PGAP is delivered in curriculum-based sessions. A PGAP provider, or “coach,” meets with each participant for one hour a week, up to a maximum of 10 times. During the first session, participants watch an informational video about recovering from disabilities and the goals of PGAP. Each participant also receives a PGAP Workbook to guide him or her through the treatment activities.
In the initial weeks, the focus of PGAP is on developing a structured activity schedule that keeps participants as active as possible during normal working hours. Participants use their Workbooks to log their daily activities, which may include household chores, errands, and recreational pursuits. They are also expected to walk or get out of the house for at least 15 minutes each day and to increase that activity gradually with the help of the PGAP coach. In the final weeks, the focus turns to activities that target psychosocial risk factors specific to each participant. Coaches help participants develop skills to overcome their fear of reinjury, to lessen any tendency to magnify the seriousness of their pain, and to rethink their perceptions about their own disabilities and limitations.
During the first week, the fourth week, and the final week of the program, PGAP participants complete five self-administered assessments that score their levels of pain, depression, perceived disability, fear and fatigue, and tendency to magnify the seriousness of their pain. These three rounds of assessments help the coaches track their clients’ progress and tailor service delivery as needed.
Previous evidence of effectiveness Findings to date suggest that PGAP could be an important service for veterans with disabilities. MDRC’s Accelerated Benefits (AB) Demonstration found that when delivered alongside medical case management and employment and benefits counseling, PGAP started to increase job search and job preparation activities within a year among individuals who receive SSDI.4 A follow-up analysis by the Social Security Administration found that beneficiaries who received PGAP and related counseling services sustained higher employment and income levels two years after the study began.5 The evidence from the AB demonstration corroborates prior nonexperimental research on the effectiveness of PGAP. In other studies, mostly in Canada, PGAP has produced positive results for individuals suffering from musculoskeletal conditions, physical injuries, and other conditions that put them at risk for prolonged disability.6 One recent study showed that individuals with whiplash who participated in PGAP and received physical therapy were more than 50 percent more likely to return to work than individuals who received only physical therapy.7 Ongoing clinical trials are assessing the efficacy of PGAP for the management of disability associated with depression and surviving cancer.
P G A P F O R V E T E R A N S I N C O N N E C T I C U T
The goals of MDRC’s PGAP for Veterans Project are to determine (1) whether PGAP is an appropriate service for veterans with disabilities and (2) the feasibility of conducting large-scale randomized controlled trials of the model in veteran service settings. In Connecticut, PGAP services were provided through the Errera Community Care Center in West Haven. Errera is part of the VA Connecticut Healthcare System and serves veterans with mental health disorders throughout the state.
N E X T S T E P S
MDRC is using its experience with PGAP for Veterans in Connecticut to expand the study to several locations in Houston, Texas. The Houston/Harris County area has one of the largest concentrations of veterans in the country, and one out of four veterans there is under the age of 45.10 MDRC has established a partnership with the Michael E. DeBakey VA Medical Center to replicate PGAP for Veterans there.
The difficulty this project encountered in recruiting younger and returning veterans at the pilot site signaled the need to reach beyond VA hospitals, however. The VA staff in Connecticut emphasized the importance of community outreach to serve younger and returning veterans, who may see immediate benefits from participating in PGAP. According to the staff, many in this group seek vocational and educational services in the community before making use of VA health services, but often lack the support they need to follow through and succeed in those endeavors. Recent government reports support these findings and suggest that the engagement of young veterans is a systemwide challenge for the VA: Only about half of eligible Iraq and Afghanistan war veterans have sought health care through the VA since the wars began.11
For these reasons, MDRC has also established partnerships with Goodwill Industries of Houston and the Lone Star College System to test PGAP in community settings and to potentially reach more young veterans. PGAP coaches began service delivery at the Houston locations in early 2013.
CHARLES’S STORY
Charles was medically discharged from the U.S. Navy after experiencing a traumatic event in basic training. When he agreed to participate in the PGAP for Veterans study, he was living in a VA transitional home for homeless veterans, and his immediate goal was to secure permanent housing. He reported having a service-connected disability and struggling with chronic back pain and substance abuse. His physical and mental health hampered his ability to perform routine daily activities.
Charles completed all 10 modules of PGAP. He spoke very positively about his experience and his PGAP coach during a follow-up interview. He said PGAP helped him develop “the Four D’s:” direction, discipline, desire, and definition of goals. Charles also reported significant changes in his physical health and well-being after completing the program: He gradually increased his daily walking routine from 5 minutes to up to 40 minutes, he was happier more often, his views on life and his future were more hopeful, and he began to feel the desire to be productive. Furthermore, a preliminary tally of Charles’s assessment scores during PGAP showed a nearly 50 percent reduction in self-perceived disability. When he last spoke with the program staff, Charles had secured VA-subsidized permanent housing and was applying to community colleges.
