Co-operation in vocational rehabilitation : methods in multiprofessional cross-sector group meetings and effects on employment
Sammanfattning: 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.
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