The Power OF PGAP: Solving The Access Problem for Delayed Recovery Rehabilitation Services in the U.S.

Aside

by Darrell Bruga

Bio-psychosocial is a buzz term these days.  If you attend any major workers’ compensation or disability conferences, you are likely to hear a session or two on whole-person approaches to rehabilitation.  Over the past several years, a significant body of research which focuses on the psychosocial risk factors and delayed recovery has become more widely known.  That is because new strategies are emerging to tackle the work-disability problem which research shows can be attributed to psychosocial risk factors.
Research over the past two decades conducted by Michael Sullivan, PhD and colleagues at the University Centre for Research on Pain and Disability, McGill University reveal that psychosocial variables can present significant obstacles to recovery following musculoskeletal injury.1 Modifiable risk factors such as fear-avoidance beliefs, catastrophic thinking, perceived disability, and perceived injustice have been identified as contributing to poor rehabilitation outcomes in individuals who have sustained musculoskeletal injuries.2–4There has been increasing interest in the development of intervention approaches that would permit early detection and treatment of psychosocial risk factors for poor recovery from musculoskeletal injury.2,5,6  Individuals with an elevated psychosocial risk profile seem to benefit less from traditional approaches to medical management, are less responsive to physical therapy interventions, and are less likely to return to work.
Dr. Sullivan’s research led to the development of an intervention program that specifically targets these modifiable psychosocial risk factors.  The concept was that if psychosocial barriers could be effectively targeted in an intervention program, then it might be possible to reduce or even prevent chronic suffering and disability following injury. The Progressive Goal Attainment Program (PGAP™) is an outgrowth of Dr. Sullivan’s published research and is considered the first disability prevention program specifically designed to target psychosocial risk factors for disability. It is an evidence-based rehabilitation program for reducing disability associated with pain, depression, and other chronic health conditions. Publish peer-reviewed research on PGAP™ has demonstrated how PGAP™ improves return to work outcomes as well as reduces treatment and pain medication.2,7,8,9
Despite its proven efficacy and wide use throughout the international workers’ compensation community, PGAP™ is considered cutting edge and not yet widely known in the U.S. work comp market.  For over a decade, PGAP™ has been successfully delivered in Canada’s workers’ compensation and disability system, which is similar to the US system. More recently, PGAP™ became part of a National Strategy in New Zealand where hundreds of providers have been trained and the Accident Compensation Corporation (ACC) approves the service.
Here in the U.S., PGAP™ was selected in 2006 to be a part of a $40 million dollar trial within the Social Security Administration to determine if PGAP™ and other services can help get SSDI recipients off of disability and re-integrated  to the workplace.  PGAP™ is the only proven early and chronic intervention work disability program that has been delivered on such a wide scale.
Beyond the scientific robustness of PGAP™ the program and delivery model are also attractive because PGAP addresses the need for increased access to evidenced-based biopsychosocial (BPS) rehabilitation services.  We have known that limited access has been a barrier to receiving evidence-based biopsychosocial (BPS) rehabilitation in the U.S.  This was highlighted in a recent issue of Back Letter, “Barriers to the Effective Prevention of Chronic Disabling Low Back Pain.”10 In this issue, there was discussion that the U.S. healthcare and insurance systems are not organized optimally to provide timely, reimbursable care for individuals with risk factors for chronic disabling low back pain.
We know that 10%-20% of individuals with work-related musculoskeletal injuries will progress toward chronic pain and disability.  We also know that this relatively small subgroup consumes most of the medical and financial resources.  Yet, we know that there is a void of targeted disability treatment services for these types of occupational related disabling health conditions. The article goes on to suggest that, “although cognitive behavioral therapy is an effective approach for several ‘yellow flags’, back pain-oriented cognitive behavioral therapy is not widely available in U.S. healthcare systems.  Nor are effective multidisciplinary rehabilitation programs for individuals with low back pain. (See Chou and Shekelle, 2010.)
PGAP’s community-based delivery model is significant because it can be delivered within the immediate geographic reach of the injured worker’s place of residence.  Furthermore, PGAP is delivered by a continuum of rehabilitation professionals including OTs, PTs, vocational counselors and psychologists.  This allows for increased access to PGAP™ through a wide variety of specially trained providers. This model has been shown to be effective in both face-to-face and telephonic interactions when a PGAP™ provider is not available.
PGAP™ has the ability to meet the demand of these populations and LifeTEAM™ Health was developed to deliver PGAP™ and other delayed recovery services to the U.S. market. Through its unique specialty outcome provider network, LifeTEAM™ Health delivers a powerful tool to payors, TPAs, employers and medical management companies with focus on the prevention and reduction of delayed recovery and needless work disability.  Because LifeTEAM™ Health is able to deliver services in large and small communities throughout theU.S., PGAP is a cost-effective option in comparison to higher cost programs which more commonly serve larger urban areas. Today, LifeTEAM™ Health’s outcome-based provider network reaches across 8 states.  By the end of 2012, LifeTEAM’s PGAP network will cross 12-15 states. This is the largest – and most focused – known U.S. network of its kind.
For inquiries about LifeTEAM™ and PGAP™ please send emails to Dr. Bruga at dbruga@lifeteamhealth.com or visit www.lifeteamhealth.com.  
Darrell Bruga is founder and CEO of LifeTEAM Health, a network focused on delayed recovery rehabilitation. He has worked as a clinical service innovator and change agent with a focus on affecting positive solutions for work disability.   Prior to LifeTEAM, he was co-founder of the SpineOne Program, an interdisciplinary functional restoration program.  He also served as the Chief Clinical Officer for SpineOne from 2005 to 2010.  He has always had a strong interest in outcome-driven rehabilitation methods.
References:
1. Sullivan MJL. Emerging trends in secondary prevention of pain- related disability. Clin J Pain. 2003;19:77–9.
2. Sullivan M, Feuerstein M, Gatchel RJ, Linton SJ, Pransky G. Integrating psychological and behavioral interventions to achieve optimal rehabilitation outcomes. J Occup Rehabil. 2005;15:475–89.
3. Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007;30:77–94. doi:10.1007/ s10865-006-9085-0
4. Lotters F, Franche RL, Hogg-Johnson S, Burdorf A, Pole JD. The prognostic value of depressive symptoms, fear-avoidance, and self- efficacy for duration of lost-time benefits in workers with musculos- keletal disorders. Occup Environ Med. 2006;63:794–801. doi:10.1136/ oem.2005.020420
5. Boersma K, Linton S. Screening to identify patients at risk: profiles for psychosocial risk factors for early intervention. Clin J Pain. 2005;21:38–43.
6. Linton SJ. New avenues for the prevention of chronic musculoskele- tal pain and disability.Amsterdam: Elsevier; 2002. doi:10.1016/ S0899-3467(07)60096-2
7.  Sullivan, M.J.L., Adams, H. Psychosocial treatment techniques to augment the impact of physiotherapy interventions for low back pain. Physiother Can. 2010; 62:180 – 189.
8.  Sullivan, M., Adams, H., Rhodenizer, T., & Stanish, W. (2006). A psychosocial risk factor targeted intervention for the prevention of chronic pain and disability following whiplash injury. Physical Therapy, 86, 8–18.
9.  Sullivan, M., Ward, L., Tripp, D., French, D., Adams, H., & Stanish, W. (2005) Secondary prevention of work disability: Community-based psychosocial intervention for musculoskeletal disorders. Journal of Occupational Rehabilitation, 15, 377–392.
10. The BackLetter. Vol. 25, No. 8, August 2010.

