2001 Conference Proceedings
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INCORPORATING VIDEOTELEPHONE CONTACT INTO PROVISION OF
SUPPORTED EMPLOYMENT
Cheryl Trepagnier
John Noiseux
Elizabeth Greene
Rehabilitation Engineering Service
National Rehabilitation Hospital
102 Irving Street NW, Washington DC 20010 length
David Wachter
Rock Creek Foundation
700 Roeder Road, Silver Spring MD, 20910
Introduction
A recent review of patient satisfaction with telemedicine calls
for large-scale, randomized-assignment controlled studies, since
available research fails to provide satisfactory explanations of
the underlying reasons for patient satisfaction or
dissatisfaction and to explore issues of communication (Mair
& Whitten, 2000). It can also be argued that in-depth case
studies are valuable avenues to generating hypotheses regarding
the sources of satisfaction or lack of it with the use of
distance communication techniques as a channel of rehabilitation
service provision.
We offer a descriptive account of two trials of videotelephone
use by vocational service providers and their clients in
supported employment contexts (Wehman & Revell, 1996). Both
sites were selected with the help of one of the authors (DW), an
experienced vocational counselor, and the supervisor of the
counselors who participated in the study. He selected both sites
based on an expectation that, while both sites were functioning
at a highly satisfactory level, use of videophone communication
had the potential to add value to the service being provided to
the clients.
In-depth structured interview of the vocational service
providers was the only data for Case 2. Case 1data included a
weekly log of ‘actual’ and video contacts and monthly
client interviews, in addition to the counselor interview. These
cases are offered as an illustration of the variety of factors
that need to be taken into account in the design of a study of
the utility of videophones in vocational rehabilitation.
Case 1 The client, an individual with developmental disability
and mental illness, aged 44, worked as part of the two-person
mailroom staff of an educational institution, under the
supervision of the senior mailroom clerk. A vocational support
provider met twice weekly with the worker, once at the job site,
and once at the agency, when the worker went there to attend
psychotherapy sessions. The counselor was a 40-year-old,
foreign-born man with a BA in Communications, a former television
commentator in his home country, who had worked in vocational
rehabilitation for 6 years. The worker had held his position for
9 years. Crises requiring the counselor to make unscheduled trips
to the job site occurred no more than two or three times per
year. The relationship between the counselor and the worker was
of one year’s standing, and was a close and successful one.
The counselor had first become aware of the videophone project
when a focus group was conducted by project staff at his agency
(Trepagnier, et al., 1999).
While the employer’s representative expressed support for
his employee’s participation in the study, his actions
communicated ambivalence. The institution had the study’s
informed consent documents reviewed by its legal department. Once
it was approved, the employer’s representative agreed to
proceed only if the project bore the cost of installing an
additional analog telephone line.
Once informed consent procedures were completed both with the
worker and the counselor, two Aiptek Hyper AVP 2000T videophones
were installed, one at the job site and the other in the
counselor’s office. These were standard-phone-line-based
video conferencing units, combining camera, display screen,
audio-video coder/decoder (codec), and a telephone with
speaker-phone, in one package. System set-up consists of plugging
in the power cord and the telephone line. The counselor logged
frequency and duration of visits and video contacts, and carried
out a brief monthly interview of the worker every four weeks.
Reports were e-mailed to the project weekly.
Case 2 This was an enclave of individuals performing janitorial
work in the evenings at a federal courthouse, under a subcontract
between the vocational service agency and an employment agency,
so that the employment agency could meet the ratio of persons
with and without disabilities (75:25) required under NISH
regulations. (NISH is a national nonprofit agency that
facilitates employment of persons with disabilities by federal
agencies.) These workers had mental illness diagnoses, and
approximately half also had had minor forensic involvement or
substance abuse history. The group of 9 workers included both men
and women, ranging in age from 20 to 55, of diverse racial
backgrounds. The senior vocational service provider was a
60-year-old man with a Master’s degree in education, who
had spent 15 years in the vocational rehabilitation field. The
other job coach, new to the field, was a 42 year-old woman with a
Master’s degree in history, a former substitute teacher,
who was assigned to this site during the second month of the
study. The enclave had been in existence for 6 months when the
study began. Both counselors were on site three out of five
evenings, and at least one was present on the remaining two
evenings. Two representatives of the employment agency were also
present, one who was on site most of the time and one who
departed once the workers had checked in. As in Case 1, the
senior vocational service provider had a close and trusting
relationship with the workers.
Like the educational institution in Case 1, the employment
agency (the direct employer) in Case 2 had the consent form
reviewed by their legal department. In contrast to the Case 1
employer, the employment agency was highly enthusiastic about
incorporating the technology, and indeed took the initiative to
become involved in the study.