NOTE: Real names of participants are not used to ensure their privacy.
JOHN’S STORY
John was discharged from the U.S. Army after being diagnosed with a chronic liver condition. After the military, John attended college and worked in real estate development, but an on-the-job injury and worsening health led to unemployment, divorce, and ultimately homelessness. He was living in a VA-supported home when he agreed to participate in PGAP for Veterans. At that time, John reported suffering from an array of physical and mental health problems, including chronic back pain, diabetes, depression, and anxiety.
Before PGAP, John stayed in his apartment most of the time and often did not get out of bed. He described himself as “more or less becoming a vegetable.” While he had many immediate goals — including securing permanent housing, enrolling in a VA work-therapy program, and socializing with fellow veterans — he felt constrained by his health and did not actively pursue these goals. With the help of the PGAP coach, John says he was able to plan his days and participate in activities outside of his home. He completed all 10 sessions of PGAP and said that the program helped lessen his anxiety and symptoms of depression, giving him a better outlook on the future. After the program, VA staff in Connecticut helped John to apply for jobs; he was working part time until he moved to another state to help a sick family member.
NOTE: Real names of participants are not used to ensure their privacy.
N O T E S
1 Waterstone (2010).
2 U.S. Census Bureau (2011); U.S. Bureau of Labor Statistics (2012).
3 Shaw, Pransky, Patterson, and Winters (2005); Gauthier et al. (2006).
4 Michalopoulos et al. (2011).
5 Ben-Shalom, Hemmeter, and Stegman (2012).
6 Sullivan, Adams, Rhodenizer, and Stanish (2006); Sullivan et al. (2005); Adams, Ellis, Stanish, and Sullivan (2007); Sullivan, Adams, and Ellis (2012).
7 Sullivan, Adams, Rhodenizer, and Stanish (2006). 8 Administrative data from the VA Connecticut
Healthcare System.
9 Michalopoulos et al. (2011).
10 U.S. Department of Veteran Affairs, National Center for Veterans Analysis and Statistics (2013).
11U.S. Government Accountability Office (2011);
U.S. Department of Veterans Affairs, Veterans Health Administration (2012).
R E F E R E N C E S
Adams, Heather, Tamra Ellis, William D. Stanish, and Michael J. L. Sullivan. 2007. “Psychosocial Factors Related to Return to Work Following Rehabilitation
of Whiplash Injuries.” Journal of Occupational Rehabilitation 17, 2: 305-315.
Ben-Shalom, Yonatan, Jeffrey Hemmeter, and Shelley Stegman. 2012. “SSA’s Disability Programs: New Findings on the Dynamics of Employment and Health.” PowerPoint presentation delivered at the Center for Studying Disability Policy Research Forum, Washington, DC, December 6, 2012.
Gauthier, Nathalie, Michael J. L. Sullivan, Heather Adams, William D. Stanish, and Pascal Thibault. 2006. “Investigating Risk Factors for Chronicity: The Importance of Distinguishing Between Return-to-Work
Status and Self-Report Measures of Disability.” Journal of Occupational and Environmental Medicine 48, 3: 312-318.
Michalopoulos, Charles, David Wittenberg, Dina A.
R. Israel, Jennifer Schore, Anne Warren, Aparajita Zutshi, Stephen Freedman, and Lisa Schwartz. 2011. The Accelerated Benefits Demonstration and Evaluation Project: Impacts on Health and Employment at Twelve Months. New York: MDRC.
Shaw, William S., Glenn Pransky, William Patterson, and Thomas Winters. 2005. “Early Disability Risk Factors for Low Back Pain Assessed at Outpatient Occupational Health Clinics.” Spine 30, 5: 572-580.
Sullivan, Michael J.L., Heather Adams, and Tamra Ellis. 2012. “Targeting Catastrophic Thinking to Promote Return to Work in Individuals With Fibromyalgia.” Journal of Cognitive Psychotherapy 26, 2: 130-142.
Sullivan, Michael J. L., Heather Adams, Trina Rhodenizer, and William D. Stanish. 2006. “A Psychosocial Risk Factor–Targeted Intervention for the Prevention of Chronic Pain and Disability Following Whiplash Injury.” Physical Therapy 86, 1: 8-18.
Sullivan, Michael J.L., Charles L. Ward, Dean Tripp, Douglas J. French, Heather Adams, and William D. Stanish. 2005. “Secondary Prevention of Work Disability: Community-Based Psychosocial Intervention for Musculoskeletal Disorder.” Journal of Occupational Rehabilitation 15, 3: 377-392.