LifeTEAM Invitation – PGAP™ Workshop 2014 Boston

LifeTEAM Invitation – PGAP Workshop 2014 – Mark Your Calendar!

 counselors

We are pleased to invite rehabilitation counselors, OTs, PTs, Voc Rehab, RNs, and other health care providers to participate with LifeTEAM Health. This is an exciting opportunity to learn how to address psychosocial risk factors from leading expert, Michael Sullivan PhD. Dr. Sullivan’s program, The Progressive Goal Attainment Program (PGAP™) is currently one of the most empirically supported interventions for targeting psychosocial risk factors for work disability. It is also an opportunity to participate with a leading edge community of rehabilitation professionals, LifeTEAM Health. LifeTEAM and PGAP are utilized for clients in workers compensation, disability (STD/LTD), and it is currently being piloted with the VA. It is utilized with clients who are disabled from health conditions such as pain, mental health issues, and other chronic occupational and non-occupational disabling conditions.

We know today that 10-20% of claims are in need of services beyond traditional clinical approaches to address the barriers to recovery. We also know that 10-20% of these delayed recovery cases drive 80% of the costs seen in most claims. Needless work disability, sometimes referred to as delayed recovery, has reached near epidemic proportions over the last 30 years. More recently, research over the last 10 years has taught us that psychosocial factors (non medical factors) are one of the major contributors that drive costs seen in both workers compensation and disability claims. Unfortunately, proven interventions have been scare to address this population. LifeTEAM was developed to target psychosocial risk factors through specialized evidence-based rehabilitation programs utilizing our national network of consultants. PGAP is an evidence-based program and has demonstrated improved RTW and health outcomes. PGAP is being utilized in 10 countries worldwide with over 30,000 people going through the program.

We are holding the workshop at the Sheraton Boston Hotel.  The dates are March 7-8. More details regarding room rates, course fees, CEUs, and how to register will be announced soon.

