- Email: [email protected]
Employment of People with Disabilities
6
Employment of People with Disabilities
Renald Peter Ty Ramiro Disability ranks as the largest public health problem in the United States. An interdisciplinary approach to treat the multifaceted implications of disability is needed to address concerns such as personal care, work and finances, social integration, and leisure (eSlide 6.1). Strategies include restoration of functional capacity, prevention of deterioration in function, maintenance and improvement of quality of life (QOL), physical rehabilitation, and prevention of secondary complications (eSlide 6.2). According to Howard Rusk, “a rehabilitation program is designed to take a disabled person from his bed back to his job, fitting him for the best life possible commensurate with his disability and more importantly with his ability” (eSlide 6.3). Return-to-work addresses the following issues: discuss the concept of disability, economic assistance, and vocational rehabilitation strategies; review national data on disability and employment and policies supporting employment of people with disabilities (PWDs); consider the economic impact of disability; enumerate the incentives and disincentives for returning to work; and postulate that vocational rehabilitation serves as a rehabilitation treatment and disability prevention strategy for PWDs (eSlide 6.4).
• CONCEPT OF DISABILITY The World Health Organization provides a global common health language on disability known as the International Classification of Functioning, Disability, and Health (formerly the International Classification of Impairments, Disabilities, and Handicaps). This reflects the biopsychosocial model of disablement, with dynamic interactions between health conditions and conceptual factors. Dimensions of dysfunction are defined as follows: impairment is the loss or abnormality of body structure or of a physiologic or psychological function; activity is the nature and extent of functioning at the level of the person; and participation is the nature and extent of a person’s involvement in life situations in relation to impairment, activities, health conditions, and contextual factors; it can be restricted in nature, duration, and quality (eSlide 6.5).
• DATA: IMPAIRMENT AND DISABILITY eSlides 6.6 and 6.7 show the 15 conditions with the highest prevalence of functional compromise or disability as well as the ranking of percentage of people with functional limitations for specific conditions. 34
CHAPTER 6 Employment of People with Disabilities 35
• SOCIOECONOMIC EFFECT OF DISABILITY Work disability or work participation restriction affect direct expenditures (medical and personal care, architectural modification, assistive technology, institutional care, and income support), which lead to impoverishment, with a higher incidence of disabled people being below the poverty level. Employment and earnings data show disparities in salaries based on disability (eSlide 6.8). Governments within the United States have responded by developing disability-related programs, such as Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medicare, and Medicaid (eSlide 6.9).
•T REATMENT OF THE INJURED WORKER Workers’ Compensation Medicine Workers’ compensation medicine involves models that promote a safe return to work through functional capacity evaluation (FCE), work hardening programs (WHPs), functional restoration programs (FRPs), and treatment. An FCE tests the physical and cognitive demands of moderately or heavily strenuous work, such as perception, range of motion, strength, endurance, coordination, the ability to lift and assume certain postures, and the ability to tolerate standing, walking, and climbing. A WHP is a multidisciplinary “work-oriented treatment program” that consists of work tolerance screening and work capacity evaluation components with job simulation activities, psychological treatment, and an interdisciplinary pain program. An FRP restores the patient’s physical, psychosocial, and socioeconomic situation through a physician-driven interdisciplinary program that emphasizes the importance of function over pain elimination, pain acceptance, pain management, and proactive coping strategies. The sessions include intensive exercise program, cognitive-behavioral therapy, and ergonomic therapy.
• DISABILITY-RELATED PROGRAMS AND POLICIES Programs Disability-related programs can be characterized as ameliorative or corrective. Ameliorative programs provide payment for income support and medical care. Corrective programs facilitate the individual’s ability to return to work and reduce or remove the disablement. Disability-related programs can be categorized into three basic types: cash transfers, medical care programs, and direct service programs.
