Considerable research over the years has strongly supported the value of job placement in promoting successful employment outcomes for persons with disabilities [43]. A landmark longitudinal study that tracked the progress of over 8,500 clients in the US public VR services program over a 3-year period found that clients who received job placement services were significantly more likely to have a successful employment outcome [44]. In addition, a study by Rogers et al. [45] found that recipients of disability benefits who had job placement services were three times more likely to become successfully employed. Thus, job placement as a service is, in effect, an evidence-based practice (EBP). While many studies have examined personal factors, such as age, marital status, and receipt of benefits in relation to outcome, few included environmental factors. One notable exception was the longitudinal study of the VR services program, which included environmental factors (e.g., community resources) and organizational culture as variables in its research designed to explore factors associated with employment outcomes [44].

Surprisingly, despite its strong association with successful outcomes, many clients within the public VR program in the United States do not receive job placement assistance. For example, using a large national database of clients with sensory and physical disabilities whose cases were closed after receiving VR services, Pack and Szirony [46] reported that only about 17 % actually received job placement assistance. Similarly, Chan et al. [47] found that only 25 % of VR clients with orthopedic disabilities received job placement services. Thus, research suggests that a majority of clients (at least 75 %) do not receive this important service.

Although job placement services have demonstrated effectiveness in helping individuals achieve employment, much more research is needed to clarify which components of job placement services and job placement models are most successful and with which individuals, as studies suggest that there is no “one-size-fits-all” approach that is beneficial to all clients of VR services. That is, individuals with specific types of disabilities may benefit from a more targeted approach [48].

The rest of this section will focus on research examining VR-related services and job placement models in relation to successful employment, as well as those that appear to be most effective for specific consumer populations. This literature review is not intended to be exhaustive; rather, the focus is on more recent research that purports to be evidence based. Table 8.1 presents a summary of this research.

Many studies have examined various aspects of job placement strategies and services and their impact on employment outcomes. For example, in a randomized clinical trial (RCT) involving individuals with musculoskeletal injuries (MSI), Li-Tsang et al. [49] found that job-seeking skills training and vocational counseling were associated with more successful job placement. Consistent with P X E fit, the study also noted that a good match between the person and the occupation was an important factor in job success. In addition, the study highlighted the benefits of attending to psychosocial aspects such as coping with stress, not just physical factors, when working with individuals with MSI.

Fleming et al. [48] reviewed 25 years of empirical research in order to create a best practices model for VR, synthesizing their findings into seven key categories that were associated with successful VR outcomes: collaboration among agencies, rehabilitation counselor education, interventions toward a targeted population (i.e., disability type, race/ethnicity, age), evidenced-based practice and supported employment, consumer self-concept and empowerment, critical service delivery components, and VR miscellaneous interventions and outcomes (e.g., working alliance, services directed to families). Overall, their review suggests a number of strategies and interventions that, when combined, contribute to successful employment and can be incorporated within the ICF framework. For example, while personal factors in the ICF model, self-concept and empowerment, are associated with positive outcomes, Fleming et al. [48] noted that other studies have shown that VR clients who have received empowerment training were more likely to be successful. Thus, this is a personal factor that could be enhanced through appropriate VR intervention in the form of specific training. In addition, certain types of VR services and interventions (which in the ICF model can be seen as environmental facilitators) are related to successful outcomes for specific groups. For example, services such as on-the-job training and counseling and guidance were more powerful predictors of employment for clients with traumatic brain injury (TBI) than psychological and demographic variables (i.e., personal factors in the ICF) that are commonly included in prediction models. This is an important finding, as it supports the ICF model of functioning and highlights the importance of including environmental variables in studies of best practices. In the category of essential service components, Fleming et al. [48] noted that successful placements are enhanced when VR agencies utilize a team approach to providing services and direct interventions to improving clients’ skills in key areas of independent functioning, such as self-care. In the area of miscellaneous interventions and outcomes, the authors identified the working alliance between the VR counselor and client as an essential best practice, as VR clients who had a stronger working relationship with their counselors were more likely to obtain employment than unemployed clients. Within the ICF model, this finding corresponds with the environmental factor of support and relationships (e.g., e360, other professionals).

Pack and Szirony [46] investigated employment predictors for clients with sensory and physical disabilities; after identifying predictors based on a series of statistical analyses, they described an evidence-based model of VR service predictors for this group of clients. As noted earlier, provision of job placement services was a strong predictor of successful outcomes, as clients who received this service were almost four times more likely to achieve competitive employment. Likewise, clients receiving on-the-job support increased their likelihood of competitive employment by 232 %. Those with a college education were 215 % more likely to obtain competitive employment. Providing clients with maintenance payments increased the chances of obtaining competitive employment by 186 %. In addition, those receiving vocational training were 186 % more likely to obtain competitive employment and those provided with rehabilitation technology were 182 % more apt to secure competitive employment. VR counseling increased the chances of competitive employment by 155 %. Surprisingly, although guidance and counseling can be provided throughout the VR process, Pack and Szirony noted that only 54 % of their sample received these services. In addition, those clients employed during the application process were almost four times more likely to secure competitive employment. This is consistent with results of other studies (e.g., [44]) and is not surprising, since individuals who are currently working are more likely to have the skills and experiences that employers seek, thus making them more competitive in the labor market. Clients who received restoration services (e.g., medical or psychological treatment for the disability) were 143 % more likely to have a successful outcome [46].