The project was introduced to the counselors and
employer’s representatives by project staff and
representatives of the employment agency and informed consent was
obtained. At that time, the senior service provider expressed
concern about use of the videophone, since regulations allowed
him to bill only for services provided on site.
The equipment consisted of a GE speaker-phone with speed-dial
buttons connected to an 8x8 desktop videophone. This unit
included a camera, display screen, and audio-video codec.
Availability of both a speaker-phone option and speed-dial
function allowed users to make hands-free calls once they had
pressed two buttons. To reduce inadvertent pressing of other
buttons, a plastic cover was fabricated to block all except the
speaker-phone and speed-dial buttons. One videophone was
installed at the work site, in the office used by the vocational
support staff. The second videophone was installed at the home of
the senior vocational support provider, so that he could be
reached on his off-site evenings. The on-site system shared the
available analog phone line with a fax machine, and an A/B switch
was installed to allow the user to switch the phone line between
the videophone and the fax machine.
Results Case 1 * Mean number of visits before videophone
installation is based on retrospective report. Figure 1.
Frequency of contacts before and after videophone installation
The data reported here were gathered over a 20-week period. While
actual baseline data were not acquired, the counselor’s
customary practice had been twice-weekly meetings, one on site
and one at the agency offices, so that meeting time plus provider
travel time (a 1-hour round-trip) was typically 3 hours/ week.
Figure 1displays mean weekly number of ‘actual’
contacts before and after installation of the videophone, and
mean weekly number of ‘videophone contacts during the 20
weeks of the study.
Both participants reported a high degree of satisfaction with
this communication mode. The service provider reported that the
worker seemed to gain a feeling of security and confidence from
the video contacts and the knowledge that he could initiate them
if he felt the need to. The worker consistently reported
satisfaction with the device. According to the counselor, the
client’s supervisor was pleased with the client’s
improved performance. While the study period was not long
relative to the worker’s previous low incidence of crises,
the absence of any crises since installation of the videophone
was consistent with the positive reports. It should also be noted
that during the last weeks of the study, there was a new source
of stress, as the counselor was preparing the client for his
departure due to promotion.
Relative to the previous routine of regular meetings, frequency
of visits involving travel decreased, and the length of these
visits was reduced. Comparison between month 1 of the study and
the subsequent months showed a decrease in counselor travel and
contact time of over 1.5 hours per week on average. This contact
included 2 to 4 videophone calls per week, averaging about 8
minutes’ duration (range 3 to 23 minutes). In summary,
while number and duration of ‘actual’ contacts, and
overall time required from the counselor to meet the needs of
this client decreased, the frequency of contacts, due to use of
the videophones, increased. Interestingly, use of the videophones
was not one-sided. Both the counselor and the worker took the
initiative to place calls, as shown in Figure 2. * Data on
call-initiation are available only for weeks 12 through 20 Figure
2. Initiation of video contacts by counselor and client Case 2 As
in Case 1, the workers were very receptive to the prospect of
using the equipment. In marked contrast to Case 1, the
videophones were on site for several weeks before they were tried
out by the vocational service providers. During the 5 months that
the videotelephones were in place, they were almost never
used.
Discussion
It is evident that we cannot conclude any causal relationships
between characteristics of these two sets of circumstances and
the adoption and use of videophone communication. It is
nevertheless interesting to point out circumstances which were
contrary to expectations: the employer’s lack of
enthusiasm, in Case 1, and the Case 2 employer’s pro-active
involvement, did not carry the day in either case. The fact that
the Case 1 counselor and worker were of quite different cultural
backgrounds was not at all a detriment to their therapeutic
relationship, and their mutual adoption and successful use of the
technology. At both sites, clients were pleased with the
videophone and interested in its use.
There were many differences that may have contributed to the
contrasting outcomes. The Site 1 counselor was younger than the
main counselor at Site 2. The Site 1 client knew when his
counselor could be reached at the agency office. Site 2 clients
worked during the evening, and the counselor was not always at
home, where the other videophone was installed, when he was not
on site. The counselor at Site 1 had a videophone in his office
at the agency, and became the videophone ‘guru’ for
his colleagues. His participation in the project was featured in
a company newsletter. The other counselor received no such peer
support.
An important factor in willingness to use the technology at one
site and not at the other appears to have been funding policy.
The worker at Site 1 is served through the state Developmental
Disabilities Administration (DDA). DDA funding is set in advance.
In contrast, funding for clients at Site 2was provided through
the Mental Health Administration (MHA), on an as-needed basis. If
a client required more hours of service, these were provided,
billed for, and reimbursed. As a result, the job coach at Site 2
had a disincentive to reducing his or her in-person hours of
service. The DDA-funded client’s provider was able to save
time otherwise spent in travel and put it to more fulfilling and
effective use, without detriment to and, as it appears, to the
benefit of, his client. It may have been possible for the clients
at Site 2 to be served with less intensive on-site staffing;
however the regulatory and funding structure removed any
incentive for exploring this.