Public Disability Policies eSlide 6.10 reviews the prominent federal disability laws that mandate that housing and transportation be accessible, education for children with disabilities be appropriate, and employment practices be nondiscriminatory. Three legislative actions deserve to be highlighted: (1) the Rehabilitation Act of 1973 extended civil rights protection to PWDs, including antidiscrimination and affirmative action in employment; (2) the Rehabilitation Act Amendments of 1978 broadened the responsibility of the Rehabilitation Services Administration to include independent living programs and created the National Council of the Handicapped; and (3) the Americans with Disabilities Act (ADA) of 1990 established a clear and comprehensive prohibition of discrimination based on disability.
36 SECTION I EVALUATION
Vocational Rehabilitation TRADITIONAL APPROACHES TO VOCATIONAL REHABILITATION
eSlide 6.11 shows the traditional approach, based on referral to a vocational rehabilitation counselor for diagnosis, evaluation, and adjustment training. Obtaining an employment history and performing vocational testing are important components of this approach.
Alternative Approaches to Vocational Rehabilitation (eSlide 6.12) SHELTERED WORKSHOPS
A sheltered workshop is a “public nonprofit organization certified by the U.S. Department of Labor to pay ‘subminimum’ wages to persons with diminished earning capacity.” This form of employment serves people with severe disabilities, including limited vision, mental illness, mental retardation, and alcoholism.
DAY PROGRAMS
Day programs provide supervised vocational activity for people with severe disabilities, usually those with mental retardation or mental illness.
HOME-BASED PROGRAMS
Home-based programs include training in a variety of jobs, including telephone solicitation, typing, or computer-assisted occupations such as graphic designing, accounting, or drafting.
PROJECTS WITH INDUSTRY
Projects With Industry is a federally sponsored collaborative program established by the Vocational Rehabilitation Act to enable competitive employment by providing specific job skills training.
TRANSITIONAL AND SUPPORTED EMPLOYMENT
Two newer strategies for returning PWDs to competitive, integrated, and gainful employment are transitional and supported employment. Transitional employment consists of providing job placement, training, and support services necessary to help people move into independent or supported employment. Supported employment requires ongoing support after placement, including counseling for the employee and co-workers, and assistance with transportation, housing, and other non–work-related activities.
INDEPENDENT LIVING CENTERS
The independent living centers movement involves a combination of vocational and nonvocational services, such as housing, independent living skills, advocacy, and peer counseling, for PWDs.
Disincentives for Vocational Rehabilitation Despite growing acceptance in the public and political arenas through better policies and attitudes, there are still a number of disincentives for vocational rehabilitation, a few examples of which include (1) “red tape” in getting cash and medical benefits from SSI and SSDI; (2) the risk of losing benefits once the PWDs are employed; (3) the pervasive stereotype of PWDs being unproductive, leading to the attitude that it is easier to give them a disability check than to implement the ADA;
CHAPTER 6 Employment of People with Disabilities 37
(4) employers’ negative attitudes toward employees with disabilities and ignorance of their vocational needs; and (5) the tendency of physiatrists and other physicians to label an individual as “totally and permanently disabled” or restrict their activities.
Incentives for Vocational Rehabilitation In an effort to overcome disincentives, government policymakers have created incentives for PWDs and potential employers (eSlide 6.13).
Incentives for Individuals Incentives for the individuals include trial work period, substantial gainful activity, extended period of eligibility, impairment-related work expenses, “blind” work expenses, and plans for achieving self-support.
Incentives for Industry Government policymakers have made various attempts to offer tax incentives to businesses and industries to make the workplace accessible. Examples include deductible expenses for barrier removal, Targeted Jobs Tax Credit, and the Work Incentives Improvement Act of 1999.
Disability Prevention The public health model defines three categories of disability prevention: primary, secondary, and tertiary (eSlide 6.14). Primary prevention is intended for healthy people to avoid the onset of a pathologic condition and for people with disabilities to prevent worsening of their impairments. Secondary prevention is aimed at early identification and treatment of a pathologic condition. Provision of assistive technology can be considered secondary prevention. Tertiary prevention focuses on arresting the progression of a pathologic condition and limiting disablement. Environmental modifications, changes in social attitudes, and reforms in legislation and policies are tertiary prevention strategies. Medical rehabilitation is traditionally considered a tertiary prevention strategy.