LifeTEAM is proud to work with major employers and national insurers. These institutions have utilized PGAP as a better spend and as a major tool to reduce costs, increase return to work, and improve the lives of many people.

Please feel free to contact us at any time for more information.

http://www.lifeteamhealth.com

Interesting Article on Spinal Fusions

From the Washington Post

Spinal fusions serve as case study for debate over when certain surgeries are necessary

By some measures, Federico C. Vinas was a star surgeon. He performed three or four surgeries on a typical weekday at the Daytona Beach, Fla., hospital that employed him, and a review showed him to be nearly five times as busy as other neurosurgeons. The hospital paid him hundreds of thousands in incentive pay. In all, he earned as much as $1.9 million a year.

Yet given his productivity, some hospital auditors wondered: Was all of the surgery really necessary?

To answer that question, the hospital in early 2010 paid for an independent review of cases in which Vinas and two other neurosurgeons had performed a common procedure known as a spinal fusion. The review was conducted by board-certified neurosurgeons working for AllMed, a company accredited to audit health-care businesses.

Of 10 spinal fusions by Vinas that were selected, nine were deemed not medically necessary, according to a summary of the report.

Vinas is still working at Halifax Health, and a hospital spokesman said that, after the AllMed report, the hospital conducted an internal review that validated his surgeries. Another review conducted this year in response to litigation also validated them, the spokesman said. The hospital would not answer further questions or release details of those reviews.

Vinas “has never and will never perform an unnecessary surgical procedure on any patient,” his attorney, Robert H. Pritchard, said in a statement.

More than 465,000 spinal fusions were performed in the United States in 2011, according to government data, and some experts say that a portion of them — perhaps as many as half — were performed without good reason.

The rate of spinal fusion surgery has risen sixfold in the United States over the past 20 years, according to federal figures, and the expensive procedure, which involves the joining of two or more vertebrae, has become even more common than hip replacement.

It can be difficult, in individual cases, to get doctors to agree about when the procedure is warranted.

But at a broader level, the rapid rise of spinal fusions in the United States, especially for diagnoses that generally don’t require the procedure, has raised questions from experts about whether, amid medical uncertainty, the financial rewards are spurring the boom.

Advancements in diagnostic and surgical technology may explain some of the increase in surgery. And patients may have become more demanding.

But a Washington Post analysis of 125,000 patient records also shows that roughly half the tremendous rise in spinal fusions in Florida has been on patients with diagnoses that experts and professional societies say should not routinely be treated with spinal fusion.

Questions are raised

Normally, information that might shed light on the ways that economics shape medical decisions by doctors and hospitals doesn’t become public. But a wide-ranging lawsuit at Halifax Health offers an unusual glimpse into these issues.

In 2009, a former compliance official at the hospital filed a whistleblower lawsuit alleging illegal financial incentives for doctors. The court filings make available an array of documents — e-mails, testimony, audits. These and other sources allow a fuller depiction of the financial rewards and relationships that depended on treatment decisions. They also show how hospital administrators responded when suspicions arose that a doctor, who was generating millions in profits, may have been performing unnecessary surgery.

Focus on the Symptoms or Focus on the Risk Factors?

Why the Focus on Risk Factors
Approximately 10%-20% of individuals with work-related injuries will progress toward chronic pain and disability. Once symptoms of pain and disability become chronic, available methods of managing pain, whether pharmacological or psychological, have only modest impact on suffering and function. Musculoskeletal injury can contribute to a trajectory of increasing distress and disability associated with discontinuation of life role activities, progressive decline toward a sedentary lifestyle, and social isolation. If individuals at risk for prolonged pain and disability following musculoskeletal injury can be identified before the problem becomes chronic, individuals’ suffering might be prevented or reduced to a significant degree.

What are the Risk Factors for Chronic Pain and Disability
Intuitively, we might presume that the severity of pain associated with a musculoskeletal condition is the primary basis of work-disability. Surprisingly, pain severity has been shown to account for only 10% of the variance in occupational disability following occupational disability. Contrary to the expectations of many clinicians, research has shown that psychosocial factors might be more important determinants of the risk for chronicity than medical factors associated with the injury.

A number of psychosocial risk factors have been shown heighten the risk of chronic pain and disability. These include catastrophic thinking (negative thinking), fear of movement, disability beliefs, and perceptions of injustice are particularly likely to follow a trajectory of persistent pain, emotional distress and prolonged occupational disability.

These “Risk Factors” do not constitute a “psychological diagnosis” but rather they are factors often seen with delayed recovery claims (claims beyond 3 months) that have an impact on recovery from injury or illness. Addressing these risk factors reduces delayed recovery and reduces costs.

What Are Some Options?

