This randomized clinical trial (RCT) will test the effectiveness of a customized
employment (CE) intervention, Achieving Competitive Customized Employment through
Specialized Services (ACCESS-Vets), to complement clinical services for Veterans with
spinal cord injury (SCI) and improve their employment outcomes.
Background: Restoring employment is an important rehabilitation goal for Veterans with
SCI because employment impacts both quality of life (QOL) and longevity. Due to the
medical complexity of SCI, however, these Veterans face unique employment barriers that
are not adequately addressed by current Department of Veterans Affairs (VA) vocational
services. Vocational services for Veterans with SCI need to address these employment
barriers, which relate to physical health, finances, time for job search, and caregiver
issues. Customized employment, an innovative strategy for tailoring vocational services
to meet individual needs of people with complex disabilities, could be adapted for use in
SCI rehabilitation. This research will evaluate a CE intervention to help Veterans with
SCI discover their strengths, customize employment plans, and find competitive integrated
employment in their communities. The proposed intervention, ACCESS, is a user-driven,
standardized CE program delivered by a trained employment specialist and is effective for
a non-clinical, community-based population of adults with disabilities. This research is
needed to test ACCESS as a complement to clinical services for a clinically defined
population and to assess the potential of CE for subsequent implementation in the VA.
Research Plan: The effectiveness of ACCESS-Vets will be tested with an RCT of 100
Veterans with SCI. The study will have a rolling enrollment period with an intervention
period of 26 months. ACCESS-Vets is typically completed in 8 months and includes the
following elements: discovery, CE planning, job development, CE negotiation, and
accommodations and job retention supports. Individual Placement and Support (IPS),
otherwise known as evidence-based supported employment, will serve as an active control
group consistent with treatment as usual. ACCESS-Vets and IPS will be compared on changes
in employment attainment. The investigators predict Veterans who participate in
ACCESS-Vets will have a higher employment rate than Veterans who receiving IPS. Among
Veterans who attain employment, the investigators predict those who received ACCESS-Vets
will report higher job satisfaction, wages, and retention. The investigators predict,
Veterans who attain employment will demonstrate statistically significant improvements in
self-sufficiency, QOL, and participation in life roles compared with those who do not
attain employment. Finally, qualitative interviews with Veterans and their providers will
identify strategies used in IPS and ACCESS-Vets for addressing barriers to employment and
how practitioners adapt the ACCESS-Vets intervention for use in a VA clinical setting.
Significance: This study is responsive to Veterans' reported desire for individualized
vocational rehabilitation services and to the Modernization Plan and the MISSION Act,
which emphasize Veteran-centered, community-based approaches to care. The proposal goals
align with the Transformation Plan of the Office of Mental Health and Suicide Prevention,
which prioritizes evidence-informed, community-based employment services. Recognizing the
rapid adoption of CE in state and federal agencies, VA is partnering with the Office of
Disability and Employment Policy (U.S. Department of Labor) to introduce and train VA
vocational staff on CE as a promising practice; however, integration of CE into standard
VA clinical services has not yet been implemented. In support of VA efforts to assist
Veterans to achieve competitive employment and reintegration into civilian life, this
proposal will evaluate CE within the context of existing VA vocational services.