• CONCLUSION Holistic management is the key in the comprehensive rehabilitation of disablement. This approach maximizes physical, mental, social, and economic functions of individuals with disabilities through various interventions directed at human functioning. The physiatrist, as a team leader, collaborates with professionals outside the traditional medical rehabilitation team, such as those involved in vocational rehabilitation. This eventually improves QOL and function, which greatly affect the individuals and society in terms of significant socioeconomic consequences (eSlide 6.15).
38 SECTION I EVALUATION
Clinical Pearls 1. Holistic management is the key in the comprehensive rehabilitation of disablement, which maximizes the physical, mental, social, and economic functions of people with disabilities through various interventions directed at human functioning. 2. Disability, being the largest public health concern in the United States, should encourage physiatrists to take the lead in its therapeutic and public health management through prevention strategies, including collaboration with professionals outside the traditional medical rehabilitation team, such as those involved in vocational rehabilitation. 3. The prevention strategies for people with disabilities are the following: • Primary prevention: preventing the worsening of impairments. • Secondary prevention: providing ameliorative and corrective programs including vocational rehabilitation, to reduce activity limitation and increase employment. • Tertiary prevention: limiting the restriction of a person’s participation by the provision of a facilitator or the removal of a barrier. 4. Vocational rehabilitation is an integral component in the holistic approach to disability management, improving QOL and function, with eventual significant socioeconomic consequences.
BIBLIOGRAPHY
The complete bibliography is available on ExpertConsult.com.
BIBLIOGRAPHY
1. Adams PF, Benson V: Current estimates for the National Health Interview Survey, 1988, Vital Health Stat 10:1–250, 1989. 2. Allaire S, Li W, LaValley M: Reduction of job loss in people with rheumatic diseases receiving vocational rehabilitation: a randomized controlled trial, Arthritis Rheum 48:3212–3218, 2003. 3. Anderson TP: Quality of life of the individual with a disability, Arch Phys Med Rehabil 63:55, 1982. 4. Anonymous: Rules and regulations, Fed Regist 65:82905–82912, 2000. 5. Anonymous: Rules and regulations, Fed Regist 68:40119–40125, 2003. 6. Bendix AE, Bendix T, Haestrup C, Busch E: A prospective, randomized 5-year follow-up study of functional restoration in chronic low back pain patients, Eur Spine J 7:111–119, 1998. 7. Berkowitz M: The socioeconomic consequences of SCI, Paraplegic News18–23, 1994. 8. Berkowitz M, Hill M, editors: Disability and the labor market: an overview. In Disability and the labor market: economic problems, policies, and programs, New York, 1989, ILR Press. 9. Colvez A, Blanche M: Disability trends in the United States population 1966-76: analysis of reported causes, Am J Public Health 71:464–471, 1981. 10. DeJong G, Lifchez R: Physical disability and public policy, Sci Am 248:40–50, 1983. 11. Haber LD: Identifying the disabled: concepts and methods in the measurement of disability, Soc Secur Bull 51:11–28, 1988. 12. Haber LD: Issues in the definition of disability and the use of disability survey data. In Daniel LB, Aitter M, Ingram L, editors: Disability statistics, an assessment: report of a workshop, Washington, 1990, National Academy Press. 13. Harris L: The ICD survey of disabled Americans: bringing disabled Americans into the mainstream, New York, 1986, Louis Harris and Associates. 14. Haveman RH, Halberstandt V, Burkhauser RV, editors: Public policy toward disabled workers: cross-national analyses of economic impacts, New York, 1984, Cornell University Press. 15. Hearne PG: Employment strategies for people with disabilities: a prescription for change, Milbank Q 69:111–128, 1991. 16. Joe TC: Professionalism: a new challenge for rehabilitation, Arch Phys Med Rehabil 62:245–250, 1981. 17. Kennedy EM, Jeffonds J, Moynahan DP, et al.: The Work Incentives Improvement Act of 1999, Senate Bill 331, 1999. 18. Kenney L: Earning histories of SSI beneficiaries working in December 1997, Soc Secur Bull 63:34–46, 2000. 19. Kuijer PP, Gouttebarge V, Brouwer S, et al.: Are performance-based measures predictive of work participation in patients with musculoskeletal disorders? A systematic review, Int Arch Occup Environ Health 85:109–123, 2012. 20. La Plante MP: The demographics of disability, Milbank Q 69:55–77, 1991. 21. La Plante MP, Kennedy J, Kaye S, et al.: Disability and employment, no. 11. In Disability Statistics Abstract Series, San Francisco, 1997, University of California. 22. Lin VW, Cardenas DD: Spinal cord medicine: principles and practice, New York, 2003, Demos Medical Publishing. 23. Matheson L, Ogden L, Violette K, Schultz K: Work hardening: occupational therapy in industrial rehabilitation, Am J Occup Ther 39:314–321, 1985.