PGAP® has a strong behavioral focus (not an educational approach)…
If we recognize that disability is a behavior, then overcoming disability requires a behavioral approach. Efforts to educate an individual out of disability can be quite challenging and met with increased resistance to change. If we also recognize that disability is a discontinuation of life roles such as social, familial, and occupational roles, then an intervention designed to re-engage individuals into those life roles will best challenge the disability.

PGAP® is unique…
As individuals’ become disabled due to an injury or debilitating illness, they abandon their involvement in many important activities of their lives including work. Many of these activities previously made up various life roles that defined the person’s sense of identity and self-worth. Some of these activities are abandoned because of significant functional limitations. However, some of the activities are abandoned due to psychosocial factors such as fears, loss of confidence and a pessimistic outlook on their lives. By engaging individuals through progressive activity planning and scheduling while targeting the psychosocial factors that are contributing to disability, PGAP® can assist individuals resume participation in activities that once gave their life
a sense of meaning and purpose. Resumption of occupational activities is a central objective of PGAP®. Therefore PGAP® can best be described as a ‘Life Role Re-integration’ program.

LifeTEAM™ PGAP®
Progressive Goal Attainment Program (PGAP®) is considered the first disability prevention program specifically designed to target psychosocial risk factors for occupational and nonoccupational disability. The primary goals of PGAP® are to reduce barriers to rehabilitation progress, promote re-integration into life-role activities, improve quality of life, and facilitate return-to-work if appropriate. PGAP® is delivered with the LifeTEAM™ Physio Program to achieve optimal outcomes with workers compensation cases.

PGAP® delivers:
-Targeted identification of psychosocial risk factors
-Structured activity scheduling and graded-activity involvement
-Goal-setting and problem-solving
-Motivational enhancement strategies

Leading national disability guidelines recently approved PGAP

Progressive goal attainment program (PGAP™) is recommended as an option where there is access to trained providers. PGAP is a standardized community-based intervention delivered by OTs or PTs who have been trained by the PGAP program. The primary goal of PGAP is to reduce psychosocial barriers to return-to-work. PGAP has produced positive results for individuals suffering from musculoskeletal conditions, depression, and cancer. This study showed that participation in PGAP increased the probability of return to work following whiplash injury by more than 50%. (Sullivan2, 2006)  Findings suggest that PGAP can be a cost-effective means of improving function and facilitating return to work in individuals at risk for prolonged disability. (Sullivan, 2010) (Adams, 2007)
Criteria for the Progressive goal attainment program (PGAP™):
- Lack of improvement with early active physical therapy
- Off work at least 5 weeks, but less than 5 months of continuous time lost
- Surgery not planned or likely
- No evidence of drug or alcohol problem
- Not currently in work hardening

- Maximum of 10 weeks treatment with one hour sessions on a weekly basis (L&I, 2013)

For more information contact LifeTEAM.

http://www.lifeteamhealth.com

LifeTEAM’s Announces National Opioid Addiction Program

LifeTEAM Introduction

LifeTEAM’s rehabilitation professionals are delivering evidence-based solutions for reducing psychosocial, medical, and return to work obstacles. By adopting high touch best evidence programs we are achieving improved health and financial outcomes.

LifeTEAM™ is leading the way and has brought together the biopsychosocial rehabilitation continuum. LifeTEAM™ consultants are available throughout the U.S. as a resource to deal with difficult cases. Our face-to-face intervention services include:

–       Progressive Goal Attainment Program (PGAP®)

–       Supervised Withdrawal of Opioids Program (SWOP©)

The LifeTEAM™ SWOP© -(Supervised Withdrawal of Opioids Program) has been made available to positively impact the growing opioid dependency problem in the U.S. A successful intervention for opioid withdrawal of a chronic pain patient requires integrated medical management of medication and disability behaviors arising from pain and opioid dependency as well as management of the clinical pathology foundation of the pain.  The LifeTEAM™ network provides addiction specialists and health psychologists to undertake the evaluation and management of these complex patients requiring medically supervised withdrawal of opioids.  The LifeTEAM™ specialists work closely with the treating provider(s) and the case manager to ensure continuity of care. The services are provided in the claimant’s home community, reducing the need for inpatient care.

LifeTEAM™ SWOP© is a comprehensive interdisciplinary opioid tapering outpatient rehabilitation program for workers’ compensation clients. The team includes an addictions case manager, addictions specialist and health and behavior psychologist, and PGAP® Plus Physio specialists.

