

💪Opportunity: with the patient, discuss the importance of sharing information and what the roles of the different parties are: 

•  Doctor/rehabilitation team at the hospital or rehabilitation centre:
  • the doctor determines the most suitable treatment (such as multidisciplinary rehabilitation) and also prescribes a period of disability.
  • the doctor gives the person  reintegration advice and discusses a schedule for a (partial) return to work or not.
  • any questions or concerns the person  has about work and returning to work can be discussed with the doctor/team. 
  • they can share their expertise and support the person  in a sustainable return to work.

• Health insurance: the advisory doctor has several roles:
  • this doctor checks the person's  (in)capacity for work.
  • this doctor assesses whether the person  should return to a previous job.
  • this doctor advises and informs the person  about the options for returning to work or retraining. 

•  Occupational doctor: the occupational doctor can be linked to an (internal or external) occupational health service and determines the person's medical suitability for employment.
  • The occupational doctor may examine the person  before returning at work.
  • The occupational doctor does not share medical information with the employer
  • This doctor translates information about the person's health condition into workplace advice. 

•  The employer:
  • most employers have little experience of an employee  with an acquired brain injury.
  • it can be important for the employer to know about the rehabilitation process and the impact of the brain injury on how the person functions at work. 

•  Employment services can help the person with reintegration into work.
  • They offer on the job coaching. The job coach supports the person  and the employer , answers questions and mediates in the reintegration process. 

Yes, you have the option to discuss Specialised Team Mediation (GTB) with individuals affected by ABI to help them find or maintain suitable employment.

• The health insurance fund's advisory doctor needs to approve this, except for job seekers or those with ABI due to a work accident that has not been finalized. 
• GTB treatment has shown promise in protecting and restoring synaptic maturation in traumatic brain injury (TBI) mice, highlighting its potential neuroprotective properties in TBI treatment. The aim is to support the reintegration of individuals with acquired brain injuries into the workforce, addressing challenges and promoting sustainable work opportunities.

On the FEDRIS website, you will find two brochures explaining the (legal) regulation of a workplace accident and common questions after a workplace accident

In addressing this query, it is essential to understand the concept of 'consolidation' within the context of settling a work-related injury.

• Consolidation, from a medical perspective, signifies that the Acquired Brain Injury (ABI) and its effects have stabilized, with no anticipated further changes in functionality.
• During the period leading up to consolidation, the individual typically receives temporary incapacity benefits, amounting to 90% of their salary.
• Following consolidation, permanent disability benefits are provided, calculated as a percentage of the economic disability.

🤝Collaborative Approach:

Engage in discussions regarding potential inquiries and apprehensions related to the settlement of a work-related accident. This collaborative dialogue aims to empower the individual to make well-informed decisions. Additionally, explore the role of the occupational accident insurance counselor in this process.

In the event of illness or accident:

• If an individual returns to work part-time under the partial employment system, they can retain a portion of the disability benefit based on their working hours.
• 💰The full benefit is maintained for work resumptions of less than 8 hours per week.
• Application for partial work resumption is submitted to the health insurance fund, allowing the individual to commence work while awaiting a decision. Required application documents must reach the health insurance fund at least one working day before resuming work.

For occupational accidents:

• During partial work resumption for consolidation, the work accident insurance adjusts the wage differential to prevent income loss temporarily.
• Post-consolidation, various options should be explored:
  • Can the individual gradually return to their previous work rhythm/percentage?
  • Is continued partial work feasible with additional recognition from the health insurance fund?
• 🤝Collaborative Decision-Making: The decision on whether to resume work for consolidation is best made in consultation with the treating doctor, allowing the individual to make an informed choice regarding their return to work.

Rights and responsibilities of individuals in the event of illness or accident:

Responsibilities towards the Employer:

• Notification Duty: Promptly inform the employer about the illness or accident.
• Medical Certificate: Submit a medical certificate if required by the collective bargaining agreement, labor regulations, or upon employer's request.
• Verification: The employer may conduct checks on the incapacity for work, often involving a control doctor.

Obligations towards the Health Insurance Fund:

• Submit a declaration of incapacity for work to the health insurance fund.

Rights:

• Guaranteed Pay: Entitled to a guaranteed salary, with the employer responsible for payment in the initial month based on contractual terms and employment duration. If incapacitated for over a month, an incapacity benefit is received through the health insurance fund.
• Welfare Rights: Governed by the Welfare Act, emphasizing workplace health and safety. Employers are mandated to enhance welfare through risk prevention and collective and individual measures.
• Right to Reasonable Accommodations:
  • According to anti-discrimination legislation, individuals have the right to request reasonable accommodations from their employer.
  • Employees with disabilities, including chronic illnesses, are eligible for reasonable accommodations.
  • If a treating physician recommends 'lighter or modified work,' the employer is obligated to adhere to this guidance.

If an employee with Acquired Brain Injury (ABI) is unable to work due to illness or accident, the employment contract is temporarily suspended.

• Initially, the employer is responsible for paying wages.
• If the incapacity continues beyond one month, the employee receives replacement income reimbursed by mandatory health insurance.
• The employer can request a medical evaluation of the disability by a designated doctor.
  • While there is no legal prohibition, an employer retains the option to terminate an employee during incapacity as long as the reason for dismissal is unrelated to the individual's health condition.

There is no legal prohibition for an employer to terminate an employee during a period of incapacity, as long as the dismissal is unrelated to the individual's health condition.

• Compliance with anti-discrimination laws is essential, particularly regarding the concept of "reasonable adjustments."
• Reasonable adjustments are tailored measures based on individual needs that facilitate access, participation, and progression in the workplace for individuals with disabilities.
• However, these adjustments should not impose an unreasonable burden on those implementing them.While there is no specific legislative procedure for requesting or providing reasonable adjustments, either the employee or employer can initiate them.
• Additionally, suggestions for reasonable adjustments may also come from the treating doctor or occupational physician if they observe challenges in task performance.