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24. Mayer TG, Gatchel RJ, Kishino N, et al.: Objective assessment of spine function following industrial injury. A prospective study with comparison group and one-year follow-up, Spine (Phila Pa 1976) 10:482–493, 1985. 25. Menchetti BM, Flynn CC: Vocational evaluation. In Rusch FR, editor: Supported employment: models, methods and issues, Sycamore, 1990, Sycamore Publishing Co, pp 111–130. 26. Muller LS: Disability beneficiaries who work and their experience under program work incentives, Soc Secur Bull 55:2–19, 1992. 27. Nagi SZ: Disability concepts revisited: implication to prevention, appendix A. In Pope AM, Tarlov AR, editors: Disability in America: toward a national agenda for prevention, Washington, 1991, National Academy Press, pp 309–327. 28. New Mexico Division of Vocational Rehabilitation: The economic impact of the New Mexico division of vocational rehabilitation, New Mexico, 2006, New Mexico Division of Vocational Rehabilitation. 29. Poiraudeau S, Rannou F, Revel M: Functional restoration programs for low back pain: a systematic review, Ann Readapt Med Phys 50:425–429, 419–424, 2007. 30. Pope AM, Tarlov AR, editors: Disability in America: toward a national agenda for prevention, Washington, 1991, National Academy Press. 31. Rigby DE: SSI work incentive participants, Soc Secur Bull 54:22–29, 1991. 32. Rocklin SG, Mattson DR: The Employment Opportunities for Disabled Americans Act: legislative history and summary of provisions, Soc Secur Bull 50:25–35, 1987. 33. Rusk HA: The growth and development of rehabilitation medicine, Arch Phys Med Rehabil 50:463–466, 1969. 34. Schaffer DC: Tax incentives, Milbank Q 69:293–312, 1991. 35. Schaafsma FG, Whelan K, Van Der Beek AJ, et al.: Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain, Cochrane Database Syst Rev (8):CD001822, 2013. 36. Scott CG: Disabled SSI recipients who work, Soc Secur Bull 55:26–36, 1992. 37. Sim J: Improving return-to-work strategies in the United States disability programs, with analysis of program practices in Germany and Sweden, Soc Secur Bull 59:41–50, 1999. 38. Social Security Administration: Report of Disability Advisory Council: executive summary, Soc Secur Bull 51:13–17, 1988. 39. Soer R, van der Schans CP, Groothoff JW, et al.: Towards consensus in operational definitions in functional capacity evaluation: a Delphi survey, J Occup Rehabil 18:389–400, 2008. 40. Symington DC: The goals of rehabilitation, Arch Phys Med Rehabil 65:427– 430, 1984. 41. Thornton C, Maynard R: The economics of transitional employment and supported employment. In Berkowitz M, Hill MA, editors: Disability and the labor market: economic problems, policies, and programs, New York, 1989, ILR Press. 42. U.S. Census Bureau: Americans with disabilities: 2010 report, Washington, 2012, U.S. Census Bureau. 43. U.S. Census Bureau: Facts for features: anniversary of Americans with Disabilities Act, Washington, 2012, U.S. Census Bureau. 44. U.S. Department of Health and Human Services: Social Security Administration: Redbook on work incentives, Washington, 1992, Government Printing Office. 45. U.S. Department of Health and Human Services: Social Security Administration: Social Security handbook, ed 13, Washington, 1997, Government Printing Office.