Twelve Week Treatment Protocol

Treatment Initiation Stage

-Peer Review and Peer to Peer Call with Prescribing Physician

-Treating Physician Order for Tapering

-Assessment by Addictionologist and Psychologist

-Treatment Plan / Recommendations

-Non–Opioid Pain Management Plan

-Medication Management Plan

-Biopsychosocial Pain Management Plan by Health Psychologist

Tapering Stage (4 weeks)

-Psychological sessions to prepare patient for tapering and non-opioid pain management

-Addictionologist tapering

-Addictions counseling and behavioral pain management

Maintenance Stage (8 weeks)

-Addictions counseling and behavioral pain management

-PGAP® Plus Physio initiated to reduce psychosocial barriers, promote reactivation to life and work roles

-Addictionologist maintenance and medication management

-Relapse planning

-Discharge and relapse prevention planning

LifeTEAM™ has physicians throughout the U.S. who are qualified as Addiction Specialists under The Drug Addiction Treatment Act of 2000.  Requirements include a current State medical license, a valid DEA registration number, specialty or subspecialty certification in addiction from the American Board of Medical Specialties, American Society of Addiction Medicine, American Osteopathic Association or State certification as an Addiction specialist.

LifeTEAM PGAP®, Physio, SWOP© and Workabilities consultants are available throughout the U.S.

Contact LifeTEAM at http://www.lifeteamhealth.com

PGAP Improves Employment Outcomes in Veterans With Disabilities

Improving  Employment Outcomes and Community Integration for Veterans with Disabilities:

EARLY IMPLEMENTATION OF THE PROGRESSIVE GOAL ATTAINMENT PROGRAM (PGAP) FOR VETERANS DEMONSTRATION

By Farhana Hossain, Peter Baird, and Rachel Pardoe

Many U.S. military veterans have mental and physical disabilities that can increase their risk of substance abuse, social isolation, unemployment, and homelessness. The wars in Iraq and Afghanistan have made it urgently necessary to address these issues once again as the nation faces “the largest wave of returning veterans with disabilities in recent 2012, in collaboration with the VA Connecticut Healthcare System. PGAP is a behavioral intervention for people struggling with a wide range of physical and mental health conditions. The program complements clinical services for the treatment of disabilities by specifically targeting psychological and social behaviors that contribute to pain, disability, and inactivity. The history.”1  One in four veterans of these conflicts reports a service-connected disability, and unemployment among the youngest subset of veterans is particularly high.2 Veterans with disabilities need quality programs to help them get on a path to  work and reintegrate into their communities. But there is limited evidence about what interventions can effectively help them do so. Past research suggests that symptoms and impairments explain only a part of what prevents people with disabilities from working, and that people with disabilities’ own beliefs and attitudes about their conditions often keep them from gainful goal is to help those with disabilities resume daily activities and get them on a path to work.

The PGAP demonstration in the VA Connecticut Healthcare System was designed to explore how feasible it is to implement the program in a veteran service setting. In the coming year MDRC, U.S. Department of Veterans Affairs (VA) have suggested in personal interviews that disabled veterans’ attitudes and beliefs about disability present at least as big a barrier to their ability to return to work as their actual physical or mental conditions.

Drawing on its experience in disability, behavioral, and employment research, MDRC began testing the Progressive Goal Attainment Program (PGAP) for Veterans in will also test PGAP for Veterans in several locations in Houston, Texas, including the VA hospital and two local community providers.

W H A T   I S   P G A P ?

PGAP is an intervention designed to target psychological and behavioral risk factors that hamper the rehabilitation of people with disabilities, including their fear that a more active lifestyle risks exacerbating their symptoms. The program — developed at McGill University’s Centre for Research on Pain and Disability — tries to reduce perceptions of disability among its participants, modify their beliefs about the degree to which their condition interferes with their ability to be active, and help them learn how to better manage pain and discomfort. It is designed  to incrementally increase participants’ activity levels and change their daily routines until those routines are consistent with an independent, active lifestyle that includes employment. PGAP was originally developed to help Canadian workers’ compensation beneficiaries, and its effects have been studied among people with various physical and mental conditions, including recipients of Social Security Disability Insurance (SSDI) in the United States. The PGAP demonstration in Connecticut is the first time that the intervention has been delivered to U.S. military veterans.

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.

 The study was targeted to those who were most likely to benefit from PGAP. Veterans were eligible if they had a disability, were between 18 and 55 years old, and were unemployed or underemployed. A total of 86 veterans consented to be part of the study, slightly lower than MDRC’s target sample size of 100. The participants were assigned at random to one  of two research groups: Half were assigned to the program group and had access to PGAP services, the other half were in the control group and did not receive PGAP services. Veterans in both groups had access to all other services provided at Errera and the VA hospital.

The Errera staff identified potential participants for PGAP from the center’s supported housing, vocational rehabilitation, and in- house community reintegration programs. Two coaches trained to provide PGAP services to veterans began working with the Errera staff to recruit and enroll participants in January 2012. Reaching and recruiting the target population proved to be challenging, primarily due to a shortage of veterans at the Connecticut VA facilities who met the study’s eligibility criteria. This experience offered insights into the VA service environment and important lessons  for reaching and working with veterans with disabilities in the future.