The counselor reported that initially the employer’s
representative perceived a threat to privacy. Eventually he came
to like having the videophone because he knew the worker could be
in touch with his counselor as needed, with the result that there
was increased confidence that work would not be impeded by
crises. Both the client and the provider reported that the client
felt more connected to the provider by virtue of using the
videophone. Videophone contact with his counselor made the worker
feel “as if he is right there with me”. The worker
used the videophone to talk about problems he was experiencing,
and the counselor used it as a channel for reminding the worker
of his goals and providing encouragement. On some occasions the
calls were primarily social (e.g., talking about vacation plans).
The mailroom supervisor reported that the worker was more
productive and had fewer difficulties during this period than
before.
It is interesting to note that the videophone was mutually
adopted. Both parties originated videophone calls. The presence
of the videophone made it possible for the worker to take the
initiative and request support when he perceived a need. This may
have contributed to a feeling of control.
Because of the success of the videophone link in this case,
another installation is being planned, and the supported
employment agency is considering eventually purchasing
videophones to serve appropriately selected clients. In keeping
with the client’s request, the existing videophones are
being left with him and his counselor. Because of the modest
amount of time spent using the videophone, the agency is
negotiating with the employer to drop the requirement of an
additional telephone line, so that the analog line used for the
fax machine will be shared, by means of an A/B switch, as
described above.
Opinions elicited from a focus group held at the service
provider agency prior to the installation of videophones had
supported the likelihood that videotelephones would be helpful in
achieving vocational goals (Trepagnier, et al., 1999). Among
perceived advantages were marketing appeal for job development,
expected increase in employer confidence, ability to respond in a
timely manner to needs and prevent crises, ability to monitor and
anticipate sources of difficulty or danger, and ability to assess
workers’ dress and hygiene, and to provide reassurance and
instruction. Potential drawbacks were seen as employer
technophobia, concerns about security of the equipment , and for
some clients, possible aggravation of paranoia. Image quality,
due to low bandwidth, was not perceived as problematic. Video was
expected to be more useful for communicating with clients with
cognitive impairments than audio alone. It was also noted that
video at the service provision center would allow for coverage
when needed even when the assigned counselor was unavailable.
These expectations were for the most part borne out in the
experiences reported here. The employer who was hesitant in
prospect came to find videophone use valuable in practice.
Videophones proved especially useful in the hands of a talented
support provider who used the technology to enable his client to
benefit from frequent brief contacts for problem-solving,
encouragement and reassurance.
Despite high demand for workers in the current economy,
employment success of persons with disabilities continues to be
limited, for numerous reasons. One is the limited amount of
funding available to provide vocational support personnel. We
have seen that apparently superior benefit resulted from addition
of videophone contact, despite a net reduction in counselor time
commitment. If the amount of counselor time needed to serve each
client was reduced as it was in the case of this client, the
counselor might be able to serve more clients as effectively, if
not more so. As the costs of equipment decrease (from the current
$550 for an Aiptek videophone), and the costs of vocational staff
rise, it is possible that availability of videotelephones will
not only add value but will at the same time reduce costs of
providing effective vocational support. If the funding structures
and policies permit, this could open the door to more individuals
who are waiting for such supports in order to have access to
employment. It remains to determine under what circumstances
videophone-enhanced job coaching can be helpful, and how big an
impact this technology can have on the quality of clients’
and service providers’ working life. Further study is
underway, using single-subject experimental design to allow for
the range of dimensions along which individuals and their work
contexts can differ.
References
F. Mair, P. Whitten (2000). Systematic review of studies of
patient satisfaction with telemedicine. British Medical Journal
320 (1517 – 1520).C. Trepagnier, J. Noiseux, & M.
Glenshaw. (1999). Video communication for vocational support.
Presented at the Biomedical Engineering Society / Engineering in
Medicine and Biology Society Joint Meeting. Atlanta GA, October
13, 1999. P. Wehman, W. G. Revell (1996). Supported employment
from 1986 to 1993: A national program that works. Focus on Autism
and Other Developmental Disabilities 11(4), 235-242.
Acknowledgements
This is a publication of the Rehabilitation Engineering Research
Center on Telerehabilitation, which is funded by the National
Institute on Disability and Rehabilitation Research of the U.S.
Department of Education under grant # H133E980025. The opinions
contained in this publication are those of the grantee and do not
necessarily reflect those of the Department of Education.
We would like to thank staff and consumers at the Rock Creek
Foundation and CHIMES, International for their invaluable
contributions.
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