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46. U.S. Department of Justice, Civil Rights Division: A guide to disability rights laws, Washington, 2005, U.S. Department of Justice. 47. U.S. Equal Employment Opportunity Commission: U.S. Department of Justice: Americans with Disabilities Act handbook (EEOC-BK-19), Washington, 1991, Government Printing Office. 48. U.S. General Accounting Office, Report to Congressional Requestors: Vocational rehabilitation: improved information and practices may enhance state agency earnings outcomes for SSA beneficiaries, Washington, 2007, Government Printing Office. 49. U.S. General Accounting Office, Testimony before the Subcommittee on Select Education, Committee on Education and Labor, House of Representatives: Vocational rehabilitation program: client characteristics, services received, and employment outcomes, Washington, 1991, Government Printing Office. 50. Vachon RA: Employing the disabled, Issues Sci Technol winter:44–50, 1989–1990. www.ada.gov/guide.htm. 51. Vachon RA: Employment assistance and vocational rehabilitation for people with HIV or AIDS: policy, practice, and prospects. In O’Dell MW, editor: HIV-related disability: assessment and management: physical medicine and rehabilitation: state of the art reviews, Philadelphia, 1993, Hanley & Belfus. 52. Vachon RA: Inventing a future for individuals with work disabilities: the challenge of writing national disability policies. In Woods DE, Vandergoot D, editors: The changing nature of work, society and disability: the impact on rehabilitation policy, New York, 1987, World Rehabilitation Fund. 53. Verville R: The rehabilitation amendments of 1978: what do they mean for comprehensive rehabilitation? Arch Phys Med Rehabil 60:141–144, 1979. 54. Wehman P, Sherron P, Kregel J, et al.: Return to work for people following severe traumatic brain injury: supported employment outcomes after five years, Am J Phys Med Rehabil 72:355–363, 1993. 55. Wilson RW: Do health indicators indicate health? Am J Public Health 71:461–463, 1981. 56. World Health Organization: International classification of functioning, disability, and health, Geneva, 2001, World Health Organization. 57. World Health Organization: Towards a common language for functioning and disablement: ICIDH-2, the international classification of impairments, activities, and participation, Geneva, 1998, World Health Organization.
Employment of People with Disabilities
Renald Peter Ty Ramiro Disability ranks as the largest public health problem in the United States. An interdisciplinary approach to treat the multifaceted implications of disability is needed to address concerns such as personal care, work and finances, social integration, and leisure (eSlide 6.1). Strategies include restoration of functional capacity, prevention of deterioration in function, maintenance and improvement of quality of life (QOL), physical rehabilitation, and prevention of secondary complications (eSlide 6.2). According to Howard Rusk, “a rehabilitation program is designed to take a disabled person from his bed back to his job, fitting him for the best life possible commensurate with his disability and more importantly with his ability” (eSlide 6.3). Return-to-work addresses the following issues: discuss the concept of disability, economic assistance, and vocational rehabilitation strategies; review national data on disability and employment and policies supporting employment of people with disabilities (PWDs); consider the economic impact of disability; enumerate the incentives and disincentives for returning to work; and postulate that vocational rehabilitation serves as a rehabilitation treatment and disability prevention strategy for PWDs (eSlide 6.4).