  • The VA Connecticut Healthcare System, like many other VA hospitals across the country, is struggling to connect young veterans to health care and other supportive services. In fiscal year 2010 — the most recent year for which data are available — more than half of the veterans who received services through the VA Connecticut system were 65 or older, and nearly 82 percent were 50 or older.8 The PGAP coaches and the Errera staff reported that the limited pool of young veterans posed a major challenge to recruitment efforts, because the veterans they met with on a regular basis did not meet the study’s age requirement. Only veterans under the age of 55 were eligible to participate. The study also gave priority to young veterans returning from the conflicts  in Iraq and Afghanistan — since providing immediate psychosocial assistance to those veterans could potentially prevent chronic problems for them in the future — but they did not often visit Errera’s facilities. The study team had to make an extra effort to locate and recruit them.
  • Meeting veterans “where they are” is an important outreach strategy for a behavioral program like PGAP. During the initial weeks of the demonstration, recruitment efforts focused on veterans who visited Errera frequently for various services. It quickly became evident that the veterans who could most benefit from PGAP — for example, chronically homeless veterans who need case management and wraparound services to remain active and housed — did not visit Errera regularly and  had to be reached where they were living. So to ramp up recruitment the PGAP coaches began accompanying Errera staff to transitional and subsidized homes for homeless veterans, which proved to be a more successful strategy for reaching veterans who may need services like PGAP. Maintaining communication with many of these veterans still proved difficult because they lacked stable housing and family ties and suffered from chronic or recurring health problems.
  • Veterans worry that engaging in employment- related supportive services may cost them other public benefits. PGAP coaches and Errera staff reported reluctance among veterans to participate in the study out of concern for financial benefits. Veterans with disabilities can be eligible for various types of public assistance from the VA (benefits for service-connected disabilities and for non- service-connected disabilities), as well as the Social Security Administration (Supplemental Security Income and SSDI). Low-income veterans are also eligible for nutrition and housing-related  assistance. While some of these benefits are means- tested, others are not predicated on income and employment. Veterans often lacked knowledge about the eligibility criteria, however, and believed they risked losing their benefits for any work-related activity, including participation in PGAP. The VA health care system offers benefits counseling but it is not known how many of the veterans connected  to Errera have taken advantage of that service. The findings in Connecticut indicate that any future implementation of PGAP among veterans should include access to quality benefits counseling.
  • The PGAP providers’ familiarity with military service and veterans’ issues mitigated some recruitment challenges and facilitated outreach and service delivery. Two local residents with ties to the veteran community were hired to help with recruitment and provide PGAP services to the program group. These staff members received extensive training in PGAP and education about people with disabilities. They were also managed and guided by a licensed social worker who worked with PGAP during the AB demonstration. Most importantly, they were very knowledgeable about local veterans’ issues and military service in general: One of the coaches is enlisted in the Navy Reserves, and the other is married to a young veteran. Errera staff emphasized that the coaches’ personal background and familiarity with veterans’ issues allowed them to gain the trust of the veterans, many of whom are distrustful of those outside their community. Since the Connecticut demonstration was the first time PGAP was being delivered to veterans, it was crucial that the veterans saw the intervention as something that could be relevant to their experience. The coaches were able to speak about the program and the study in a way veterans could relate to.

Implementation of PGAP services

  • PGAP was implemented and provided largely as designed, and program services were integrated into the existing VA service structure with relative ease. PGAP coaches reached out to each participant  in the program group soon after he or she enrolled into the study. Coaches met with participants in person for the PGAP sessions, generally at Errera or at other local VA facilities. Approximately half (51.2 percent) of the individuals assigned to the program group took advantage of PGAP services between February and September of 2012.  Of those who started PGAP, half completed all 10 sessions of the program. These participation rates are slightly higher than those observed among the SSDI beneficiaries in MDRC’s AB demonstration, which had a much larger sample.9
  • Errera staff members who assisted with the study said that PGAP, when used in conjunction with other case management and vocational supports, has great potential to help veterans they serve, especially those served by the VA housing programs for homeless veterans. More than a dozen transitional facilities in Connecticut aim to help homeless veterans achieve long-term housing stability, income stability, and greater self-determination. The VA also provides subsidized, long-term housing to chronically homeless veterans with case management needs. Many veterans who reside in these transitional and subsidized homes need help to engage consistently in activities related to their rehabilitation (such as substance abuse and mental health counseling) and to reconnect with their families, the community, and the workforce. VA staff members who work with these veterans believe that PGAP may provide a part of that help.

Anecdotes from the Errera staff and the PGAP coaches suggest that the program helped those who engaged in it. PGAP participants reported increased activities and engagement in supportive services, reduced and stabilized anxiety, and improved ability to pursue goals. The coordinator of the transitional housing program at the Connecticut VA reported that one of his clients believed that the tasks he performed for PGAP — such as setting goals, writing out his thoughts, and planning structured schedules — will help him pursue his goal of higher education and eventual employment.