In combining these predictors into an evidence-based model, Pack and Szirony [46] proposed a flowchart of VR services for individuals with sensory and physical disabilities to increase the likelihood of competitive employment. In this model of VR services, every client should have a career assessment that includes assessment of assistive technology needs and a vocational evaluation that includes assessment of work-related values, skills, interests, and aptitudes. From this, the consumer and counselor can develop an individualized plan for employment, which may include the identified predictors of training (college/university, vocational, on-the-job), job-seeking assistance, and job placement services. Throughout the process, the VR counselor provides ongoing counseling and guidance, as well as maintenance payments, when appropriate. This proposed model is consistent with the ICF framework in that it includes potential environmental variables, such as rehabilitation technology, education and training, and employment services.

Test and Cease-Cook [50] reviewed an array of studies in the field of transition to highlight evidence-based strategies for students with disabilities who are making the transition from school to work. For example, students who had strong career awareness skills as a result of instruction were more likely to be successfully employed after leaving school, as were students who had been trained in traditional interview and job search skills. Students also benefitted from being included in general education courses such as math, reading, and science. In addition, integrating community experiences (e.g., transportation, mobility, recreation) within the educational program was an important predictor of post-school success, as were independent living skills and having strong social support systems that include teachers, family, and friends. In addition, students who participated in transition programs that included paid work experiences as well as those who received vocational education and opportunities for work study had a higher likelihood of success after leaving school. Social skills were another important predictor associated with employment, as was interagency collaboration involving parents, special education teachers, rehabilitation counselors, regular teachers, and other professionals. In addition, students who had stronger skills in the areas of decision-making, self-awareness, and self-advocacy had greater likelihood of employment. Many of these variables could be cross-linked to ICF codes in the domains of activities/participation and environmental factors (e.g., in areas related to independent living skills, transportation, education and training, and support and relationships).

As previously noted, research suggests that individuals with specific types of disabilities benefit from a targeted approach to job placement [48]. A number of studies that have examined evidence-based practices in relation to various disabilities, such as TBI, mental illness, spinal cord injury, substance abuse, and vision impairment, are reviewed in the following section.

Brain Injury. Tyerman [51] systematically reviewed empirical research spanning a 45-year period (1967–2012) to examine VR models for individuals who have sustained brain injuries (TBI). The models reviewed included VR models with TBI adaptations (e.g., supported employment), brain injury programs with VR components (e.g., work trials), consumer-directed (where participants are involved in running their own programs), and case coordination-resource facilitation models (case management involving coordination of multiple services). While noting the effectiveness of these models, Tyerman pointed out that direct comparisons between models were not feasible due to a lack of consistent methodologies and recommended conducting more controlled studies. These findings suggest an important role for the specificity and universality of the ICF, as ICF-based research could help provide consistency needed for comparisons among studies and different disciplines. Depending on the location and severity of damage, individuals with TBI can experience a broad range of effects in many areas of function, including communication, cognition, emotional responses, perception, and coordination, among others [52]. These disparate variables complicate research to identify evidence-based practices with this population; instruments based on the ICF, or cross-linked to it, could provide more consistency in identifying and classifying patient characteristics that would then allow for more productive cross-comparisons across studies.

Grauwmeijer et al. [53] investigated employment outcomes 3 years post-injury for individuals with moderate to severe TBI. They found that clients with psychiatric symptoms (e.g., depression and anxiety) as well as cognitive functioning limitations at hospital discharge were more likely to be unemployed at 3-year follow-up. This study investigated demographic variables, as well as scores on measures used to assess functioning during hospitalization. When compared to patients who were unemployed, those who were employed 3 years later were more likely to be younger, had shorter hospitalization periods, and were less likely to have psychiatric symptoms. At the time of hospital discharge, the employed patients had higher scores on the Glasgow Coma Scale, Barthel Index, Functional Independence Measure, and Functional Assessment Measure (FAM, which includes assessment of communication and cognitive functioning). Based on further analysis, Grauwmeijer et al. also found that FAM scores at 65 or under predicted unemployment and should be noted by rehabilitation professionals, as it underscores the need for adopting a holistic approach with this population that addresses both mental health problems (particularly depression and anxiety) and cognitive limitations. Early identification of factors associated with poorer outcomes would enable TBI treatment programs to develop more effective interventions that are targeted to individualized needs. Future studies could utilize existing measures, such as the FAM, which could be mapped onto the ICF categories [26] and used to identify evidence-based practices for individuals with TBI for a holistic approach to job placement.

Trexler et al. [54] conducted a randomized controlled trial (RCT) of an innovative approach to working with individuals with brain injury called Resource Facilitation (RF). Created by the Brain Injury Association, RF involves determining individuals’ needs and resources; identifying appropriate community resources, goals, and services based on consumer input and matched to their needs; promoting access through education and advocacy; and active contact with clients by a Resource Facilitator (i.e., case manager) at least every 2 weeks to monitor progress. In addition, individuals in the RF group were encouraged to use VR services provided by the state-federal VR agency. Specifically, this study examined the impact of RF on employment and community participation for clients with brain injury. Results of the study indicated that at follow-up, individuals in the RF group were significantly more likely to be employed; this group had a 64 % employment rate, compared to 36 % for the control group. In addition, individuals in the RF group were more likely to be involved in community and home activities and to be clients of VR services, since this was promoted in the RF group. These results suggest that a structured program that includes regular contact through case management provided by the Resource Facilitator, combined with consumer education, referral for services targeted to individual needs, and coordination of services, can help improve employment outcomes for individuals with TBI.