• CONCEPT OF DISABILITY The World Health Organization provides a global common health language on disability known as the International Classification of Functioning, Disability, and Health (formerly the International Classification of Impairments, Disabilities, and Handicaps). This reflects the biopsychosocial model of disablement, with dynamic interactions between health conditions and conceptual factors. Dimensions of dysfunction are defined as follows: impairment is the loss or abnormality of body structure or of a physiologic or psychological function; activity is the nature and extent of functioning at the level of the person; and participation is the nature and extent of a person’s involvement in life situations in relation to impairment, activities, health conditions, and contextual factors; it can be restricted in nature, duration, and quality (eSlide 6.5).
• DATA: IMPAIRMENT AND DISABILITY eSlides 6.6 and 6.7 show the 15 conditions with the highest prevalence of functional compromise or disability as well as the ranking of percentage of people with functional limitations for specific conditions. 34
CHAPTER 6 Employment of People with Disabilities 35
• SOCIOECONOMIC EFFECT OF DISABILITY Work disability or work participation restriction affect direct expenditures (medical and personal care, architectural modification, assistive technology, institutional care, and income support), which lead to impoverishment, with a higher incidence of disabled people being below the poverty level. Employment and earnings data show disparities in salaries based on disability (eSlide 6.8). Governments within the United States have responded by developing disability-related programs, such as Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), Medicare, and Medicaid (eSlide 6.9).
•T REATMENT OF THE INJURED WORKER Workers’ Compensation Medicine Workers’ compensation medicine involves models that promote a safe return to work through functional capacity evaluation (FCE), work hardening programs (WHPs), functional restoration programs (FRPs), and treatment. An FCE tests the physical and cognitive demands of moderately or heavily strenuous work, such as perception, range of motion, strength, endurance, coordination, the ability to lift and assume certain postures, and the ability to tolerate standing, walking, and climbing. A WHP is a multidisciplinary “work-oriented treatment program” that consists of work tolerance screening and work capacity evaluation components with job simulation activities, psychological treatment, and an interdisciplinary pain program. An FRP restores the patient’s physical, psychosocial, and socioeconomic situation through a physician-driven interdisciplinary program that emphasizes the importance of function over pain elimination, pain acceptance, pain management, and proactive coping strategies. The sessions include intensive exercise program, cognitive-behavioral therapy, and ergonomic therapy.
• DISABILITY-RELATED PROGRAMS AND POLICIES Programs Disability-related programs can be characterized as ameliorative or corrective. Ameliorative programs provide payment for income support and medical care. Corrective programs facilitate the individual’s ability to return to work and reduce or remove the disablement. Disability-related programs can be categorized into three basic types: cash transfers, medical care programs, and direct service programs.
Public Disability Policies eSlide 6.10 reviews the prominent federal disability laws that mandate that housing and transportation be accessible, education for children with disabilities be appropriate, and employment practices be nondiscriminatory. Three legislative actions deserve to be highlighted: (1) the Rehabilitation Act of 1973 extended civil rights protection to PWDs, including antidiscrimination and affirmative action in employment; (2) the Rehabilitation Act Amendments of 1978 broadened the responsibility of the Rehabilitation Services Administration to include independent living programs and created the National Council of the Handicapped; and (3) the Americans with Disabilities Act (ADA) of 1990 established a clear and comprehensive prohibition of discrimination based on disability.
36 SECTION I EVALUATION
Vocational Rehabilitation TRADITIONAL APPROACHES TO VOCATIONAL REHABILITATION
eSlide 6.11 shows the traditional approach, based on referral to a vocational rehabilitation counselor for diagnosis, evaluation, and adjustment training. Obtaining an employment history and performing vocational testing are important components of this approach.
Alternative Approaches to Vocational Rehabilitation (eSlide 6.12) SHELTERED WORKSHOPS
A sheltered workshop is a “public nonprofit organization certified by the U.S. Department of Labor to pay ‘subminimum’ wages to persons with diminished earning capacity.” This form of employment serves people with severe disabilities, including limited vision, mental illness, mental retardation, and alcoholism.