The findings reported here are based on information collected through observation of program activities and interviews with VA and PGAP staff. A final assessment of the demonstration in Connecticut will also employ an analysis of measurements collected during service delivery, as well as surveys of both program and control group members at baseline and six months after enrollment. Data collection and analysis for the Connecticut site is expected to be complete in 2013.

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.

LifeTEAM Program Meets Leading Disability Guidelines

For immediate release

LifeTEAM Program Meets Leading Disability Guidelines

PGAP® becomes a recommended option for occupational and non-occupational disability claims

 

LOS GATOS, CA – June 18, 2013 – LifeTEAM, a leader in delayed recovery for individuals who are struggling with occupational and non-occupational disability following an injury or health event. LifeTEAM is an outcomes focused rehabilitation network delivering Progressive Goal Attainment Program (PGAP®) and other programs throughout the U.S. PGAP® has recently been included in the Official Disability Guidelines (ODG).

counselorsODG provides the most up to date evidence-based medical treatment and disability duration guidelines to improve as well as benchmark outcomes in workers’ comp and non-occupational disability. ODG 2013 is succinct, straightforward, complete, and authoritative – based on an aggregate of over 10 million cases and a decade and a half of research, including a systematic medical literature review. In this ongoing task to make tangible and accessible the results of important and emerging medical evidence to minimize the impact of illness and injury in the workplace, Work Loss Data Institute is pleased to introduce ODG 2013.

A program delivered by LifeTEAM, PGAP® has been approved by the ODG Guidelines as a recommended option when there is access to trained providers.  LifeTEAM leads a network of over 300 providers across the United States.

PGAP® is considered the first disability prevention program specifically designed to target psychosocial risk factors for occupational and non-occupational disability. The primary goals of PGAP® are to reduce barriers to rehabilitation progress, promote re-integration into life-role activities, improve quality of life, and facilitate return-to-work if appropriate.

PGAP has produced positive results for individuals suffering from musculoskeletal conditions, depression, and cancer. One study showed that participation in PGAP increased the probability of return to work following whiplash injury by more than 50%. (Sullivan2, 2006)  Findings suggest that PGAP can be a cost-effective means of improving function and facilitating return to work in individuals at risk for prolonged disability. (Sullivan, 2010) (Adams, 2007)

About LifeTEAM:

Founded in 2011, LifeTEAM™ programs have been made available to impact the escalating disability problem in North America.  By delivering innovative biopsychosocial rehabilitation programs to workers’ compensation and disability carriers, self-insured employers and third party administrators, LifeTEAM has been able to make a practical difference both economically and functionally. To learn more, log onto www.LifeTEAMHealth or call 800.994.3220

 

About ODG:

The Work Loss Data Institute (WLDI) is an independent database development company focused on workplace health and productivity, with offices in California, Texas and Montana. WLDI produces the Official Disability Guidelines (ODG) now in its 18th edition, which provides evidence-based disability duration guidelines and benchmarking data for every reportable condition. To learn more log onto www.disabilitydurations.com

PGAP® was developed at the University Centre for Research on Pain and Disability. To learn more about PGAP® visit http://www.pdp-pgap.com/pgap/en/index.html or visit http://www.lifeteamhealth.com/

 

 

 

 

 

Official Disability Guidelines and PGAP – RTW Workshop

LifeTEAM Invitation-PGAP Workshop 2013 San Diego – ODG Recommends PGAP

We are pleased to invite rehabilitation counselors, OTs, PTs Voc Rehab, RNs, and other health care providers to participate with LifeTEAM Health. This is an exciting opportunity to learn how to address psychosocial risk factors from leading expert, Michael Sullivan PhD. Dr. Sullivan’s program, The Progressive Goal Attainment Program (PGAP™) is currently considered one of the most empirically supported interventions for targeting psychosocial risk factors for work disability. It is also an opportunity to participate with a leading edge community of rehabilitation professionals, LifeTEAM Health. LifeTEAM and PGAP is utilized for clients in workers compensation, disability (STD/LTD), and it is currently being piloted with the VA. It is utilized with clients who are disabled from health conditions such as pain, mental health issues and other chronic occupational and non-occupational disabling conditions.
From ODG: 