DAY PROGRAMS
Day programs provide supervised vocational activity for people with severe disabilities, usually those with mental retardation or mental illness.
HOME-BASED PROGRAMS
Home-based programs include training in a variety of jobs, including telephone solicitation, typing, or computer-assisted occupations such as graphic designing, accounting, or drafting.
PROJECTS WITH INDUSTRY
Projects With Industry is a federally sponsored collaborative program established by the Vocational Rehabilitation Act to enable competitive employment by providing specific job skills training.
TRANSITIONAL AND SUPPORTED EMPLOYMENT
Two newer strategies for returning PWDs to competitive, integrated, and gainful employment are transitional and supported employment. Transitional employment consists of providing job placement, training, and support services necessary to help people move into independent or supported employment. Supported employment requires ongoing support after placement, including counseling for the employee and co-workers, and assistance with transportation, housing, and other non–work-related activities.
INDEPENDENT LIVING CENTERS
The independent living centers movement involves a combination of vocational and nonvocational services, such as housing, independent living skills, advocacy, and peer counseling, for PWDs.
Disincentives for Vocational Rehabilitation Despite growing acceptance in the public and political arenas through better policies and attitudes, there are still a number of disincentives for vocational rehabilitation, a few examples of which include (1) “red tape” in getting cash and medical benefits from SSI and SSDI; (2) the risk of losing benefits once the PWDs are employed; (3) the pervasive stereotype of PWDs being unproductive, leading to the attitude that it is easier to give them a disability check than to implement the ADA;
CHAPTER 6 Employment of People with Disabilities 37
(4) employers’ negative attitudes toward employees with disabilities and ignorance of their vocational needs; and (5) the tendency of physiatrists and other physicians to label an individual as “totally and permanently disabled” or restrict their activities.
Incentives for Vocational Rehabilitation In an effort to overcome disincentives, government policymakers have created incentives for PWDs and potential employers (eSlide 6.13).
Incentives for Individuals Incentives for the individuals include trial work period, substantial gainful activity, extended period of eligibility, impairment-related work expenses, “blind” work expenses, and plans for achieving self-support.
Incentives for Industry Government policymakers have made various attempts to offer tax incentives to businesses and industries to make the workplace accessible. Examples include deductible expenses for barrier removal, Targeted Jobs Tax Credit, and the Work Incentives Improvement Act of 1999.
Disability Prevention The public health model defines three categories of disability prevention: primary, secondary, and tertiary (eSlide 6.14). Primary prevention is intended for healthy people to avoid the onset of a pathologic condition and for people with disabilities to prevent worsening of their impairments. Secondary prevention is aimed at early identification and treatment of a pathologic condition. Provision of assistive technology can be considered secondary prevention. Tertiary prevention focuses on arresting the progression of a pathologic condition and limiting disablement. Environmental modifications, changes in social attitudes, and reforms in legislation and policies are tertiary prevention strategies. Medical rehabilitation is traditionally considered a tertiary prevention strategy.
• CONCLUSION Holistic management is the key in the comprehensive rehabilitation of disablement. This approach maximizes physical, mental, social, and economic functions of individuals with disabilities through various interventions directed at human functioning. The physiatrist, as a team leader, collaborates with professionals outside the traditional medical rehabilitation team, such as those involved in vocational rehabilitation. This eventually improves QOL and function, which greatly affect the individuals and society in terms of significant socioeconomic consequences (eSlide 6.15).
38 SECTION I EVALUATION
Clinical Pearls 1. Holistic management is the key in the comprehensive rehabilitation of disablement, which maximizes the physical, mental, social, and economic functions of people with disabilities through various interventions directed at human functioning. 2. Disability, being the largest public health concern in the United States, should encourage physiatrists to take the lead in its therapeutic and public health management through prevention strategies, including collaboration with professionals outside the traditional medical rehabilitation team, such as those involved in vocational rehabilitation. 3. The prevention strategies for people with disabilities are the following: • Primary prevention: preventing the worsening of impairments. • Secondary prevention: providing ameliorative and corrective programs including vocational rehabilitation, to reduce activity limitation and increase employment. • Tertiary prevention: limiting the restriction of a person’s participation by the provision of a facilitator or the removal of a barrier. 4. Vocational rehabilitation is an integral component in the holistic approach to disability management, improving QOL and function, with eventual significant socioeconomic consequences.
BIBLIOGRAPHY
The complete bibliography is available on ExpertConsult.com.
BIBLIOGRAPHY
1. Adams PF, Benson V: Current estimates for the National Health Interview Survey, 1988, Vital Health Stat 10:1–250, 1989. 2. Allaire S, Li W, LaValley M: Reduction of job loss in people with rheumatic diseases receiving vocational rehabilitation: a randomized controlled trial, Arthritis Rheum 48:3212–3218, 2003. 3. Anderson TP: Quality of life of the individual with a disability, Arch Phys Med Rehabil 63:55, 1982. 4. Anonymous: Rules and regulations, Fed Regist 65:82905–82912, 2000. 5. Anonymous: Rules and regulations, Fed Regist 68:40119–40125, 2003. 6. Bendix AE, Bendix T, Haestrup C, Busch E: A prospective, randomized 5-year follow-up study of functional restoration in chronic low back pain patients, Eur Spine J 7:111–119, 1998. 7. Berkowitz M: The socioeconomic consequences of SCI, Paraplegic News18–23, 1994. 8. Berkowitz M, Hill M, editors: Disability and the labor market: an overview. In Disability and the labor market: economic problems, policies, and programs, New York, 1989, ILR Press. 9. Colvez A, Blanche M: Disability trends in the United States population 1966-76: analysis of reported causes, Am J Public Health 71:464–471, 1981. 10. DeJong G, Lifchez R: Physical disability and public policy, Sci Am 248:40–50, 1983. 11. Haber LD: Identifying the disabled: concepts and methods in the measurement of disability, Soc Secur Bull 51:11–28, 1988. 12. Haber LD: Issues in the definition of disability and the use of disability survey data. In Daniel LB, Aitter M, Ingram L, editors: Disability statistics, an assessment: report of a workshop, Washington, 1990, National Academy Press. 13. Harris L: The ICD survey of disabled Americans: bringing disabled Americans into the mainstream, New York, 1986, Louis Harris and Associates. 14. Haveman RH, Halberstandt V, Burkhauser RV, editors: Public policy toward disabled workers: cross-national analyses of economic impacts, New York, 1984, Cornell University Press. 15. Hearne PG: Employment strategies for people with disabilities: a prescription for change, Milbank Q 69:111–128, 1991. 16. Joe TC: Professionalism: a new challenge for rehabilitation, Arch Phys Med Rehabil 62:245–250, 1981. 17. Kennedy EM, Jeffonds J, Moynahan DP, et al.: The Work Incentives Improvement Act of 1999, Senate Bill 331, 1999. 18. Kenney L: Earning histories of SSI beneficiaries working in December 1997, Soc Secur Bull 63:34–46, 2000. 19. Kuijer PP, Gouttebarge V, Brouwer S, et al.: Are performance-based measures predictive of work participation in patients with musculoskeletal disorders? A systematic review, Int Arch Occup Environ Health 85:109–123, 2012. 20. La Plante MP: The demographics of disability, Milbank Q 69:55–77, 1991. 21. La Plante MP, Kennedy J, Kaye S, et al.: Disability and employment, no. 11. In Disability Statistics Abstract Series, San Francisco, 1997, University of California. 22. Lin VW, Cardenas DD: Spinal cord medicine: principles and practice, New York, 2003, Demos Medical Publishing. 23. Matheson L, Ogden L, Violette K, Schultz K: Work hardening: occupational therapy in industrial rehabilitation, Am J Occup Ther 39:314–321, 1985.
38.e1
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