Progressive goal attainment program (PGAP™)
Recommended as an option where there is access to trained providers. PGAP is a standardized community-based intervention delivered by OTs or PTs who have been trained by the PGAP program. The primary goal of PGAP is to reduce psychosocial barriers to return-to-work. PGAP has produced positive results for individuals suffering from musculoskeletal conditions, depression, and cancer. This study showed that participation in PGAP increased the probability of return to work following whiplash injury by more than 50%. (Sullivan2, 2006)  Findings suggest that PGAP can be a cost-effective means of improving function and facilitating return to work in individuals at risk for prolonged disability. (Sullivan, 2010) (Adams, 2007)
Criteria for the Progressive goal attainment program (PGAP™):
- Lack of improvement with early active physical therapy
- Off work at least 5 weeks, but less than 5 months of continuous time lost
- Surgery not planned or likely
- No evidence of drug or alcohol problem
- Not currently in work hardening

- Maximum of 10 weeks treatment with one hour sessions on a weekly basis (L&I, 2013)

We are holding the Workshop at the Historic Hotel del Coronado http://www.hoteldel.com/. The Del is truly a unique destination and the weather is beautiful in September! The dates are September 6-7.
We are approved for 12 hours of CEUs for certified rehabilitation counselors (CRCs) and CCMS. We are in the process of being approved by AOTA for OTs, and CCMs, PTs, and RNs as well.
Additional Background
Needless work disability, sometimes also referred to as delayed recovery, has reached near epidemic proportions over the last 30 years. More recently, research over the last 10 years has taught us that psychosocial factors (non-medical factors) are one of the major contributors that drive costs seen in both workers compensation and disability claims. Unfortunately proven interventions have been scarce to address this population. LifeTEAM was developed to target psychosocial risk factors through specialized evidence-based rehabilitation programs utilizing our national network of providers. One of the innovative programs we have adopted is Progressive Goal Attainment Program (PGAP).
PGAP and Dr. Sullivan:
Progressive Goal Attainment Program (PGAP™) is considered the first disability prevention program specifically designed to target psychosocial risk factors for work disability. It is an evidence-based rehabilitation program for reducing work disability associated with pain, depression, PTSD and other chronic health conditions. Published peer-reviewed research on PGAP has demonstrated how PGAP improves return to work outcomes as well as reduces treatment and pain medication utilization at 1 year follow-up, resulting in improved outcomes and lower claims costs. Over 30,000 work disabled clients have participated in PGAP in Canada over the last 10 years. It should be noted that the Canadian workers compensation and disability systems are very similar to the systems here in the U.S. and the Canadian workers compensation and disability systems are not related to their socialized medical system.
PGAP is a cost-effective alternative to higher priced ‘cottage industry’ functional restoration programs. Payors are finding PGAP an attractive option for delayed recovery injured workers because of the published PGAP research documenting successful outcomes and because the intervention is both accessible and affordable. PGAP can be a smart choice for payors when medical interventions have not been successful in getting injured workers back to work.
Michael Sullivan, Ph.D.is Scientific Research Director at the Centre on Pain and Disability at McGill University and serves as a senior consultant to LifeTEAM Health. As you may know, Dr. Sullivan is a leading international expert in clinical interventions that mitigate bio-psychosocial risk factors that are shown to delay return-to-work in workers’ compensation and disability cases. Progressive Goal Attainment Program (PGAP) is an evidence-based clinical intervention which is shown to reduce these risk factors and improve return to work and health outcomes. PGAP is heavily used in Canada and was selected by the US Social Security Administration to be an integral part of its recent 5-year, $40 million study with MDRC to determine the efficacy of the PGAP approach to improve return to work results for their long-term disability recipients. That study has now resulted in a second trial with MDRC for disabled Veterans returning to the U.S. who are having difficulty re-integrating back to civilian life. PGAP is also being piloted in the State of Washington with Labor and Industry (the workers compensation system in Washington) as well as in the province of British Columbia as a preferred rehabilitation strategy.
http://sullivan-painresearch.mcgill.ca/ Dr. Sullivan’s research site.
More about LifeTEAM
LifeTEAM™ Health was developed to implement cost-effective strategies to transform how work disability is managed in North America. LifeTEAM™ is delivering Progressive Goal Attainment Program (PGAP™) through its network of rehabilitation providers. LifeTEAM has been delivering PGAP since the summer of 2011. With its large panel of rehabilitation providers expressly trained in PGAP, LifeTEAM has providers in 43 states today and growing. We have the ability to deliver services telephonically anywhere in the U.S. LifeTEAM selects providers based on a personal interview, provider treatment philosophy, years in practice and reputation as well as input from colleagues within insurance companies, managed care companies and other rehabilitation professionals. We have built a quality assurance team/system and a clinician to clinician mentorship program as well as an online documentation system (LifeTRACK) so that we can obtain the outcomes our partners expect. LifeTEAM is a community of outcome rehabilitation providers specialized in psychosocial risk factor targeted interventions delivering services to the workers compensation and disability insurance industry.
Thank you again for your interest in LifeTEAM!
Please contact me if you would like more information on how to register, compensation, etc.